Health Care

After colonoscopy death, KC-area hospital corrects problems, but hygiene issues cited

Attorney wants accountability for patient who died after routine colonoscopy

Lee's Summit attorney Aaron Woods wants hospitals to be held accountable after his client's mom died from internal bleeding following a routine colonoscopy.
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Lee's Summit attorney Aaron Woods wants hospitals to be held accountable after his client's mom died from internal bleeding following a routine colonoscopy.

After a colonoscopy led to a woman’s death, a Kansas City-area hospital has passed a follow-up inspection and is no longer in danger of losing Medicare payments.

But inspectors said they found several new infractions for poor hygiene and cleanliness that the hospital had to address.

Cass Regional Medical Center in Harrisonville came under scrutiny from state and federal regulators after 83-year-old Martha Wright of Pleasant Hill died of internal bleeding there in August the day after her colonoscopy.

Inspectors who came to the facility in November found that the hospital hadn’t recognized the seriousness of the incident or done a proper review to determine how it happened and how to prevent another incident.

The federal Centers for Medicare and Medicaid Services, or CMS, gave the hospital an “immediate jeopardy” designation, putting its Medicare certification at risk.

CMS spokeswoman Julie Brookhart confirmed via email that that designation had been lifted after the follow-up inspection in February.

“Their termination action has been rescinded,” Brookhart said.

Wright’s daughter, Dena Royal, said she couldn’t comment, based on legal advice.

Cass Regional CEO Christopher Lang said via email that the hospital “was found to have taken appropriate actions necessary to put it back in compliance” but also acknowledged that inspectors “found some new elements” during the follow-up visit.

Those included:

A nurse anesthetist who touched several items inside a patient’s room before and after touching the patient and injecting medication into the patient’s IV during a colonoscopy, all without wearing gloves as required by hospital policy.

A registered nurse who touched several items in a patient’s room, picked up a pill bare-handed, cut it in half and administered it to a patient without washing his or her hands.

Un-washable paper products and a potentially contaminated cellphone in a “sterile processing clean room” in the surgical area.

IV tubing in use on patients but not labeled with the date when it was originally hung, or when it should be replaced.

“These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increase the potential to spread infection,” the inspectors wrote.

Lang said the hospital submitted a plan to address the deficiencies on March 11.

“This plan has been accepted,” Lang said, “and Cass Regional has been informed that all deficiencies noted in the February survey are correct and that Cass Regional is currently and again in compliance.”

In a colonoscopy, patients are sedated while a doctor inserts a small flexible tube with a tiny camera through the patient’s rectum and into the large intestine. It’s a key tool for detecting colorectal cancers, but according to the Centers for Disease Control, about one-third of Americans who should be getting the test aren’t.

Still, it’s one of the most common medical procedures in the United States and it’s usually safe. Serious complications occur in only about 1.6 percent of patients, though experts say that’s still too high, given that millions of colonoscopies are done each year.

Deaths are even more rare.

In one of the largest studies done on the topic, researchers examined 16,318 colonoscopies performed in Kaiser Permanente hospitals between 1994 and 2002. They found only one death they could attribute to the procedure — a rate of 0.006 percent. A 2008 study on Canadian colonoscopy patients came up with a similar number.

By contrast, the five-year death rate for people with localized colorectal cancer is about 10 percent, and it spikes to almost 30 percent once the cancer spreads to surrounding tissues or organs.

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Kansas City Star health reporter Andy Marso was part of a Pulitzer Prize-finalist team at The Star and previously won state and regional awards at the Topeka Capital-Journal and Kansas Health Institute News Service. He has written two books, including one about his near-fatal bout with meningitis.