Nine U.S. hospitals have been placed under immediate jeopardy warnings in late 2023 and 2024, placing them at risk of losing federal funding from CMS.
Immediate jeopardy status does not happen often. Typically, within one year, only 2.4% of citations issued by CMS to hospitals are immediate jeopardy situations.
Here are the most recent hospitals or health systems that have been at risk of losing CMS funding since December 2023 due to noncompliance:
NYC Health + Hospitals/Woodhull, based in New York City, was placed in immediate jeopardy and a physician was fired following two patient deaths in the hospital's maternity ward. The first patient was a baby who did not live following an emergency cesarean section. The second was a 30-year-old mother whose incision during an emergency C-section was too long and she bled internally. State health officials issued the hospital an immediate jeopardy warning, which was lifted shortly after when the hospital submitted its corrective plan.
Thomas Jefferson University Hospital, based in Philadelphia, received an immediate jeopardy warning — and resolved it in a few hours — after a disoriented nursing home resident walked out of the emergency department unnoticed. Shortly before 11 a.m. Jan. 23, a 71-year-old man was brought to the emergency department by ambulance with an "altered mental status," a urinary tract infection and aggressive behavior. The man sat in the waiting room for about 12 hours before walking out of the ED unnoticed. Three hours passed before the staff reported him missing internally, and nearly 10 hours passed before the police were notified, the report said. The patient was found the next day when he returned to the hospital, according to police reports. State inspectors issued an immediate jeopardy warning to the hospital during a Jan. 26 investigation. Sanctions were lifted hours later after Jefferson administrators provided a plan of corrections.
Penn Medicine's Cedar Avenue location, based in Philadelphia, was placed in immediate jeopardy for five hours after a possible preventable death. The citation was handed out in November, but the corrections were published in late February. A behavioral health patient fell in the waiting room Nov. 3, according to a CMS report. About seven minutes after she fell, a rapid response nurse began compressions. A defibrillator pad and ambu bag were used. Resuscitation ended at about 9:26 p.m., and the patient was transferred to the morgue by 10 p.m. A CMS assessment revealed the facility did not have policies for post-fall assessments and assessment of patient's vital signs during admission. One of the nurses on the scene was also unsure how to call a code and left the patient to grab a computer.
Northlake Behavioral Health System, based in Mandeville, La., has received two immediate jeopardy designations for substandard patient care within a year and is at risk of losing the ability to collect Medicare and Medicaid reimbursements. A Jan. 22 inspection found that several employees were unaware that they had patients under their care who had to be supervised closely or kept away from other patients. In a Jan. 31 letter, the Louisiana Department of Health told Northlake it violated federal hospital standards and must submit a corrective action plan. A spokesperson for Northlake told Becker's that the immediate jeopardy warning was lifted after 24 hours and it is implementing a plan of correction.
Carilion Roanoke (Va.) Memorial Hospital received an immediate jeopardy citation by CMS after an investigation found sterilization issues with surgical equipment that reportedly occurred between March and September 2023. The unsterile tools were not used on patients, but the sterilization issues did lead to surgeries being rescheduled or transferred to another location in August. The hospital has since received approval from the Virginia Department of Health on its action plan to address the issues.
Good Samaritan Medical Center, based in Brockton, Mass., was cited for immediate jeopardy, The Boston Globe reported Feb. 14, after reports of a patient collapsing and dying while waiting in the registration line at the emergency department. State health inspectors arrived at the Steward Health Care-owned hospital to investigate and found multiple cases of patients not receiving timely care due to staffing shortages. The hospital submitted a plan to fix the issue and the immediate jeopardy status was removed.
Hospital of the University of Pennsylvania-Cedar Avenue, a Penn Medicine hospital, was briefly placed in immediate jeopardy by state officials following the November death of a patient. The patient reportedly died after slumping over in a walker and sliding down a wall, then ultimately collapsed on the floor of HUP-Cedar's behavioral health unit. Workers did not immediately call a code blue or begin performing CPR until 10 minutes into the incident, a state investigation found. The state's report, published Dec. 26, does note that although the hospital implemented immediate corrective actions such as educating staff on code blue procedures and what to do in the event of a patient fall to address the situation, it continues to not be in compliance for the Condition of Participation for Patient Rights as well as for Nursing Services.
Mission Hospital, based in Asheville, N.C., was cited with immediate jeopardy after three patient deaths. The CMS report said the hospital's leadership "failed to ensure a medical provider was responsible for monitoring and ensuring the delivery of care to patients" in the emergency department, and ensure care was provided according to policy. It also described deficiencies in other areas such as oncology where a patient received expired chemotherapy, and the behavior health unit where a child was given medication without authorization from a parent or guardian. CMS on Feb. 1 sent a letter to the hospital, notifying leadership that the facility is in immediate jeopardy and must take action to avert the loss of federal funding. CMS had set a Feb. 6 deadline for Mission Hospital to submit a plan of correction indicating how it will come back into compliance with regulations related to its governing body, emergency services, nursing services, patients' rights, quality assurance and laboratory services.
Providence Milwaukie (Ore.) Hospital received an immediate jeopardy warning from CMS after a patient died Dec. 12 following discharge from the emergency department. Four hours after the patient entered the hospital, security guards called police to force him to leave. Officers expressed concern that he still needed medical treatment, but staff reportedly said he was "playing possum." Police handcuffed and wheeled the patient, Jean Descamps, into a police vehicle around 10:49 p.m. While waiting for the behavioral health staff to bring a wheelchair to the police vehicle, the officers found Mr. Descamps unresponsive and were unable to revive him. The hospital, which launched its internal investigation Dec. 12, submitted a corrective plan for the immediate jeopardy warning. The Oregon Health Authority has signaled approval of Providence's plan, but the federal CMS investigation continues.