HospitalInspections.org

Based on 8 of 14 MR reviewed (1, 13, 7, 8, 9, 12, 11, 10), 2 of 5 personnel/credential files reviewed (L, O), P&P review, and 11 of 11staff interviews (F, C, K, H, J, D, I, E, L, G, M) by surveyor #13469, the GB failed to ensure that Surgeon (B) follow hospital P&P, medical staff by-laws, and standards of practice in the surgery department. This affected all Surgeon (B) surgical patients and surgical staff.

Findings include:

1. The GB failed to assume responsibility for Surgeon (B) behavior and practices in the surgery department. See Tag C-241

2. The GB failed to ensure that Surgeon (B) follow facility P&P, follow infection control practices, follow manufacturers directions while using surgical equipment and skin preps, perform surgical procedures in a safe manner, maintain professional conduct and treat OR staff, fellow surgeons, and patients with dignity and respect, and protect patients and staff from harm. See Tag C-320

3. The GB failed to ensure that staff assisting Surgeon (B) with surgery are trained, credentialed and privileged to do so. See Tag C-321

4. The GB failed to ensure that Surgeon (B) is available to supervise the CRNA and commence with surgical procedures when patients have been placed under anesthesia. See Tag C-323

The cumulative effect of the above examples related to Surgeon (B) resulted in the facility's inability to ensure patient and staff safety and provide optimal patient care for all Surgeon (B) surgical patients.

Based on documentation review, and 5 of 5 staff interviews (H, C, F, D, M) by surveyor
#13469, the GB failed to assume responsibility for Surgeon (B) behavior and practices in the surgery department. This affected all Surgeon (B) surgical patients and surgical staff.

Findings include:
Per documentation review and staff interviews, GB President (H) was informed multiple times between 12/19/11 and 2/24/12 of concerns with Surgeon (B) surgical practices and adversarial behavior in the surgery department. Surgeon (B) surgical privileges were not removed until 2/24/12.

12/19/11: Per review of a typed document completed by GB President (H) and interview, with GB President (H) on 3/13/12 at 8:00 AM, (H) met with surgical staff, OR Manager (C) and CNO (F) on 12/19/11 related to Surgeon (B). "Scheduling problems, his always being in a hurry and, and badgering staff was discussed." Per review, of typed notes completed by OR Manager (C) on 12/19/11, she was present at this meeting and informed the group that Surgeon (B) was mistreating staff, displaying inappropriate behaviors toward OR staff, and making demands that were unrealistic and influencing unsafe patient care. Per (C), no actions were taken.

2/1/12: GB President (H) was informed by COS (G) per email of ongoing problems with Surgeon (B) and of the incident with Pt. #1 who was taken to surgery on 1/27/12 for a dehiscence (see Tag C-320 for details).

2/2/12: Per OR Manager (C) typed notes, on 2/2/12, she and OR staff reported the following to GB President (H) and CNO (F): There have been "multiple incidences of aggressive behaviors by Surgeon (B), inconsistency of treatment to staff, inconsistency of standards of care, rushed, unsafe environment for patients and staff. Examples include: ripping Patient #1 two week old abdominal wound open with his hands while in an angry demeanor. That he required staff to wear gloves when holding non sterile spray bottle of betadine, yet touching/handling female genitalia without gloves himself. That he yells at staff, threatening staff, creating hostile work environment and displaying significant mood swings. That he lets patients wait in OR or Procedure room due to being in a bad mood and then blaming this delay on staff or staff inefficiency which has happened multiple times. Unnecessary rushing causing unsafe patient environment, and doesn't allow time to do proper surgical sponge counts without grabbing and using the sponges before the count is complete. Grabs and wheels patients into procedure room without allowing nursing staff to perform proper assessments, nurse literally running along next to cart trying to listen to heart and lungs, not allowing time for IV insertion or proper check in. Not following P&P for proper site marking after being told on 2 occasions, one year ago and 6 months ago. Forcing staff to cut off the protective safety devices from needles. Using dangerous techniques in surgery that has caused harm and blood borne exposure to staff, then laughs and jokes about it. Staff report being "fearful, scared and nervous" with Surgeon (B) and others have reported nightmares, feeling nauseous when it's time to go to work and feeling like they need to lock their doors at night to protect themselves from Surgeon (B). Unsafe scheduling practices by blocking 15-20 hours worth of surgery on some days and nothing on other days. Per (H), he emailed COS (G) on 2/1/12 with OR staff concerns after meeting with surgery staff on this date.

2/2/12: The following was reported to GB President (H): Surgeon (B) did not do a proper surgical scrub, use sterile gloves, nor allow nursing staff the opportunity to do a skin prep and apply a sterile drape before opening a large surgically closed abdominal wound allowing for potential cross-contamination and the introduction of microorganisms into Pt. #1 abdomen.

2/2/12 The following was reported to GB President (H): The alcohol based skin prep Chloroprep was not used per manufacturers directions resulting in potential harm to patients and a possible surgical fire.

The above reports to GB President (H) were confirmed in interview and review of documentation with PCS Manager (D), OR Manager (C), and CNO (F) during the survey on 3/12/12 and 3/13/12.

On 2/9/12, (H) met with COS (G), Surgeon (P), CNO (F), HR Director (R), and CFO (N) to discuss Surgeon (B) on-going struggling relationship with the OR supervisor and surgical staff. Per (H), Surgeon (B) wanted OR Manager (C) removed from the surgery department and wanted her office as a dictation room. Per (H), they met Surgeon (B) demands and removed (C) from the OR department and gave Surgeon (B) (C) office for dictation. Per interview, with CNO (F) on 3/13/12 at 8:50 AM, this was the day that Surgeon (B) refused to do his scheduled surgeries for the day until his demands were met. Per CNO (F) when she was told that OR Manager (C) was being removed from the OR she informed GB President (H) that (C) had an impeccable history (23 years) and has a critical position in the OR and that legal needs to get involved as (B) is holding the OR team hostage by saying he won't do surgery until OR Manager is removed from her position.

On 2/16/12 an emergency medical staff meeting was called. Both (F) and (C) were placed on administrative leave on 2/17/12. Per interview, with OR Manager (C) on 3/13/12 at 11:00 AM, the GB, medical staff and administration placed Surgeon (B) in charge of the OR department on 2/17/12. Per (C) staff felt that they now had no where to turn as the two people who were trying to protect patients and staff were now gone and that the person who they had concerns with is now in charge of the OR.

On 2/21/12 the hospitals legal team and a outside third party attorney began an investigation into allegations made against Surgeon (B) by the OR staff and CNO (F). Per (H), a 25 page report was completed and it "revealed patient safety and harassment concerns related to Surgeon (B)." Per (H), he detailed the results to Surgeon (B). Per email on 4/26/12 at 2:44 PM, PCS Manager (D) revealed that the 25 page report was completed on 2/24/12 and the GB reviewed it on 2/29/12.

2/23/12: Per interview, with PCS Manager (D) on 3/12/12 at 1:40 PM, it was revealed that on 2/23/12 RN (I) called him and said she could not take anymore with Surgeon (B) who was in surgery at the time. Per (D) he paged COS (G) and HR Director (R) and GB President (H) who happened to be in the HR department at the time and they all went immediately to the OR. Surgeon (B) was told to finish his current case (strangulated hernia and one more case that day with PCS Manager (D) present in the OR during the cases to observe Surgeon (B).

2/23/12: Per (H), he met with COS (G) and Surgeon (B) on 2/23/12 to discuss the tension in the OR between OR staff and (B) and suggested to (B) that "we have a 10-day to 2-week cooling off time to see if we could work things out.

On 2/24/12 GB President (H) received a call from OR RN (I) informing him that things were not getting better and discussed concerns of things going in the OR. He went to the hospital and was given an update by surgical staff as to what was going on. He then met with COS (G) and the decision was made to remove Surgeon (B) surgical privileges in the OR and ED pending medical staff investigation of Surgeon (B) per medical staff by-laws. Surgeon (B) was allowed to see patients in the hospital-owned clinic and perform procedures there, and could continue to see patients in the hospital. Surgeon (B) was informed on 2/23/12.

4/20/12: Per phone conference with hospital Administrator (M) at 2:50 PM, the hospital Board of Directors, after medical staff recommendations, reinstated Surgeon (B) surgical privileges in the OR and ED effective 4/19/12.

Based on 8 of 14 MR reviewed (1, 13, 7, 8, 9, 12, 11, 10), 2 of 5 personnel/credential files reviewed (L, O), P&P review, review of medical staff by-laws, and 11 of 11 staff interviews (F, C, K, H, J, D, I, E, L, G, M) by surveyor #13469, the medical director failed to ensure that Surgeon (B) follow hospital P&P, medical staff by-laws, and standards of practice in the surgery department. This affected all Surgeon (B) surgical patients and surgical staff.

Findings include:
1. The medical director failed to assume responsibility for Surgeon (B) behavior and practices in the surgery department. See Tag C-256

2. The medical director failed to ensure that Surgeon (B) follow facility P&P, follow infection control practices, follow manufacturers directions while using surgical equipment and skin preps, perform surgical procedures in a safe manner, maintain professional conduct and treat OR staff, fellow surgeons, and patients with dignity and respect, and protect patients and staff from harm. See Tag C-320

3. The medical director failed to ensure that staff assisting Surgeon (B) with surgery are trained, credentialed and privileged to do so. See Tag C-321

4. The medical director failed to ensure that Surgeon (B) is available to supervise the CRNA and commence with surgical procedures when patients have been placed under anesthesia. See Tag C-323

The cumulative effect of the above examples related to Surgeon (B) resulted in the facility's inability to ensure patient and staff safety and provide optimal patient care for all surgical patients.

Based on documentation review, review of medical staff by-laws, and 5 of 5 staff interviews (H, C, F, D, M) by surveyor #13469, the medical director failed to assume responsibility for Surgeon (B) behavior and practices in the surgery department. This affected all of Surgeon (B) surgical patients and all surgical staff.

Findings include:
Medical Staff by-laws (dated 3/10/09) review on 4/13/12 in the afternoon, revealed that under Article II. Purpose and responsibilities the medical staff are directed to the following: "1. To provide that all patients admitted to or treated in any of the facilities, departments, or services of the facility receive a high level of medical care. 2. To seek a high level of professional performance from all practitioners and affiliates authorized to practice in the Hospital through the appropriate delineation of the clinical privileges that each may exercise in the Hospital, and Nursing Home, and through an ongoing review and evaluation of their performance in the facility. Article III- Medical staff Membership B. Qualifications for Membership: 1. Medical Staff who can demonstrate continued competence, adherence to the ethics of their profession, good reputation, health, and ability to work with other physicians and members of the supporting staff with sufficient adequacy to assure the Medical Staff and the Governing Board that any patient treated by them in the facility will be given a high quality of care." "B. Functions of Chiefs of Service 1. Each service Chief shall: a. be accountable for all professional and administrative activities within his service. c. maintain continuing review of the professional performance of all practitioners."

Per documentation review and staff interviews, COS (chief of staff) (G) was informed multiple times between 12/7/11 and 2/24/12 of concerns with Surgeon (B) surgical practices and adversarial behavior in the surgery department. Surgeon (B) surgical privileges were not removed until 2/24/12.

Per interview, with COS (G) on 3/12/12 at 4:05 PM, it was revealed that he was made aware in late December of 2011 by CNO (F) and GB President (H) that there were problems with Surgeon (B). Per (G), he thought the problems were related to staff issues. He was told people were not getting along. COS (G) repeatedly told this surveyor that it was not his problem and he does not get involved with HR (human resource) issues. Per (G), they don't report to me unless there are medical care issues with physicians. When asked if the medical staff by-laws address behavioral issues with physicians and whether he was responsible to ensuring that medical staff by-laws were followed, (G) responded by saying yes.

Per staff interviews and reports provided to surveyor during the survey reflect the following:

12/7/11 report to COS (G): Surgeon (B) does not allow enough time between cases to ensure that nursing staff have completed their nursing assessment of each patient before they are taken to the OR, and to ensure that nursing staff have enough time to review MR requirements are met before surgery starts.

12/7/11 report to COS (G): Surgeon (B) does not allow enough time to ensure that nursing staff have enough time for appropriate cleaning of OR suites between cases to prevent cross-contamination.

2/1/12: GB President (H) was informed by COS (G) per email of ongoing problems with Surgeon (B) and of an incident with Pt. #1 who was taken to surgery on 1/27/12 for a dehiscence (see Tag C-320 for details).

2/2/12 - The following was reported to COS (G): Surgeon (B) did not do a proper surgical scrub, use sterile gloves, nor allow nursing staff the opportunity to do a skin prep and apply a sterile drape before opening a large surgically closed abdominal wound, allowing for potential cross-contamination and the introduction of microorganisms, into Pt. #1 abdomen.

2/2/12 - The following was reported to COS (G): Alcohol based skin prep Chloroprep was not used per manufacturers directions resulting in potential harm to a patient.

2/2/12 - The following was reported to COS (G): Surgeon (B) opened a large surgically closed abdominal wound using his hands on Pt. #1.

2/8/12 - COS (G) was notified of the following: Surgeon (B) is advising surgical staff to cut off needle guards allowing for possible exposure to blood borne pathogens.

2/8/12 - The following was reported to COS (G): Cautery use in surgery by Surgeon (B) did not follow manufacturers direction which may have caused the burn to a surgical technician.

The above reports to COS (G) were confirmed in interview and review of documentation with PCS Manager (D), OR Manager (C), and CNO (F) during the survey on 3/12/12 and 3/13/12.

On 2/9/12, per interview with GB President (H) on 3/13/12 at 8:00 AM, he met with COS (G), Surgeon (B), CNO (F), HR Director (R), and CFO (N) to discuss Surgeon (B) on-going struggling relationship with the OR supervisor and surgical staff. Per (H), Surgeon (B) wanted OR Manager (C) removed from the surgery department and wanted her office as a dictation room. Per (H), they met Surgeon (B) demands and removed (C) from the OR department and gave Surgeon (B) (C) office for dictation. Per interview, with CNO (F) on 3/13/12 at 8:50 AM, this was the day that Surgeon (B) refused to do his scheduled surgeries for the day until his demands were met. Per CNO (F) when she was told that OR Manager (C) was being removed from the OR she informed GB President (H) that (C) had an impeccable history (23 years) and has a critical position in the OR and that legal needs to get involved as (B) is holding the OR team hostage by saying he won't do surgery until OR Manager is removed from her position.

On 2/16/12 an emergency medical staff meeting was called. Both (F) and (C) were placed on administrative leave on 2/17/12. Per interview, with OR Manager (C) on 3/13/12 at 11:00 AM, the GB, medical staff and administration placed Surgeon (B) in charge of the OR department on 2/17/12. Per (C), staff felt that they now had no where to turn, as the two people who were trying to protect patients and staff, were now gone and that the person who they had concerns with, is now in charge of the OR.

On 2/21/12 the hospital's legal team, with an outside third party attorney, began an investigation into allegations made against Surgeon (B) by the OR staff and CNO (F). Per (H), a 25 page report was completed and it "revealed patient safety and harassment concerns related to Surgeon (B)." Per (H), he detailed the results to Surgeon (B). Per email on 4/26/12 at 2:44 PM, PCS Manager (D) revealed that the 25 page report was completed on 2/24/12 and the GB reviewed it on 2/29/12.

2/23/12: Per interview, with PCS Manager (D) on 3/12/12 at 1:40 PM, it was revealed that on 2/23/12 RN (I) called him and said she could not take anymore with Surgeon (B) who was in surgery at the time. Per (D) he paged COS (G) and HR Director (R) and GB President (H) who happened to be in the HR department at the time and they all went immediately to the OR. Surgeon (B) was told to finish his current case (strangulated hernia and one more case that day with PCS Manager (D) present in the OR during the cases to observe Surgeon (B).

2/23/12: Per (H), he met with COS (G) and Surgeon (B) on 2/23/12 to discuss the tension in the OR between OR staff and (B) and suggested to (B) that "we have a 10-day to 2-week cooling off time to see if we could work things out. COS (G) reviewed his notes and confirmed the above.

On 2/24/12 GB President (H) received a call from OR RN (I) informing him that things were not getting better and discussed concerns of things going on in the OR. He went to the hospital and was given an update by surgical staff. He then met with COS (G) and the decision was made to remove Surgeon (B) surgical privileges in the OR and ED pending medical staff investigation of Surgeon (B) per medical staff by-laws. Surgeon (B) was allowed to see patients in the hospital-owned clinic and perform procedures there and continue to see patients in the hospital. Surgeon (B) was informed on 2/23/12.

The above was confirmed in interview with COS (G) on 3/12/12 at 4:05 pm.

Based on documentation review, 3 of 14 MR reviewed (1, 13, 7), 1 of 4 personnel files reviewed (O), and 8 of 8 staff interviews (F, C, K, H, J, D, I, E) by surveyor #13469, the hospital failed to ensure that Surgeon (B) follow facility P&P, follow infection control practices, follow manufacturers directions while using surgical equipment and skin preps, perform surgical procedures in a safe manner, maintain professional conduct and treat OR staff, fellow surgeons, and patients with dignity and respect, protect patients and staff from harm, utilize staff assisting Surgeon (B) who are trained, credentialed and privileged to do so, and be physically located in the OR and immediately available to CRNA when patients have been placed under anesthesia. This affects all Surgeon (B) surgical patients and surgical staff.

Findings include:
1. Facility P&P are not followed by Surgeon (B). Examples include: adding an elective surgery pt to an already full surgery schedule against the advice of the OR Manager resulting in a 16 hr day for the same staff. Failure to mark surgical sites that are clear and follow hospital policy. Failure to allow nursing staff adequate time to do patient nursing assessments and chart reviews before surgery.

P&P #01 Scheduling Surgery, reviewed on 4/17/12, directs the following: "A) Priority: Surgical operations that have to be done immediately due to medical emergency, shall have priority over all elective procedures. B) Elective cases shall be scheduled on a first come first serve basis. C) All surgery shall be scheduled through the OR department staff by the physician."

Surgeon (B) overrode facility policy for scheduling surgery and added an elective surgery to an already full 15 hour day against OR Manager (C) directive. Per interview, with CNO (F) on 3/13/12 at 8:50 AM, it was revealed that on 12/19/11 Surgeon (B) asked to add on an elective gallbladder surgery to an already full 15 hour surgery schedule for 12/20/11. Per (F), OR Manager (C) informed Surgeon (B) that the schedule was full and the elective gallbladder surgery could be scheduled for the next day, on the 21st. Per CNO (F), Surgeon (B) added the elective surgery on anyway, forcing a 16 hour surgery day for all surgery staff on 12/20/11. The above example was confirmed in interview with OR Manager (C) on 3/13/12 at 11:00 AM.

P&P (dated 12/21/09) entitled, "Prevention of Wrong Site Surgery," was reviewed on 4/17/12, and directs the following: "For side specific surgery, a mark will be placed on the operative side by the surgeon. The mark will consist of the initials of the surgeon. This mark will be clearly identified and verified by the surgical team during the time out team verification process. This mark will remain clearly visible by the surgeon after the patient has been properly prepped and draped for surgery."

Per interview, with OR Manager (C) on 3/13/12 at 11:00 AM, Surgeon (B) does not follow this hospital policy for surgical site marking. He places a very small dot on the skin that can barely be seen instead of using his initials that can be clearly visible.

Surgeon (B) does not allow enough time between cases to ensure that nursing staff have completed their nursing assessment of each patient before they are taken to the OR, and to ensure that nursing staff have enough time to review MR requirements are met before surgery starts. Per interview, with ST (K) on 3/13/12 at 1:00 PM, Surgeon (B) "is always in such a rush and does not allow enough turnaround time for the nurses to do assessments on the next patient. This happens with almost every case; shortcuts are being taken." Per interview, with CNO (F) on 3/13/12 at 8:50 AM, the OR Manager has build-in time between cases for an appropriate turnaround time for nursing staff. Per (F), Surgeon (B) does not like that and is always rushing staff between cases. Per (F), COS (G) and Administrator (P) were informed on 12/7/11 that Surgeon (B) was rushing staff between cases and compromising patient safety. Per interview, with Hospital GB President (H) on 3/13/12 at 8:00 AM, it was revealed that he was informed by surgery staff on 12/19/11 that Surgeon (B) is "always in a hurry and badgering staff."

2. Infection control practices by Surgeon (B) are not followed. Examples include: cutting off needle guards, patients not prepped appropriately for dehiscence surgery, rushing staff between cases and not allowing for proper cleaning and prepping of rooms between cases, and touching female genitalia without washing hands or dawning gloves.

Surgeon (B) is advising surgical staff to cut off needle guards allowing for possible exposure to blood borne pathogens. Per interview, with CRNA (J) on 3/13/12 at 12:15 PM, (J) said he has witnessed Surgeon (B) remove needle guards himself when staff would not do it. Per interview, with ST (K) on 3/13/12 at 1:00 PM, Surgeon (B) asked her to cut off needle guards that protect staff from needle sticks when she first started to work in the OR in November of 2011. After informing OR Manager (C) she was told she cannot do that as it is against CDC and OSHA guidelines. When asked again by Surgeon (B) to remove needle guards she informed him she could not and why. Per ST (K), Surgeon (B) then removed them himself. Per interview, with PCS Manager (D) on 3/12/12 at 1:40 PM, he said OR Manager (C) informed him that Surgeon (B) was cutting off needle guards and that (C) informed COS (G) but that (G) said he was going on vacation and would deal with it later, so OR Manager (C) went to Surgeon (B) directly and he told her to "get out of his office." Per interview, with RN (I) on 3/12/12 at 3:05 PM, she has seen Surgeon (B) or his MA surgical assistant cut them off routinely. Per typed notes of OR Manager (C) dated 2/8/12 "COS (G) was notified that Surgeon (B) was forcing staff to cut off the protective safety devices from needles in the OR which is unsafe and also an OSHA violation."

Surgeon (B) does not allow enough time to ensure that nursing staff have enough time for appropriate cleaning of OR suites between cases to prevent cross-contamination. Per interview, with ST (K) on 3/13/12 at 1:00 PM, Surgeon (B) "is always in such a rush and does not allow enough turnaround time for the nurses to clean rooms appropriately between cases. This happens with almost every case. Shortcuts are being taken." Per interview, with CNO (F) on 3/13/12 at 8:50 AM, the OR Manager has build in time between cases for an appropriate turnaround time for nursing staff and teardown and setup for next case. Per (F), Surgeon (B) does not like that and is always rushing staff between cases. Per (F), COS (G) and Administrator (P) were informed on 12/7/11 that Surgeon (B) was rushing staff between cases and compromising patient safety. Per interview, with Hospital GB President (H) on 3/13/12 at 8:00 AM, it was revealed that he was informed by surgery staff on 12/19/11 that Surgeon (B) is "always in a hurry and badgering staff."

Surgeon (B) did not do a proper surgical scrub, use sterile gloves, nor allow nursing staff the opportunity to do a skin prep and apply a sterile drape before opening a large surgically closed abdominal wound allowing for potential cross-contamination and the introduction of microorganisms into Pt. #1 abdomen. Review of Pt. 1 MR on 4/17/12 at 4:35 PM, it was noted that Pt. #1 underwent a large ventral hernia repair with multiple adhesions on 1/13/12 by Surgeon (O). Pt. #1 was readmitted on 1/27/12 for repair of fascia dehiscence by Surgeon (B). Per interview, with RN (E) on 3/12/12 at 12:05 PM, RN (E) said she was present in the OR suite on 1/27/12 when Surgeon (B) entered the OR suite, and without the benefit of a surgical scrub, using non-sterile gloves, and without the benefit of a patient surgical prep and sterile draping, Surgeon (B) began removing Pt. #1 abdominal staples, placed a hand on each side of her abdominal incision and spread apart the large incision with his hands instead of using a scalpel. Per RN (E), he then grabbed the alcohol based skin prep chloroprep and began to prep the skin, entering the abdominal wound and repeating this in and out of the wound several times. RN (E) said staff tried to stop him from using the Chloroprep in the wound. Per interview, with CRNA (J) on 3/13/12 at 12:15 PM, (J) remembers Surgeon (B) pulling Pt. #1 abdominal wound apart with his hands. Per interview, with RN (I), she was present in the OR suite on 1/27/12. RN (I) repeated the above observations exactly as described by RN (E) in a separate interview. Per RN (I), Surgeon (B) had smeared tissue and blood all over Pt. #1 abdomen. He then started to leave the room to go do a surgical scrub and told nursing staff to prep the patient. Per interview, with ST (K) on 3/13/12 at 1:00 PM,(K) described Surgeon (B) taking out Pt. #1 staples and spreading open her abdominal wound using non-sterile gloves and before nursing staff had completed a surgical scrub of the abdomen and applied sterile draping. Per ST (K), Surgeon (B) then scrubbed inside and outside Pt. #1 abdominal wound repeatedly using Chloroprep. The above examples were confirmed in interview with PCS Manager (D) on 3/13/12 in the afternoon. Per RN (I), she reported the above observations to OR Manager (C) who reported the observations to CNO (F), who then reported to COS (G). Per interview, with GB President (H) on 3/13/12 at 8:00 AM, he was informed on 2/2/12 of what Surgeon (B) did to patient #1 on 1/27/12 during the repair of a dehiscence. Per (H), he shared this information with other board members.

Surgeon (B) did not wash hands or dawn gloves when touching female genitals. Per interview, with RN(E) on 3/12/12 at 12:05 PM, OR staff attempted to remove a clitoris ring from a patient prior to a scheduled hysterectomy. When unsuccessful, Surgeon (B) came into the OR suite and without washing his hands or dawning gloves attempted to remove the clitoris ring. Per ST (K), OR staff attempted to remove a clitoris ring from a patient who was supposed to remove it before surgery. The patient was already under anesthesia. When they could not get it out she observed Surgeon (B) came into the OR suite and without washing his hands or dawning gloves attempted to remove the patients clitoris ring. Per RN (I), in interview on 3/12/12 at 3:05 PM, Surgeon (B) attempted to remove a clitoral ring from a patient when staff were unable to without the benefit of washing his hands or dawning gloves.

3. Manufacturers directions using surgical equipment and surgical skin preparations to prevent injuries and fires in the OR, are not followed by Surgeon (B). Examples include: An external use-only alcohol based skin preparation was used inside an abdominal wound, and does not follow manufacturers recommendations for the use of cautery equipment which resulted in a surgical team member being burned.

Alcohol based skin prep Chloroprep was not used per manufacturers directions resulting in potential harm to a patient and a possible surgical fire. Review of Pt. 1 MR on 4/17/12 at 4:35 PM, it was noted that Pt. #1 underwent a large ventral hernia repair with multiple adhesions on 1/13/12 by Surgeon (O). She was readmitted on 1/27/12 for repair of fascia dehiscence by Surgeon (B). Per interview, with RN (E) on 3/12/12 at 12:05 PM, RN (E) said she was present in the OR suite on 1/27/12 when Surgeon (B) entered the OR suite. Per (E), Surgeon (B) began removing Pt. #1 abdominal staples, placed a hand on each side of her abdominal incision and spread apart the large incision with his hands instead of using a scalpel. Per RN (E), he then grabbed the alcohol based skin prep chloroprep and began to prep the skin, entering the abdominal wound and outside to the abdominal skin and then repeating this in and out of the wound several times. RN (E) said staff tried to stop him from using the Chloroprep in the wound as it is not for internal use and Surgeon (B) said "the patient can't feel it anyway she is out." Per RN (E), Surgeon (B) was angry, aggressive and red faced while opening Pt. #1 abdominal incision. Surgeon (B) then told staff to prep and drape the patient and he left the room to do a surgical scrub. Per interview, with CRNA (J) on 3/13/12 at 12:15 PM, (J) remembers Surgeon (B) pulling Pt. #1 abdominal wound apart with his hands. Per interview, with RN (I), she was present in the OR suite on 1/27/12. RN (I) repeated the above observations exactly as described by RN (E) in a separate interview.

Per interview with ST (K) on 3/13/12 at 1:00 PM, described Surgeon (B) using Chloroprep inside Pt. #1 open abdominal wound on 1/27/12. She said she tried to stop him and he said "she cannot feel it as she is asleep." Per ST (K), Chloroprep is not to be used internally per manufacturers directions. The above examples were confirmed in interview with PCS Manager (D) on 3/13/12 in the afternoon.

Review of Chloroprep insert and manufacturers directions the "warnings" say "For external use only; flammable, keep away from fire or flame to reduce the risk of fires." As this product was used inside Pt. #1 deep abdominal wound, and then the pt. was draped, created a potential for a flash fire when the cautery machine was used by Surgeon (B) during the wound repair. Per RN (I), she reported the above observations to OR Manager (C) who reported the observations to CNO (F), who then reported to COS (G). Per interview with GB President (H) on 3/13/12 at 8:00 AM, he was informed on 2/2/12 of what Surgeon (B) did to patient #1 on 1/27/12 during the repair of a dehiscence. Per (H), he shared this information with other board members.

Cautery use in surgery by Surgeon (B) did not follow manufacturers direction which caused a burn to a surgical technician. Per MR review, on 4/17/12 at 2:15 PM, Pt. #7 had an incisional ventral hernia repair by Surgeon (B) on 1/31/12. Per interview, with OR Manager (C) on 3/13/12 at 11:00 AM, she was present in the OR when Surgeon (B) used a technique called "buzzing the hemostat" to cauterize tissue in the wound. This is only done by Surgeon (B) and not recommended per manufacturers directions. It involves a person holding a hemostat to the area to be cauterized and then placing the cautery to the hemostat which heats up and thus cauterizes the tissue. Per (C), Surgeon (B) instructed her to turn the cautery machine to 60/60 cut/coagulation. Sparks started flying and ST (L) jumped and said "ouch, you just burned me." RN (C) removed ST surgical glove and noted a small black burn on her hand. At that time Surgeon (B) joked and laughed about how he burned her and then he asked for the cautery to be turned up to 80. Per interview, with RN (E), Surgeon (B) uses the "buzzing the hemostat" instead of the cautery tip directly to the tissue to be cauterized. The buzzing method has a much greater potential for burns to staff. Per RN (E), the cautery is usually set at 25/25. She has seen Surgeon (B) have nursing staff set it as high as 100. Per review, of typed documentation dated 2/6/12 by CNO (F) on 4/17/12 in the AM, on 2/6/12 Surgery Manager (C) reported that Surgeon (B) burned a ST using a technique not recommended by the manufacturer. (C) was advised to bring this to the attention of the COS (G). Per review, on 3/17/12 in the AM, typed notes by OR Manager (C) revealed that COS MD (G) was notified by (C) on 2/8/12 at 4:00 PM that Surgeon (B) was using the "buzzing the hemostat" method for cauterizing that do not follow manufacturers directions.

OR Manager (C) then sends out an email to surgery staff about manufacturers directions for the recommended use of the cautery. Per documentation review of emails dated 2/6/12 by Surgery Manager (C), the Valley Lab manufacturer of the cautery used by Surgeon (B) stated that "applying monopolar electricity to a metal object is not a recommended practice; the gloves a person is wearing have no protection or grounding effects against the current flowing through the metal object and this practice may continue to cause injuries and potential blood borne exposures." Review of an article in the Journal of American College of Surgery, Megadyhne Newsletter for electrosurgical news Volume 1111, Clinical Hotline news from Valley Lab dated 12/1997 and 1999 on 4/17/12, supported the risk for burns and surgical fires using this method with high power and high voltage waveform which was used during this incident. Per OR Manager (C), COS (G) was given a copy of all ValleyLab and other articles mentioned on 2/8/12.

4. Surgical procedures are not planned/performed in a safe manner by Surgeon (B). Examples include:
Sponge counts are interrupted, female patients are not checked for pregnancy before abdominal surgery, and a large surgically closed abdominal wound was spread open with hands instead of a surgical scalpel.

Surgeon (B) opened a large surgically closed abdominal wound using his hands. Review of Pt. 1 MR on 4/17/12 at 4:35 PM, it was noted that Pt. #1 underwent a large ventral hernia repair with multiple adhesions on 1/13/12 by Surgeon (O). Pt. #1 was readmitted on 1/27/12 for repair of fascia dehiscence by Surgeon (B). Per interview, with RN (E) on 3/12/12 at 12:05 PM, RN (E) said RN (E) she was present in the OR suite on 1/27/12, and she observed a pencil size opening at the bottom of the abdominal incision that was open about an inch and an inch deep. There was a small amount of sero-sanginous drainage. The rest of the suture line looked intact. Per RN (E), Surgeon (B) entered the OR suite, and without the benefit of a surgical scrub, using non-sterile gloves, and without the benefit of a patient surgical prep and sterile draping, Surgeon (B) began removing Pt. #1 abdominal staples. Per (E) the tissue looked healthy and pink, Per RN (E), Surgeon (B) then placed a hand on each side of her abdominal incision and "ripped open" the large incision with his hands instead of using a scalpel. Per RN (E), she had to turn her head away as it was "disgusting and the sound of ripping flesh made her sick." Per interview, with CRNA (J) on 3/13/12 at 12:15 PM, (J) remembers Surgeon (B) pulling Pt. #1 abdominal wound apart with his hands. Per interview, with RN (I), she was present in the OR suite on 1/27/12. RN (I) repeated the above observations exactly as described by RN (E) in a separate interview. Per RN (I), she could not believe what she saw when Surgeon (B) used his hands to open Pt. #1 abdominal wound. Per interview, with ST (K) on 3/13/12 at 1:00 PM, described Surgeon (B) taking out Pt. #1 staples and spreading open her abdominal wound using non-sterile gloves and before nursing staff had completed a surgical scrub of the abdomen and applied sterile draping. Per ST (K), she could not believe Surgeon (B) tore Pt. #1 flesh with his hands. The above examples were confirmed in interview with PCS Manager (D) on 3/13/12 in the afternoon. Per RN (I), she reported the above observations to OR Manager (C) who reported the observations to CNO (F), who then reported to COS (G). Per interview, with GB President (H) on 3/13/12 at 8:00 AM, he was informed on 2/2/12 of what Surgeon (B) did to patient #1 on 1/27/12 during the repair of a dehiscence. Per (H), he shared this information with other board members.

Surgeon (B) interrupts sponge counts allowing for the potential of leaving a sponge in the patient at the end of surgery. Per interview, with CNO (F) on 3/13/12 at 8:50 AM, she was informed by ST (Q) on 2/2/12 (President of the GB (H) was present) that " Surgeon (B) interrupts sponge counts by taking them to use before she is done counting. As a result she does not know how many sponges they started with. When she tries to stop him he "takes the sponges anyway." Per interview, with ST (K) on 3/13/12 at 1:00 PM, it was revealed that Surgeon (B) "interrupts sponge counts almost every surgery." No other surgeon does that. Per (K), she is afraid to stop him because he will do it anyway."

Surgeon (B) refused to give an order to do pregnancy testing prior to abdominal surgery. Per interview, with RN (I) on 3/12/12 at 3:05 PM, and MR review on 4/17/12 at 3:45 PM, Pt. #13 was scheduled for a cholecystectomy to be performed by Surgeon (B). (B) saw Pt. #13 on 2/10/12 and cleared her for surgery. Per RN (I), on the day of surgery (2/22/12) she noted that Pt. #13 had not received a PG (pregnancy) test per hospital standing protocol. When she went to Surgeon (B) and informed him she needed an order to do a PG test he responded saying "I'm not giving you one." RN (I) knew the test needed to be done so she had a test done per protocol and Pt. #13 was indeed pregnant. As a result, surgery was canceled on 2/22/12 to protect the mother and unborn child.

5. Surgeon (B) fails to maintain professional conduct and treat OR staff, other surgeons, and patients with dignity and respect. Examples include: touching genitals without wearing gloves, handling patients roughly with potential for harm, disrespectful and intimidating behavior toward OR staff, maligns other surgeons, throws instruments/supplies in the OR, gives money to OR staff, holds OR and scheduled patients "hostage" until demands are met, falisified MR documentation on Pt. #7 operative report regarding lab results.

Per interview, with CNO (F) on 3/13/12, it was revealed that Surgeon (B) consistently tells surgery staff they are incompetent, and don't know what they are doing. Per (F), after Surgeon (O) was hired in December of 2011, Surgeon (B) was often heard saying that Surgeon (O) was incompetent and complaining about (O) to hospital staff. Per (F), there have been no reports of problems with Surgeon (O) since she began working at the hospital. Review of Surgeon (O) personnel file on 3/13/12 did not reveal any problems with Surgeon (O). Per CNO (F), on 2/9/12 Surgeon (B) decided to not continue with the surgery schedule for the day and held the surgery staff and scheduled patients "hostage" until his demands were met. Demands were that OR Manager (C) be removed from the OR and that her office be given to him for a dictation room. His demands were met with the support of the COS (G) and Administrator. Per OR Manager (C), Surgeon (B) refused to do surgery for an emergency incarcerated bowel on this day (2/9/12) until his demands were met. Per (F), on 2/2/12 she and GB President (H) met with surgery staff to discuss problems in the OR with Surgeon (B) and how he harasses them. Per (F), all but one of the staff present were crying during the meeting. Per (F), GB President (H) said he would speak with Surgeon (B). Per review of GB President (H) notes, he did not meet with Surgeon (B) until 2/9/12.

Per interview with RN (E) on 3/12/12 at 12:05 PM, it was revealed that Surgeon (B) has had conflicts with OR Manager (C). He also "is mean to ST (I) and degrades her and yells at her. Staff are confused and afraid of him. Per (E), she has heard Surgeon (B) put down Surgeon (O). Says he has to fix Surgeon (O) problems. Per (E), she observed Surgeon (B) grab a Foley catheter away from ST (I) on 1/13/12 during the prep for Pt. #1 surgery, and threw it across the room in anger because he felt she broke sterile field while placing a Foley catheter and then yelled at her. He asked her "aren't you an RN, weren't you taught this in school" in front of other surgery staff. Per RN (E), she and ST (I) do not feel physically safe around Surgeon (B). Per (E), OR staff attempted to remove a clitoris ring from a patient. When unsuccessful, Surgeon (B) came into the OR suite and without washing his hands or dawning gloves attempted to remove the patients clitoris ring. In addition, per (E), when Surgeon (B) marks female breasts before surgery, he does not wear gloves. Per (E), Surgeon (B) threatened to cancel surgeries on 2/9/12 until OR Manager (C) and CNO (F) were removed from their positions. Per interviews with (E), (C) and (F), all indicated they were trying to protect staff and patients from Surgeon (B). Per RN (E), she has witnessed Surgeon (B) repeatedly handle patients roughly after they are under the influence of anesthesia. He turns patients roughly and throws their arms and legs around.

Per interview with OR Manager (C) on 3/13/12 at 11:00 AM, on 2/9/12, Surgeon (B) refused to perform an emergency surgery for an incarcerated bowel until his (personnel) demands were met.

Per interview, with ST (K) on 3/13/12 at 1:00 PM, Surgeon (B) gets really angry with staff. He has directed a lot of his anger toward ST (I). During one procedure, while placing ear tubes, Surgeon (B) threw (metal-like hemostats) instruments toward ST (K). Per (K), this has happened a couple of times when Surgeon (B) is angry or frustrated. Per (K), she could have been hit and injured. Per ST (K), OR staff attempted to remove a clitoris ring from a patient before surgery. When they could not get it out she observed Surgeon (B) came into the OR suite and without washing his hands or dawning gloves attempted to remove the clitoris ring. Per (K), an older lady who was in a lithotomy position, had her legs jerked roughly by Surgeon (B). When the RN told him to be careful he responded by saying "she can't feel it" because she is under anesthesia. Per (K), she has heard Surgeon (B) tell staff to call him if surgery is needed when Surgeon (O) is the one on-call for the hospital surgery department. Per ST (K), Surgeon (B) has given $100 bills to bribe staff and this has been going on for awhile.

Per interview, with RN (I) on 3/12/12 at 3:05 PM, she has observed Surgeon (B) be very rough with patients. He pulls them quickly and limbs flop around. Per (I), sometimes when he turns patients, he does not alert the anesthesia staff so they can monitor patient airways, and as a result, airways are being pulled on. Per (I), he began yelling at her from the day she started in the OR. She was in her first weeks of orientation and he told her she was incompetent. He gets into her personal space and with an angry red face and voice raised Surgeon (B) puts her down in front of other staff. Per RN (I), an unsuccessful attempt to place a Foley catheter into a patient resulted in Surgeon (B) getting mad because she could not get it in and he "yanked the patient's legs really hard ((RN (I) is crying and shaking during this interview) and she told Surgeon (B) you are hurting her, and he yelled back at her "I'm not hurting her, she is under anesthesia."

Per interview, with CRNA (J) on 3/13/12 at 12:15 PM, he has heard Surgeon (B) tell surgery staff "you don't know what you are doing" implying they were incompetent. Per (J) he is angry and red-faced. Per (J), he has had Surgeon (B) say to him that Surgeon (O) is incompetent and that he is always having to fix Surgeon (O) mistakes.

Per MR review on 4/17/12 at 2:15 PM, Pt. #7 had a large ventral incisional hernia repair done on 1/31/12. Per review of Pt. #7 typed operative report dictated 2/2/12, the report has a hand written addendum dated 2/23/12 by Surgeon (B). Per hand written addendum the "intestine was removed and sent to pathology." Per review of the operating room nursing record dated 1/31/12 under Specimen: the nurse documents the following: "Specimen: not sent in per Surgeon (B) request." Under additional nursing notes the nurse documents "Surgeon (B) does not want tissue sent in." Follow-up with PCS Manager (D) on 4/18/12 confirmed that there was no tissue sample sent to the lab for analysis as there was no record in the lab and no pathology report found in the MR.

Per interview, with GB President (H) on 3/13/12 at 8:00 AM, he was informed by surgery staff on 12/19/12 that Surgeon (B) was badgering surgical staff.

6. Staff assisting Surgeon (B) in the OR are not trained, credentialed and privileged to do so. See Tag C-321

7. Surgeon (B) is not available to supervise the CRNA and commence with the surgical procedure when patients have been placed under anesthesia. See Tag C-323

The cumulative effect of the above examples related to Surgeon (B) resulted in the facility's inability to ensure patient and staff safety and provide optimal patient care for all Surgeon (B) surgical patients.

Based on 1 of 14 MR reviewed (#8), review of 1 of 1 personnel file (L), and 6 of 6 staff interviews (C, L, E, J, I, D) by surveyor #13469, the hospital failed to ensure that staff assisting Surgeon (B) with surgery are trained, credentialed and privileged to do so. This affects all Surgeon (B) surgical patients.

Findings include:
Per interview, with OR Manager (C) on 3/13/12 at 11:00 AM, MA (medical assistant) (L) was hired on 6/2/02 and worked in the hospital from June 2002 until 7/31/08 at which time she went to work at the hospital-owned clinic as a MA. MA (L) started coming to the hospital OR with with Surgeon (B) on a regular basis around November 2010. Per (C), MA (L) assists with the surgery procedure, manipulates tissue and closes the skin with Surgeon (B) and has closed on her own after (B) has left the OR suite/department. Per (C), MA (L) has not gone through formal ST training but was trained in-house by Surgeon (B). Per (C), there is another ST with all Surgeon (B) cases who passes instruments. Per (C), MA (L) is not a member of the hospital surgery department but rather an employee of the clinic and therefore not supervised by hospital OR Manager (C).

Per OR Manager (C), MA (L) is identified in the intra-operative notes as a first-assist but has not gone through formal training that would allow her to work in the OR as a first assist. Per (C), MA is not titled as a ST and has not been since she went to work for the the clinic as an MA. Per review of MA (L) personnel file on 3/13/12 at 2:20 PM, she completed MA training in May of 2002.

Per review of MA (L) job description dated 5/30/02 her duties in the OR during surgery consist of the following: "7. Scrubs and functions within the sterile field as a scrubbed person, passing instruments and supplies to members of the surgical team while maintaining the instrument, needle, and sponge count with the circulating nurse. 8. Assists with preparation of surgical specimens per procedure/policy and transports to laboratory." Her orientation checklist to surgery dated 9/13/02 also talks to opening and dispensing sterile supplies, counting sponges/sharps/instruments and handling of specimens. Neither the ST job description nor the orientation checklist allows MA (L) to assist with procedures, manipulate tissue and close the skin with or without Surgeon (B).

Per OR Manager (C), MA (L) works in the hospital-owned clinic but is not a hospital employee and has not gone through the hospital medical staff credentialing and privileging process nor privileged by the GB to work in the OR with Surgeon (B). Per (C), other ST, such as dental assistants, who accompany surgeons into the hospital OR, have gone through the medical staff credentialing and privileging process.

Per interview, with RN (E) on 3/12/12 at 12:05 PM, MA (L) assists with surgery and closes for Surgeon (B). Per RN (E), MA (L) is not a trained ST and was taught by Surgeon (B) to help him and close. Per RN (E), MA (L) has closed the skin after Surgeon (B) has left the OR. As a result, she is unsupervised. Per RN (E), patients are not made aware that a MA (L) is assisting with surgery and then closing with and without the Surgeon (B) present.

Per interview, with MA (L) on 3/13/12 at 2:05 PM, confirmed she has not gone through ST training. She started to help Surgeon (B) during surgery and also closes skin. She has closed by herself but does not remember if the surgeon left the OR. Per (L), she is not identified on the patient consent as assisting with surgery and closing. Per MA (L), Surgeon (B) uses the title of First Assist even though she has not gone through the extensive training to be called a First Assist.

Per interview, with CRNA (J) on 3/13/12 at 12:15 PM, (J) has observed MA (L) assist with surgery and close surgical incisions for Surgeon (B).

Per interview, with RN (I) on 3/12/12 at 3:05 PM, MA (L) routinely assists Surgeon (B) with surgeries and routinely closes for Surgeon (B). Sometimes (B) is in the OR room and sometimes he leaves before she is done closing. The consent for surgery does not include evidence that the patients are told that MA (L) is assisting with surgery and closing.

Per interview, with PCS Manager (D) on 3/13/12 in the AM, it was revealed that Pt. #8 who had a left inguinal hernia repair on 2/22/12 was an example of a patient who MA (L) closed after Surgeon (B) left the OR. Per MR review, on 4/17/12 at 1:30 PM, it was noted on the nursing intraoperative note that MA (L) was listed as assisting Surgeon (B) with this case. The consent for surgery does not include evidence that Pt. #8 was made aware that MA (L) would be assisting with the surgery and closing by herself. The operative report does identify MA (L) as the first assist.

Based on 5 of 14 MR reviewed (#7, 9, 12, 11, 10), and 5 of 5 interviews with facility staff (F, E, K, I, C) by surveyor #13469, the hospital failed to ensure that Surgeon (B) is available to supervise the CRNA and commence with surgical procedures when patients have been placed under anesthesia. This affects all Surgeon (B) surgical patients.

Findings include:
Per interview, with CNO (F) on 3/13/12, it was revealed that Surgeon (B) at times leaves the OR after patients are given anesthesia. At other times he calls to have patients taken to the OR, that he is on his way and to start anesthesia, and then staff cannot find him. Patients are under the influence of anesthesia longer than necessary. On 12/7/11 OR Manager (C) informs (F) that it has been a problematic day in the OR and that Surgeon (B) is upset about turnaround times and leaves the OR with cases ready to go. (C) had to go and find him in the clinic and convince him to return to the OR to perform surgery that is ready. Per (F), she and OR Manager (C) informed COS (G) and Administrator (P) on 12/7/11 about Surgeon (B) leaving the OR after patients are under the influence of anesthesia and that surgery staff cannot find him, and that this was occurring often.

Per interview, with RN (E) on 3/12/12 at 12:05 PM, Surgeon (B) tells staff to get patients and take them to the OR and start anesthesia and then he leaves the OR and staff cannot find him. He won't answer his page or his phone. Staff have to search for him. Patient's are under anesthesia longer than necessary. At times up to 45 minutes longer than necessary.

Per interview, with ST (K) on 3/13/12 at 1:00 PM, Surgeon (B) leaves the OR after CRNA has started anesthesia on patients. Per (K), the staff cannot find (B). Sometimes he calls the OR and tells CRNA to start anesthesia, that he will be right there, and then he does not come to the OR and surgery staff are trying to locate him. Per (K), she remembers up to 1/2 hours waits while searching for Surgeon (B).

Per interview with RN (I), on 3/12/12 at 3:05 PM, Surgeon (B) is either in the OR or calls and says he is on his way and to start anesthesia on the patient and then he cannot be found. He either leaves the OR after anesthesia is administered or does not come to the OR when he said he would. He won't answer overhead pages or his cell phone. Sometimes patients will wait in the prep area for two hours because Surgeon (B) cannot be found.

On 4/13/12 at 4:20 PM, PCS Manager (C) presented surveyor #13469 with a list of patients that staff had to wait for Surgeon (B) while under anesthesia, and as a result surgery was delayed and the patients were under anesthesia longer than necessary. Examples include:

Per MR review on 4/17/12 at 2:12 PM, Pt. #7 was admitted for a large ventral hernia repair on 1/31/12. Per anesthesia notes dated 1/31/12 general anesthesia was started between 10:30 and 11:00 AM. Surgery started at 11:15 AM.

Per MR review on 4/17/12 at 1:45 PM, Pt. #9 was admitted on 2/24/12 for excision of a pilonidal cyst. Per anesthesia notes dated 2/24/12 general anesthesia was started at 10:40 AM. Surgery did not start until 11:18 AM.

Per MR review on 4/17/12 at 2:20 PM, Pt. #12 was admitted on 2/7/12 for cystocele and enterocele repair. Per anesthesia notes dated 2/7/12, general anesthesia was started at 8:30 AM. Surgery did not start until 9:05 AM.

Per MR review, on 4/17/12 at 2:00 PM, Pt. #11 was admitted on 2/24/12 for excision of a lipoma on left arm. Per anesthesia notes dated 2/24/12, general anesthesia was started at 8:15 AM. Surgery did not start until 8:52 AM.

Per MR review, on 4/17/12 at 1:50 PM, Pt. #10 was admitted on 10/21/11 for repeat cesarean-section and tubal ligation. Per anesthesia notes dated 10/21/11, a spinal was administered at 9:00 AM. The procedure did not begin until 9:22 AM. Per interview, with RN (E) on 3/12/12 at 12:05 PM, she was present when this patient was given a spinal by the CRNA and then the surgeon left the OR. Staff could not find him for almost a 1/2 hour. He was located by OR Manager (C) walking the hospital hallways. Per RN (E), the patient was upset in the OR because she had to lay there for that long before they found the surgeon. Per RN (E), spinals can affect the health of the baby so this was a problem.