Why 20 hospitals have been at risk of losing CMS funding

When emergency situations arise in hospitals that threaten the health and safety of individuals and patients, CMS can place a facility in "immediate jeopardy" and threaten to pull funding for programs such as Medicare or Medicaid in an effort to address any issues.

Immediate jeopardy status does not happen often. A 2021 study published in the National Library of Medicine found that 30,808 deficiencies reported by CMS in hospitals over a 10-year period only led to 730 — or 2.4 percent — immediate jeopardy situations. Hospitals where a patient's death occurred were more likely to be associated with immediate jeopardy status.

Here are 20 hospitals or health systems that have been at risk of losing CMS funding since May 2022 due to noncompliance with the agency's policies: 

Main Line Health's Lankenau Medical Center in Wynnewood, Pa. was given an immediate jeopardy warning in August 2023 after a nurse mistakenly gave a patient double the prescribed dose of opioid hydromorphone. The warning was lifted a day later after all nurses at the hospital were retrained on "medication administration, wasting of controlled substances, controlled substance inventory discrepancy procedures, and controlled substances monitoring." The hospital also agreed to conduct 30 observation audits per week for at least 30 days. As of Sept. 28, the hospital had met its auditing goals. 

HCA's Bayonet Point Hospital in Hudson, Fla. was placed in immediate jeopardy between late August and mid-September after a patient died because he was moved to the wrong room and employees couldn't find him. In response, the hospital developed and provided an education plan for its staff to clarify lethal cardiac rhythm escalation and the process for moving a patient in the monitoring system, along with additional actions. CMS removed the immediate jeopardy notice Sept. 15, and follow-up, on-site surveys have confirmed the hospital is complying with its plan. 

Oregon State Hospital in Salem received an immediate jeopardy warning in September 2023 for failing to take immediate action after a patient who was awaiting felony charges escaped using a hospital van. Oregon Health Authority, which oversees the hospital, said Sept. 20 that it had submitted a corrective plan and begun implementing it.

Centinela Hospital Medical Center in Inglewood, Calif. was placed in immediate jeopardy status in February following an investigation that was launched when a Black woman admitted for labor and delivery died. Regulators found several patient safety concerns, including failure to ensure the patient was properly assessed and treated to prevent blood clots. The immediate jeopardy status was removed after the hospital submitted a corrective action plan to state officials. California also fined the hospital $75,000 for "deficient practices" that led to a patient's death, the Los Angeles Times reported in August.

Johnstown (Colo.) Heights Behavioral Health was hit with an immediate jeopardy citation in July, the second one it has been issued since November 2022, ABC affiliate KMGH reported. An April investigation was conducted following patient reports of being held at the facility longer than necessary, including claims of a patient being carried out by her arms and legs and dumped in a parking lot. The facility's immediate jeopardy citation from late 2022 has been resolved, and the hospital must undergo the same process to ensure CMS compliance once again.

St. Christopher's Hospital for Children in Philadelphia was placed in immediate jeopardy status following a survey of the facility by state officials in January 2023. CMS documents shared with Becker's showed investigators found that the hospital failed to initiate a "Code Pink" after an alleged child abduction, and staff was not trained annually on abduction protocols. The immediate jeopardy designation has since been lifted, and CEO Donald Mueller is now on-site five days each week, per the hospital's plan of correction. On July 20, CMS conducted another survey and found the hospital in compliance.

Adventist Health Simi Valley (Calif.) received an immediate jeopardy warning after medical staff gave an 81-year-old woman two doses of Lovenox, a blood thinner, within two hours. CMS found the error "probably caused" a brain bleed, and the patient died 18 hours later. Investigators determined that the medical error was a "system wide failure" because the physician ordering the medications did not follow hospital protocol, two pharmacies filled the prescription without talking to each other, and both doses were not correct. CMS removed the immediate jeopardy warning in May 2023 after the hospital presented a corrected plan that included pharmacy alerts for certain medications.

Northridge Hospital Medical Center in Los Angeles was given an immediate jeopardy warning in February 2023 after a patient had to be resuscitated from receiving the wrong medication. The patient, who was recovering from anesthesia after an operation, was given a blood pressure medication instead of naloxone. Northridge Hospital submitted a corrective plan in May, and the immediate jeopardy warning was lifted.

California Medical Center in Los Angeles was at risk of losing CMS funding in April 2023 after state officials found deficiencies at the hospital led to the death of a patient hours after she had a C-section in March. According to the investigation, the hospital, owned by Dignity Health, missed signs that the patient was bleeding internally. More than a dozen deficiencies were listed in the report, including that the hospital did not adequately maintain a quality assessment and performance improvement program. CMS later removed the immediate jeopardy designation after the hospital submitted a corrective action plan.

Loretto Hospital, a safety-net hospital in Chicago, was placed in immediate jeopardy status by CMS in March following an investigation. The onsite visit was spurred by a patient's death in February that occurred after no one was around to treat the individual in the emergency department. The hospital acknowledged "staffing challenges" and confirmed the waiting area and triage room were staffed by one nurse when the incident occurred. Inspectors conducted a follow-up visit in April, and the immediate jeopardy warning was lifted.

Brynn Marr Hospital in Jacksonville, N.C., was at risk of losing Medicare funding following a federal investigation that found the facility violated safety measures, Carolina Public Press reported May 12. The investigation, which took place from December 2022 until March, was spurred by complaints that alleged mistreatment of patients and sexual assault of a minor. A hospital spokesperson confirmed with Becker's in August that the hospital's immediate jeopardy status was removed in March and the facility has no oustanding compliance issues.

St. Michael Medical Center in Silverdale, Wash.,regained compliance with CMS regulations in May 2023 following investigations into staffing issues, patient rights and quality assessment issues that began last fall. The issues came to a head in October, when an emergency department charge nurse called 911 to get patient care assistance from the fire department. After a follow-up investigation in February and further corrective actions, the facility is back in compliance and was notified of the new status by CMS, the Kitsap Sun reported May 14.

Wilson (N.C.) Medical Center has been at risk of losing its Medicare contract three times since the start of 2022. The medical center received its first immediate jeopardy citation last summer following three safety incidents in early 2022, two of which resulted in patients' deaths. By August, the hospital was no longer in danger of losing its Medicare contract. In October, the hospital received a second immediate jeopardy citation for potential violations of the Emergency Medical Treatment and Labor Act. In March 2023, the hospital received its third immediate jeopardy citation from CMS after the agency identified numerous care deficiencies, including "inappropriate encounters" between a nurse and a patient. On April 6, CMS rescinded the facility's immediate jeopardy status, the hospital confirmed with Becker's. The hospital reconfirmed in August it is in full compliance with CMS' conditions of Medicare participation.

Saint Francis Health System in Tulsa, Okla., was threatened with the loss of Medicare and Medicaid/CHIP funding in April 2023 after the five-hospital system refused to put out a sacred candle burning in a hospital chapel, which is in accordance with its Catholic faith. The Joint Commission said the flame violated patient safety policy in February and told the health system to extinguish it, a decision later affirmed by CMS. Following the threat of a religious liberties lawsuit from the system in May, CMS is no longer pursuing the matter.

The University of Kansas Health System in Kansas City was notified by CMS in April 2023 that two major incidents with patients last year caused "immediate jeopardy conditions," which led to it "placing the health and safety of all patients at risk." CMS launched the investigation after it had received reports that the health system and its facility in Joplin, Mo., may have violated the Emergency Medical Treatment and Active Labor Act. The health system has taken steps toward coming into compliance and no further enforcement measures are being taken, according to CMS.

John Muir Health's Walnut Creek (Calif.) Medical Center saw four preventable pediatric patient deaths since 2014 in the intensive care unit, prompting a surprise visit from state investigators in January 2023. A CMS statement of deficiencies found the hospital failed to define certain conditions and procedures that would require a patient to be transferred for more intensive care. The hospital implemented a corrective action plan in April and no longer faces disruption to its Medicare funding.

Oregon Health and Science University Hospital in Portland was placed in immediate jeopardy status after a fire broke out in an operating room in December 2022, causing minor patient injuries. The incident prompted a CMS investigation in January and a corrective action plan from the hospital, which was approved and validated by the agency on Jan. 23, thereby lifting the jeopardy status.

New Hanover Regional Medical Center in Wilmington, N.C., was at risk of losing Medicare funding in June after state inspectors identified deficiencies regarding patient rights, nursing services, emergency services, quality assessment and performance improvement. Many of the care issues were related to nursing shortages at the hospital, which caused long wait times in the emergency room. CMS accepted Novant Health's plan of correction in August and the hospital was in compliance shortly after.

University of North Carolina Medical Center in Chapel Hill was threatened with the loss of Medicare funding in June 2022 after state inspectors found the hospital failed to meet four conditions of participation in the Medicare program, including infection control and patients' rights. UNC was required to submit a plan of correction to CMS by July 23 and is now in compliance with regulations.

Eleanor Slater Hospital in Cranston, R.I., was at risk of losing Medicare and Medicaid reimbursements for putting patients in "immediate jeopardy," according to CMS in May 2022. The agency said it had received acceptable plans for correction for many deficiencies cited in a January report, but unannounced visits in March and April 2022 found additional noncompliance issues. Details of those incidents were not disclosed, but previous issues included failure to complete required observation and safety checks for 17 patients, failure to provide necessary supervision to maintain safety, and failure to monitor patients placed in restraint devices to ensure physical and psychological needs were met. In August 2022, CMS found that the deficiencies had been corrected, according to the Providence Business Journal.

This report was updated Dec. 18, 2023.

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