Investigation’s over, but still no answers

By Marshall Allen

Friday, Sept. 26, 2008 | 2 a.m.

Michelle McCutchen deserves an answer.

And the fact that she hasn’t gotten one says a lot about the rigor of medical regulators who are supposed to watch out for her — and all Nevada patients.

Patients who have complaints against hospitals are told to report them to the Nevada Licensure and Certification Bureau. The agency can investigate complaints, demand corrective action and issue sanctions.

McCutchen certainly had a complaint. Her insurance company sent her to Montevista Hospital, a mental health facility in Las Vegas, seeking a counseling referral. What was supposed to be a quick visit to the lobby that spring day in 2007 ended up being a five-day ordeal in which she was held against her will because the staff thought she was suicidal.

On June 19, 2007, she complained to the Licensure and Certification Bureau. During the months of silence that followed, McCutchen contacted the agency multiple times to check on her complaint.

Still no response. It’s been 15 months.

Turns out the agency received the complaint through its Web site, but never followed up by starting an investigation.

The head of the agency now admits the system failed the patient.

“We never took her complaint in,” said Marla McDade Williams, the bureau’s chief. “We have a record that says she complained to us. We had a systemic breakdown.”

McCutchen’s biggest problem was with the intake process.

She arrived at Montevista with her husband, Mark, and a staff person asked whether she had ever been suicidal. McCutchen acknowledged that, as a multiple sclerosis patient, she had considered death as an alternative to the pain she suffered. But the couple stressed that she never really considered killing herself.

She was asked: If you were to kill yourself, how would you do it? With sleeping pills, she said — adding that she would never do so.

With that, Montevista officials said they were placing her on a three-day suicide hold and that she’d be arrested if she tried to leave. Over the next five days she was drugged with morphine and placed in the presence of dangerous mental patients.

The couple suspect the hospital was actually interested in billing her insurance company.

The McCutchens learned later that Montevista classified her admission as voluntary. The records include consent forms signed by McCutchen, which she says she thought were a mandatory part of the admission process.

In reporting the incident, the Sun found many problems with the hospital’s records of its treatment of McCutchen, including incomplete patient assessments, an absence of notes documenting nurses’ observations and care, and apparent alterations of records. The hospital did not dispute the Sun report.

The quality of Montevista’s medical record would “fail miserably” if it were examined by regulators, one expert told the Sun.

In response to the Sun’s story, not the patient’s complaint, the Licensure and Certification Bureau conducted an investigation of the incident, but never contacted the McCutchens.

The bureau did not cite the hospital.

It’s unknown whether Montevista showed investigators the same records provided to McCutchen, because no investigator ever saw McCutchen’s records.

When Williams, the chief regulator, was asked whether that amounted to a “rigorous investigation,” she replied: “It was a standard investigation.”

The couple never heard any outcome of an investigation until they were informed by the Sun.

They said they had given up hope in the regulators so they could move on with life.

“It has to be enough for us that we do know the truth,” Mark McCutchen said. “Almost everything that Montevista and everyone on the other side has said has been a lie.”