Las Vegas Sun

November 20, 2019

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State failed to inspect clinic for seven years

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The Nevada agency in charge of inspecting medical facilities issued a memo in 2001 promising complete inspections of medical facilities every three years.

Since 2001, however, the state had not conducted a single full inspection of the Endoscopy Center of Southern Nevada before investigators traced a hepatitis C outbreak to facility in January, leading to the largest public health crisis of its kind.

There is no guarantee that an inspection would have uncovered the practices that led to 40,000 former patients being notified last week that they need to be tested for hepatitis B, hepatitis C and HIV. But it was the best chance the state had to spot the deliberarly risky procedures that created the outbreak.

If the state Licensure and Certification Bureau had followed its announced schedule, the center would have been inspected in 2007 and in 2004 — the year health officials believe supervisors there adopted the careless procedures.

Asked Wednesday whether inspections would have uncovered the problem earlier, the bureau's chief, Lisa Jones, said: “Maybe. We just don’t know the answer to that.”

She ascribed the failure to inspect to a lack of resources and difficulty in recruiting inspectors.

If the agency had followed its schedule, two inspectors would have spent two days at the clinic in 2004--the same year health officials believe the clinic adopted the flawed procedures. The inspectors would have observed medical protocols and discussed them with staff, Jones said. Those discussions could have offered employees a chance to quietly reveal that they were being asked to follow the medically risky procedures. One of the many questions surrounding the outbreak is why none of those employees blew the whistle.

“We have to count on education,” Jones said, “and we have to rely on health care practitioners taking responsibility for standards of practice.” Jones stressed that even the full inspections are “only snapshots in time.”

Such a snapshot did take place in January after a cluster of hepatitis C cases pointed to the Endoscopy Center of Southern Nevada as a source.

Health investigators watched nurses reuse syringes to draw anesthesia from vials. If the reused syringes had been in contact with a diseased patient, the vials became contaminated. That alone would not have spread the disease if the nurses had thrown away each vial after it was used on a single patient, as intended. Instead, anesthetic was withdrawn from the vials and used on other patients, spreading the disease.

Assemblywoman Sheila Leslie, D-Reno, is chairing a meeting today to review the state’s oversight and response to the Endoscopy Center crisis. Told of the seven-year lapse in inspections, Leslie said Wednesday that it “is completely unacceptable. The state needs to do better than that.”

Jones said the state is focused on inspecting all facilities. “Going forward now, we’re retooling all our resources and working to get on-site at all these centers,” she said.

The state has been at the Endoscopy Center of Southern Nevada other times since 2001. But those visits by state surveyors have been in response to complaints. And during those inspections, state surveyors more narrowly focus on addressing the subject of the complaints, Jones said. None of the complaints was based on syringe or single-dose medicine use.

In explaining the shortage of resources, Jones said her agency’s 25 inspectors are responsible for routine inspections and for responding to complaints at 1,100 facilities statewide.

The volume of complaints forced the agency to cut back on routine, thorough inspections, she said.

The Licensure and Certification Bureau is supported by fees paid by facilities. Earlier this decade, Jones said, fees weren’t keeping up, so vacant positions were frozen and eventually eliminated. In this past session, in 2007, the Legislature allocated seven more positions to the agency, though it has been difficult recruiting people, Jones said.

Leslie said, “I guess the moral of the story is that you get what you pay for.”

State legislators today will look at the state’s role in the public health crisis.

Among questions Leslie said she intends to ask:

• Are the fines sufficient?

• Are inspections of medical facilities by the state sufficient?

• Was the state’s response to the crisis sufficient?

The Endoscopy Center of Southern Nevada has so far been given a $3,000 penalty. If that seems mild, consider that if this had happened in Colorado, Oregon or California, the clinic would have faced no fines. In New Mexico, the maximum fine would have been $15,000.

In Nevada, the fines were capped by a 1989 state law at a maximum of $1,000 per violation. The level of fines was intended to encourage compliance, not as a punishment for bad operators who corrected their ways, Jones said.

Leslie said the fines struck her as too low. But she said, “To be fair, I don’t think anyone envisioned malfeasance or behavior this egregious.”

The assemblywoman also said Nevadans have frequently resisted granting government more oversight, arguing that it could squelch business.

“Nevada has a libertarian, ‘regulation is bad’ attitude,” she said. “This tragedy may make people realize regulation is there to protect the people, not harass business.”

Larry Matheis, executive director of the Nevada State Medical Association, said professional organizations and governmental agencies should use this as an opportunity to come together and review regulations.

“You don’t want to make this so difficult that it discourages available services,” Matheis said. “At the same time, the first responsibility of all agencies is protecting the public.”

State Sen. Randolph Townsend, R-Reno, wrote letters to state officials asking them to prepare by early next month a report on how the hepatitis outbreak occurred.

“Do they need more authority, more regulatory authority?” he asked. “We don’t know.”

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