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Based on record review, interview and policy review, the hospital failed to ensure patients were free from sexual abuse by Physician #1. This affected three (Patients #1, #2 and #3) and had the potential to affect an additional 13 patients (Patients #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #17, #18 and #19) who were seen by Physician #1 on 11/28/22 and 11/29/22.

See A-0145

Based on record review, policy review, and interview, the hospital failed to ensure patients were free from sexual abuse by Physician #1. This affected three (Patients #1, #2 and #3) and had the potential to affect an additional 13 patients (Patients #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #17, #18 and #19) who were seen by Physician #1 on 11/28/22 and 11/29/22. This had the potential to affect all patients examined by Physician #1. The hospital census was 1107.

Findings include:

Review of the hospital's complaint log for November and December 2022 revealed the hospital had received two complaints of inappropriate touching by Physician #1.

On 11/27/22, Patient #1 reported via email that Physician #1 inappropriately touched her breasts and asked her to pull down her pants during an exam in the endoscopy outpatient area on 11/11/22..

Patient #2 was seen by Physician #1 by appointment on 11/28/22. Patient #2 left the exam room at 10:00 AM and reported to Nurse Manager #14 that Physician #1 touched her breasts and began to put his hand down her pants during an exam in the gastroenterology outpatient clinic. Patient #2 also contacted the hospital police department to file a report.

During interview via video conference on 12/21/22 at 11:12 AM, the Director of the Ombudsman stated the incident involving Patient #1 was reported by email on 11/27/22, a Sunday, and was received on 11/28/22 at approximately 8:42 AM. Police Inspector #11 was contacted and interviewed Patient #1 and Patient #2. Physician #1 was then interviewed by Police Inspector #11 who also contacted the Cleveland Police. The Director of the Ombudsman stated there is a team that handles all abuse cases. The team does the investigation and interacts with human resources for any disciplinary actions. Physician #1 was not removed from patient care during the investigation. The Director of the Ombudsman verbalized there was one other incident which was reported on 03/25/22 involving Patient #3 and an allegation of inappropriate sexual touching by Physician #1. This incident was investigated but was not substantiated at the time.

During interview via video conference on 12/21/22 at 1:00 PM, Police Inspector #11 stated one primary person in the legal department, as well as three hospital ombudsmen, were involved in sexual assault investigations. Review of the police reports with Police Inspector #11 during the interview revealed the first incident involving Physician #1 was reported to the hospital's Ombudsman office in April 2022. Patient #3 alleged that on 03/25/22 during an office visit Physician #1 had touched her breast and nipple during an exam of the liver and that this was different than previous liver exams by physicians . The hospital investigative staff was unable to reach Patient #3 until May 2022 due to the patient's work schedule and Patient #3's failure to return requested calls. There were no witnesses and no evidence to support the allegations. These allegations were additionally reported to the Cleveland Police Department's sexual assault division. Physician #1 was interviewed by police staff, but denied the allegations and reported he did not remember the patient. The nurse who had worked that date was not aware of any issues. The Cleveland Police detective was unable to find any evidence and Patient #3 declined to press charges at that time.

On 11/28/22 at 10:20 AM, the hospital's police department's responding officer took a report from Patient #2 and then notified the hospital's Police Inspector #11. Patient #2 was interviewed on 11/28/22 and stated she stopped a physical examination being performed by Physician #1 during a scheduled appointment on 11/22/22 after Physician #1 groped and fondled her breasts during a liver examination.

On 11/28/22 during the process of investigating Patient #2's allegations, Police Inspector #11 was notified by the hospital Ombudsman's office that the hospital had received another complaint regarding Physician #1 via an online internet concern portal. Review of the Police Inspector's report revealed Patient #1 alleged two incidents of sexual inappropriate touching by Physician #1. Patient #1 reported she had a physician's appointment on 09/09/22 with Physician #1 at which time the physician examined her stomach, but then inserted his hands under her bra and fondled her breasts. She "thought it was weird, but it was brief, and she thought it was part of the exam." Patient #1 had a follow up visit with Physician #1 on 11/11/22. Physician #1 again reached into her shirt and under her bra and fondled both her breasts. The inspector's report documented that Physician #1 asked Patient #1 if she wanted him to stop. Patient #1 requested Physician #1 to stop twice and the physician refused. Physician #1 then requested Patient #1 to lower her pants, which Patient #1 refused to do and left the office.

Police Inspector #11 stated this made a total of three patient complaints and four allegations against Physician #1. Police Inspector #11 interviewed Physician #1 on 11/29/22. Physician #1 admitted he had touched the breasts of Patients #1, #2 and #3 and had touched other patients as well. Physician #1 could not remember how many patients or who they were. Physician #1 did not think it was more than ten, but was not sure if it was less than ten. At that point, Physician #1 was unwilling to elaborate any further. The Cleveland Municipal Police detective was notified of the status of Physician #1. The case of Patient #3 (from March 2022) was revisited and Patient #3 was interviewed again. Patient #3 then filed charges against Physician #1. Patients #1 and #2 also filed charges. All three victims were alone in the patient examination room with Physician #1 and, hence, there were no witnesses to any of the incidents. Police Inspector #11 stated that, unfortunately, the way the law is written, it is difficult to file charges of sexual imposition by just the victim report without a witness or physical evidence unless a pattern was established. A pattern was established based on the three patients' allegations and four separate incidences of inappropriate sexual touching. Physician #1 was arrested on 12/20/22.

During interview via video conference on n 12/21/22 at 2:15 PM, the hospital's Chairman for the Center for Emergency Medicine and the Department Chief Legal Officer for Staff Affairs stated on 11/28/22 they were notified of the incidents and awaited the information from Police Inspector #11 and the hospital's Ombudsman. Physician #1's conduct was prohibited. Physician #1 was removed from all patient care at all locations on 11/29/22. They met with the Physician #1 on Friday 12/02/22 at 12:00 PM at which time he was terminated. Physician #1 lost privileges to all of the hospital's system locations. Physician #1 admitted to the allegations and stated this was not like him. Physician #1 stated that this had only gone on for six months and it was three to five patients. The Chairman for the Center for Emergency Medicine and the Department Chief Legal Officer Staff Affairs could not remember any other allegations of this kind.

During interview on 12/21/22 at 2:35 PM, the Director of Regulatory Affairs reported that Physician #1 only practiced at the main campus and not at any of the hospital's affiliated facilities.

Interview with Administrative Staff #13 on 01/03/22 at 11:30 AM revealed Nurse Manager #14 contacted her on 11/28/22 at about 10:00 AM and requested her presence for an interview with Patient #2. Patient #2 alleged inappropriate sexual touching by Physician #1. The complaint was moved up to higher levels of management, as well as the hospital's Ombudsman office. The physician was scheduled to see patients all day on 11/28/22 and in the morning of 11/29/22. Physician #1 had endoscopy procedures scheduled in the afternoon on 11/29/22. Administrative Staff #13 stated Physician #1 saw patients as scheduled on 11/28/22 and 11/29/22. Staff #13 and the Institute Chair met with Physician #1 on 11/29/22 at 4:00 PM. At this time, Physician #1 was removed from further patient care duties.

During interview on 01/03/23 at 1:55 PM, Physician #12 stated a routine liver examination would be conducted in a patient's street clothes, and would focus on the abdominal area with palpitation of the abdomen for detection of enlargement of the liver or spleen and a visual exam of the skin and eyes for the presence of jaundice (yellow skin or whites of eyes). There would never be any need to examine or touch a patient's breasts or genital area or to remove any clothing. This physical examination would last approximately two minutes.

Review of Physician #1 credentialing and personnel file revealed his current State of Ohio medical license was active with an expiration date of 09/08/24. He was board certified by the American Board of Medical Specialties in gastroenterology and internal medicine and both certifications were current. The physician had an initial credentialing date of 06/12/20 with the hospital. Physician #1 signed that all the major policy and procedures for the Professional Staff were reviewed and attested to on 11/02/20. The most recent report of the National Provider Bank Data Base was completed on 06/12/22 with no result. Physician #1's current credentialing cycle was 07/01/21 through 07/01/23 with core privileges in gastroenterology and MAC sedation granted by the hospital's governing body.

During interview on 01/05/22 at 1:26 PM, the medical Chief of Staff stated in addition to her office, the Office of Professional Affairs would also be involved in allegations of abuse by a physician. The hospital would ascertain if there would be a need for safe guards to be put in place. Safeguards include chaperones or could rise to the level of removal from practice. The Chief of Staff stated Physician #1 was not removed from practice until 11/29/22 at 4:00 PM as prior to this time there were only "allegations".

Review of Physician #1's clinic schedule revealed he was scheduled to see patients on 11/28/22 from 7:30 AM until 4:00 PM and again on 11/29/22 from 8:00 AM until 11:30 AM. Review of the medical records revealed Physician #1 saw 13 patients on 11/28/22 from 10:00 AM until 11/29/22 at 4:00 PM when he was removed from patient care.

Further interview on 01/05/22 at 1:26 PM with the medical Chief of Staff revealed when the hospital was notified the allegations would likely be substantiated, Physician #1 was then removed from practice. The Chief of Staff confirmed Physician #1 was allowed to see patients from the time of the allegation on 11/28/22 until 11/29/22 at 4:00 PM.

Review of the hospital's policy and procedure titled "Adult Abuse, Neglect and Exploitation Standard Operating Procedure", effective date of 06/09/21, revealed the purpose of the standard operating procedure was to ensure the rights of adults were protected by providing an environment that was free from all forms of abuse, neglect, harassment, and exploitation from staff, other patients, and visitors and reporting suspicions of abuse or neglect to the appropriate agency. The policy contained no guidance to staff on how to protect patients when the allegation was staff to patient abuse.

During interview on 01/05/22 at 5:06 PM, Regulatory Affairs Staff #4 verified the policy did not address staff to patient abuse.

This deficiency substantiates Substantial Allegation OH00138557.