HospitalInspections.org

Based on observations, policy review, medical record review, and interview, the hospital failed to ensure acceptable standards of practice consistent in quality with inpatient care were utilized to ensure the health and safety of patients. Specifically:
1. The hospital failed to ensure Surgeon (Staff K) maintained continuous attendance and responsibility for Patient #2 during a surgical procedure, by allowing the surgeon to leave the hospital building while the patient's abdomen was open and the procedure was incomplete.

2. The hospital failed to promptly and thoroughly investigate verbal and written complaints, dated May 8th and May 13th, 2025, from a staff member (Staff V) regarding inappropriate, high-risk, and potentially harmful behaviors by surgical staff (Staff L and Staff K) in the operating room (OR). The lack of timely investigation persisted for approximately one month.

Findings #1:

Observation on 06/12/25 from 10:45 AM to 04:15 PM revealed the surgical OR suites were located on the first floor of the main hospital building. There is a parking ramp across the street from the main hospital building that houses the surgery clinic for Staff (K), Surgeon, on the seventh floor (above the parking ramp).

Review of policy "Sponge, Sharp, and Instrument counts in the Operating Room (OR) ...," dated 01/2022, revealed under no circumstances will the surgeon leave the hospital until the patient is in the recovery room, deemed stable by the anesthesia staff.

Review of "Rules and Regulations of the Medical and Dental Staff..." dated 2025, revealed all consults are required to be completed within 24 hours of notification of consult, unless a stat consult is requested.

Review of the medical record for Patient #2 revealed on 05/08/25 from 01:48 PM to 05:50 PM, Patient #2 was in the OR, where Staff (K), Surgeon, was listed as present to conduct a hernia (condition where an organ or tissue protrudes through a weak spot in a muscle or connective tissue wall) repair. (The medical record does not indicate that Staff (K), left the building during the surgical procedure).

Review of the clinic medical record for Patient #4 revealed on 05/08/25 at 04:33 PM, Staff (K), Surgeon, documented Patient #4 was to be scheduled for a robotic cholecystectomy (surgery to remove the gall bladder). (This consult was conducted while Patient #2 was still in the surgical OR with their abdomen opened). On 05/23/25, Patient #4 had a robotic cholecystectomy (The procedure for the consult was not performed emergently or urgently).

Interview on 06/12/25 at 11:47 AM with Staff (H), Registered Nurse, revealed on 05/08/25, Patient #2's hernia repair was completed, but the abdominal incision was not closed, when Staff (K) needed to leave the OR to consult on Patient #4 at the clinic (across the street above the parking ramp) for a potential surgery. Staff (H) stated that while Staff (K) was gone, they were responsible for monitoring the sterile field, and a certified registered nurse anesthetist, was responsible for monitoring Patient #2.

Interview on 06/12/25 at 12:00 PM with Staff (K), Surgeon, revealed they started Patient #2's hernia surgery. When Patient #2 was stable, Staff (K) stopped the surgery, and alerted Staff (H), Registered Nurse, that they needed to leave the OR to perform an urgent medically necessary consult on Patient #4 (an outpatient surgical clinic patient), to schedule surgery. Staff (K) saw Patient #4 briefly (in office across the street from the main hospital), returned to the OR, rescrubbed into the case, and completed Patient #2's surgery.

Findings #2:

Review of the policy "Conflict/Dispute Resolution," dated 12/2024, revealed upon receipt of a formal complaint, the director/department head must schedule a meeting with the employee to discuss the complaint. Human Resources may call a meeting and gather information with the parties directly involved to facilitate a resolution.

Review of the policy "Discrimination and Harassment Policy," dated 12/2024, revealed all supervisors and managers who receive a complaint or information about suspected discrimination or harassment are required to report to the director of human resources. A prompt and thorough investigation will be conducted whenever a complaint about discrimination, harassment, or retaliation is received in writing or verbally.

Review of the email complaint submitted by Staff (V), Surgical Technician, to Staff (I), Hospital Administration, dated 05/13/25 at 02:05 PM, revealed that on 05/08/25, Staff (L), Surgeon, entered the OR with street clothes on and screamed at Staff (V) to give them a gown. Staff (L) did not perform a surgical scrub or wash their hands at any time. When Staff (L) received a gown, they put it on over their yoga pants and tee-shirt and began to position the patient. Staff (L) put both patient ' s legs in the stirrups but did not strap them down. Staff (L) did not use sterile drapes during the procedure. Staff (L) did not dilate the cervix and used a size 13 curette as an introducer. Staff (L) had difficulty inserting the curette and Patient #1 started to hemorrhage. Patient #1 was injured. Staff (L) did not provide Patient #1 a sanitary pad. Staff (L) ' s behavior was erratic, hostile, and their pupils were extremely dilated. Post operatively, Staff (V) spoke to Staff (J), Hospital Administrator, and told them about Staff (L)'s behavior and contamination. Also, on 05/08/25, Staff (K), Surgeon, placed a wet towel on Patient #2 and left the OR. Registered nurses were left monitoring Patient #2 for 25 minutes while Staff (K) went across the street to their office to conduct a consult on another patient. Staff (V) included additional complaints of inappropriate touching, rude language, and inappropriate behaviors between other hospital and non-hospital employees. Staff (V) requested a follow up (via phone/email) after the investigation was conducted to determine if corporate compliance and the New York State Department of Health needed to be notified.

Review of email from Staff (V), Surgical Technician to Staff (I), Hospital Administration, dated 06/06/25 at 09:14 AM, revealed Staff (V) had not yet received an update or a resolution for the complaint submitted. On 06/11/25 at 09:50 AM, Staff (V) received an email from Hospital Administration indicating that every issue raised will be fully investigated and if any allegations are found to be valid, necessary steps would be taken. (No documentation of any investigation activities was provided to onsite surveyors).

Interview on 06/12/25 at 10:30 AM and at 03:45 PM with Staff (D), Nursing Administrator revealed they were notified by Staff (F), Nursing Administrator, who stated Staff (V) wanted to quit and gave a laundry list of concerns, but did not state anything specific or list any specific date. Staff (D) did not speak to Staff (V), but no concerns brought to them needed to be escalated to Human Resources.

Interview on 06/12/25 at 11:26 AM and on 06/13/25 at 11:50 AM with Staff (I), Hospital Administration, Staff (V), Surgical Technician, came to their office on 05/09/25 indicating they told Staff (F), Nursing Administrator, they quit due to concerns related to a surgeon who came into the OR in street clothes, "under the influence," and another surgeon left the OR while a patient was on the table. Staff (I) informed Staff (V) to fill out the complaint form and follow the process on submission of their complaint. On 05/13/25, Staff (I) received an email from Staff (V), however, they did not read the email and forwarded it to Staff (G), Hospital Administration. Staff (V) continued to call asking about the status of their complaint. Staff (I) informed Staff (V) each time that they would need to contact Staff (G), Hospital Administration. On 06/09/25, Staff (V) re-sent their email complaint to Staff (I), who forwarded the email to Staff (G), Hospital Administration.

Interview on 06/13/25 at 12:00 PM with Staff (G), Hospital Administration, never received the original email complaint but did receive an email on 06/09/25 from Staff (V), Surgical Technician, and immediately sent the email to Staff (U), Medical Director. Staff (G) stated they are in the process of interviewing staff but did not provide any documentation of an investigation.