Assembly woman. Susan Gerhardt from Las Vegas says she was incredulous when she read about the outbreak.
" I have got to know, in the back of my mind, they knew they were doing something wrong."
That was just one of the many pointed questions law makers had for Clark County and State health investigators today.
And while that answer was harder to come by. What happened is easier to tell.
Clark County's epidemiologist Brian Labus testified he was able to track down six cases of hepatitis to the Endoscopy Center here in Las Vegas.
Upon further investigation he says his agency along with the C-D-C found the clinic routinely re-used syringes ultimately contaminating vials and infecting other patients.
" You now have a contaminated vial, that was then reused for additional patients. Now syringes should never be reused, and in this particular case the vial was labeled as single use only."
Assembly Speaker Barbara Buckley wanted to know.
"Who directed the vials be reused."
While that is still being investigated, Debra Scott from the state nursing board says her agency got word about the outbreak in February and promptly took action.
"We contacted immediately with the five CRNAS. It would be in the public's best interest, for us to be able to have their license and certificate on hold (so they are not practicing)They are not practicing."
But while the state board of nursing got word earlier, the state board of medical examiners which regulates doctors in Nevada just heard about the outbreak last Thursday.
Tony Clark is the executive director for the board of examiners.
"The minute we found out about it was we issued subpoenas that were issued by out board, and sent to Las Vegas with one of our investigators for service on the clinic."
And that communication breakdown doesn't stop there, according to Lisa Jones from the Bureau of Licensure and Certification, her state agency has yet to shut down the Endoscopy Center because she doesn't have the paperwork yet.--that move had to come from the business license bureau in Las Vegas.
Chairman Sheila Leslie replied she didn't like that bureaucracy is getting in the way of a life threatening situation.