Report: Hospital failed to take basic steps to prevent tuberculosis spread

Summerlin Hospital Medical Center didn’t take basic precautions this past summer when a woman with tuberculosis visited one of her twins in intensive care, potentially infecting others, according to a state report released Friday.

Hospital logs show a doctor talked “at length” with the mother at the infant’s bedside May 31, according to the investigation from Nevada’s Bureau of Health Care Quality and Compliance, which licenses medical facilities. The woman had a 103-degree fever, but the cause of her illness was unclear at the time. The baby had been admitted to the Neonatal Intensive Care Unit.

Summerlin Hospital staff told state investigators months later that they would have advised parents running a temperature not to visit. If parents persisted, staff would have required them to wear a gown and mask.

But hospital documentation said nothing about the mother wearing a gown or mask, aimed at stopping airborne diseases such as TB from spreading, and it is unclear if she was advised to stay away from the NICU. The hospital had 10 days since receipt of the report to submit to the state a plan of correction to ensure it takes proper precautions in the future.

Summerlin Hospital received the report Oct. 22, according to Martha Framstead, a spokeswoman for the State Health Division, which includes the investigating agency.

A spokeswoman for Valley Health System, which runs Summerlin Hospital, said a plan of correction was hand-delivered Friday. A copy was not immediately available. Earlier this month, hospital administrators said employees wear special respiratory masks when necessary and post signs outside doors alerting visitors and staff to a patient with a contagious disease. Hospital staffers also get tested yearly for TB.

Hospitals can face sanctions depending on if or how problems are corrected.

The state’s eight-page document gives more details in the unfolding story of the death of 25-year-old Vanessa White and her premature twin babies, Abigail and Emma. The mother died in July at a Southern California medical facility, after giving birth at Summerlin Hospital. An autopsy showed TB as her cause of death.

Since she died in California, health officials there notified Nevada’s TB office, which in turn told the Southern Nevada Health District. The county agency contacted Summerlin Hospital, which isolated baby Abigail. She tested positive for tuberculosis and died in August at the hospital. She had contracted TB from her mother.

Emma, who lived only 21 days, died in June from respiratory failure and extreme prematurity. She was not tested for tuberculosis.

Nevada state Epidemiologist Ihsan Azzam said the missed steps noted in the report are basic and intended to protect other patients as well as those providing care.

“These are simple concepts,” said Azzam, who read the report but was not involved in the investigation. “These are very important principles that have to be applicable to any patients that you’re dealing with.”

The Southern Nevada Health District in July began tracking down people who could have been exposed to TB in the NICU. Some parents whose babies were in the Level III NICU at Summerlin received letters from the Health District in August telling them their families weren’t at risk. At that time, the agency tested 200 hospital staffers and people close to White.

By October, 26 people — including at least one hospital staffer — had tested positive for TB. Two were contagious. The Health District then began testing at least 140 babies who had been in the Summerlin NICU, and their parents. At least 400 people total have been tested.

A Health District spokeswoman would not divulge details about the ongoing testing process, including whether any results had come back.

“Because TB testing sometimes takes multiple steps, we are not releasing numbers until everything is finalized and we can ensure the information is accurate and complete,” Jennifer Sizemore said.

The state investigation was launched Aug. 2 after state TB Controller Patricia Townsend got word from California that White had died. They remained onsite until Sept. 24. The controller works to combat the spread of tuberculosis and also tracks deaths. In 2012, statistics show, the disease killed 84 people in Nevada.

Townsend said she contacted the state agency because of the way she found out about White’s death.

“We don’t see as many notifications from out of state as we do from our local clinicians,” Townsend said.

The report that followed her concerns also shows even medical staff failed to take the proper measures to prevent infection consistently.

The hospital treated a patient with symptoms of meningitis in June, according to the report. Staff said in September that they had isolated the patient since meningitis can spread through touching or through the air. Investigators noted there was no documentation to prove that.

In August, the hospital was treating a patient with staph infection. A nurse used her bare hands while working with the patient, according to the report. When interviewed, the nurse said she forgot to put on gloves.

The report extends the list of problems and negative headlines in recent years at Summerlin Hospital.

In 2006, a baby in the NICU died after a nurse gave the preemie 1,000 times the zinc she was prescribed. A pharmacist had mishandled the baby’s prescription.

In 2010, a neurosurgeon died at the hospital and his family filed a malpractice suit alleging he was not treated properly by the emergency room doctor and that he wasn’t transferred to intensive care quickly enough.

In 2012, Summerlin ranked among the worst hospitals in the nation for its rate of deaths from serious treatable complications after surgery.

Contact reporter Adam Kealoha Causey at acausey@reviewjournal.com or 702-383-0401. Follow on Twitter @akcausey.