In operating rooms at Mission Hospital Regional Medical Center, insects buzzed and temperatures dipped dangerously low, problems that could cause deadly infections, a federal inspection report shows.

The report provides a rare, unobstructed look at conditions inside the private nonprofit hospital, which risked losing its accreditation last year over a small but severe outbreak of infections related to hip and knee surgeries.

Mission Hospital is one example of how hospitals – even some with shining reputations and awards and special certifications – can fail to follow protocols aimed at preventing dangerous infections that can easily start and spread inside their facilities.

At some of the other big hospitals in Orange County, problems ranged from bad hand hygiene to rusty procedure tables to a dirty diaper strewn on the floor of a neonatal intensive care unit, a Register review of Centers for Medicare and Medicaid Services inspection reports from the past five years has found.

Such reports are meant to help hospitals improve. They’re shown initially to hospital management and become available to the public after the hospital fixes it problems, often several months after an inspection. Obtaining a copy requires filing a Public Records Act request.

The Register reviewed the reports on Mission Hospital and others following the outbreak at Mission Hospital, where four patients developed serious and unusual infections following hip and knee replacement surgeries in May and June 2014. For about two weeks in October, the hospital closed operating rooms under pressure from regulators as it scrambled to find the source of that outbreak.

Mission Hospital stands out. Of the reports for five hospitals reviewed by the Register, Mission was the only one cited for having insects and for an under-staffed infection control department. It was one of two hospitals dinged for cold temperatures in operating rooms, a problem for which Mission Hospital was cited multiple times.

Linda Sieglen, chief medical officer for Mission Hospital, said at least one of the low temperatures in the report was a result of a misrecording, and she disputes they ever dipped as low as 54 degrees, as the report shows

But Sieglen and other administrators acknowledged the other problems, and said over the past year the hospital overhauled its infection control department and put a number of other fixes in place. The hospital’s response, they said, has been effective.

Still, Sieglen said the hospital never found the source of the infections.

Inspectors did not pinpoint a cause either.

A HOSPITAL IN TROUBLE

After an Oct. 14, 2014, visit, which was spurred by the infection outbreak, inspectors reported the following about Mission Hospital:

• The infection control department was short-staffed and under-funded. The hospital employed one full-time infection control doctor and a part-time consultant – not enough to “provide oversight of the infection control practices” at a hospital, which has two campuses in Mission Viejo and Laguna Beach with 533 beds and that performs about 7,000 surgeries a year. Asked if enough funding was allocated to the department, the doctor who oversaw it told inspectors he “would have to say, ‘no.’”

• Several times in the summer and fall, temperatures in operating rooms were too cold, ranging from 54 to 66 degrees – well below the temperatures recommended by the nurses associations whose standards are used by regulators to prevent patients from developing hypothermia and surgical site infections. Three operating rooms recorded temperatures of 57, 56 and 59 degrees on Oct. 5, and for three days in August, they ranged from 54 to 58 degrees.

• A machine that circulates air to reduce airborne pathogens malfunctioned during an orthopedic surgery on July 29, 2014, in the operating room where three of the four patients who later suffered life-threatening infections had their surgeries.

• There was no evidence the hospital followed up on four abdominal surgical site infections from operations in April, May, July and August.

• There was black residue in a procedure room that had been cleaned and disinfected the night before.

• A “large fly” was seen in an operating room during a surgery on Aug. 8, 2014. Three weeks later, on Aug. 29, an insect dropped from an operating room ceiling during surgery. Insects aren’t strangers to hospitals, but they are especially hazardous in an operating room because they carry bacteria and fungus that can contaminate surfaces or incision wounds.

“These are issues that are both common and egregious,” said Leah Binder, CEO of Leapfrog Group, a health industry watchdog group that gives letter grades to hospitals for preventable errors, accidents, injuries and infections. “Everyone should look twice at this hospital.”

The findings were so concerning to regulators that they told the hospital it had 12 days to fix the problems or it would lose funding from Medicare, which pays for one-fifth of its patient revenue.

Fewer than 1 percent of hospitals nationwide are denied accreditation each year, according to The Joint Commission, which certifies agencies for Medicare and Medicaid funding.

At the time of the inspection, Mission Hospital was the only hospital in California in jeopardy of losing its Joint Commission accreditation.

THE OUTBREAK

In May and June last year, four patients who underwent knee and hip replacement surgeries fell seriously ill when enterobacter, a bacteria that lives harmlessly in the gut, invaded their incision wounds. Each underwent one to three follow-up operations.

Mission Hospital isn’t identifying any of those patients, but Robert Driggers, 61, of Laguna Niguel believes he was one of them.

Driggers arrived at Mission Hospital’s Mission Viejo campus June 17, 2014, for a hip replacement, expecting to stay four days. He wound up staying three weeks because he contracted an enterobacter infection in his hip wound.

“They said they didn’t know where I got it; nobody would say,” he said of Mission Hospital. “They actually said, ‘We don’t know where it comes from.’”

Driggers needed three additional surgeries and extensive antibiotics. He said he suffered fevers, lost weight and couldn’t walk without a walker.

“My infectious disease specialist told me, ‘You really dodged a bullet.’ It was a really serious infection in his mind,” he said.

Driggers has recovered. In June, one year after his surgery, he filed a medical malpractice lawsuit against the hospital.

Doctors at Mission Hospital connected the four infections in late July. They came up with a plan to fix nearly a dozen issues, including the temperature and humidity in the operating room, sterilization of instruments, and cleaning of operating rooms, according to Sieglen and the report.

But the hospital did not alert state or federal health officials – and by law it did not have to. A hospital employee tipped off the Joint Commission and the Centers for Medicare and Medicaid Services, which launched its inspection in October.

The state requires hospitals to report certain mistakes and errors, including: wrong-site surgeries, severe bed sores, wrong dosages of medication and contaminated devices that kill or disable a patient. These “adverse events” can trigger fines up to $100,000 per incident.

But an outbreak of infections like the one that hit Mission Hospital is not on that list.

Mission Hospital has been fined six times for adverse events in the past five years, more than any other hospital in the county.

TEMPERATURES UP, INSECTS OUT

Before the outbreak, Sieglen said, administrators hadn’t considered more staffing because the hospital’s infection rates were in line with industry norms. In 2013, its rates were on par with state averages for most infection types tracked by the California Department of Health, including infections related to hip and knee replacements.

Even in 2014, Mission earned high marks from the Joint Commission, which accredits most U.S. hospitals, for administering the appropriate amount of antibiotics to prevent infections during hip and knee replacement surgeries.

The situation was different last fall.

On Oct. 8, after the Joint Commission got involved, administrators voluntarily shuttered the hospital’s 14 operating rooms to elective surgeries for two weeks. It canceled 176 surgeries, one-quarter of which were never rescheduled.

The hospital since then has hired more infection control professionals; the department now consists of six full-time doctors and nurses, Sieglen said.

“We tripled the number of people as well as implemented a true program. … We put a lot of fixes in place,” she said.

Mission Hospital also installed a temporary replacement for the malfunctioning heating, ventilating and air conditioning system. The hospital has budgeted $1.5 million for a new, permanent system to be installed next year.

“There was a lot of planning that had to go into it, you can’t just pull it off the shelf,” Seiglen said of replacing the operating room air systems. “It’s a sensitive thing to try to control the balance between temperatures and humidity.”

Hospital administrators said they first became aware of high humidity in one operating room – a condition that can lead to growth of bacteria and infection – as early as February. But they continued allowing surgeries even as temperatures in some operating rooms dropped as low as 54 degrees in mid-August, the inspection report shows.

“I was not aware, or I had not heard,” Sieglen said. She later said some of the temperatures cited in the report were recording errors.

After a cricket jumped on a patient’s lower torso during surgery, Sieglen said the hospital resealed openings to the operating room area to keep insects out. There were no complications or infections in that case, she said.

It’s unclear if the cricket is the same insect referenced in the report.

‘AN EXEMPLARY MODEL’

At least one outside expert lauded Mission’s decision to temporarily close operating rooms.

“That’s a really tough decision to make because it immediately impacts patients and also the revenue stream for the hospital,” said Dr. Richard Martinello, an associate professor of infectious diseases at Yale University.

“Whether they’re operating or not, the hospital still has bills to pay. It takes a lot of courage for them to do the right thing.”

Though hospital administrators had come up with a plan in July to correct 11 issues that might have caused the outbreak, inspectors wrote that the hospital did not follow through in making all of the fixes.

In May, the hospital regained its good standing with the Centers for Medicare and Medicaid Services. Next month, the Joint Commission is set to publish an article highlighting the hospital’s improvements.

Sieglen said the Joint Commission is holding up the hospital as “an exemplary model when dealing with issues such as this.”

“Mission Hospital remains a great community resource for outstanding care and we know our improvements are making Mission an even safer environment for patients to receive excellent care,” she said.

This article was produced as a project for The California Health Journalism Fellowship, a program of the USC Annenberg School for Communication and Journalism.

Contact the writer: jchandler@ocregister.com Twitter: @jennakchandler