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Based on interviews, medical record review, and review of policies and procedures and other hospital documentation, it was determined that the hospital failed to ensure an effective governing body which protected and promoted the rights of all patients, including the rights to receive care in a safe setting and to be free from all forms of abuse, including sexual abuse.

Findings include:

1. Refer to the deficiency cited at Tag 049, CFR 482.12(a)(5), Governing Body, Medical Staff Accountability; which reflects the failure of the medical staff to be accountable for the safety of patients.

2. Refer to the deficiency cited at Tag 057, CFR 182.12(b), Governing Body, Chief Executive Officer; which reflects the failure of the Chief Executive Officer (CEO) to be accountable for the safety of patients.

3. Refer to the Condition-level deficiency cited at Tags A115 and A145 under the Condition of Participation CFR 482.13 Patient Rights; which reflects the failure of the hospital to protect and promote patient safety, and to prohibit and prevent sexual abuse, including conducting timely and thorough investigations of allegations of sexual abuse.

Based on interviews, medical record review, and review of policies and procedures and other hospital documentation, it was determined that the medical staff failed to be responsible and accountable for the quality of care and safety of patients.

Findings include:

Refer to the Condition-level deficiency cited at Tags A115 and A145 under the Condition of Participation CFR 482.13 Patient Rights; which reflects the failure of the executive medical staff to protect and promote patient safety, and to prohibit and prevent sexual abuse, including conducting timely and thorough investigations of allegations of sexual abuse.

Based on interviews, medical record review, and review of policies and procedures and other hospital documentation, it was determined that the CEO failed to be responsible and accountable for the quality of care and safety of patients.

Findings include:

Refer to the Condition-level deficiency cited at Tags A115 and A145 under the Condition of Participation CFR 482.13 Patient Rights; which reflects the failure of the CEO and executive staff to protect and promote patient safety, and to prohibit and prevent sexual abuse, including conducting timely and thorough investigations of allegations of sexual abuse.

Based on observation, interviews, documentation in 8 of 8 medical records reviewed (Patient #s 1, 2, 3, 4, 5, 6, 7, 10), and review of policies, procedures, and other hospital records and documents, it was determined that the hospital failed to ensure that it protected and promoted each patient's right to receive care in a safe setting. The hospital failed to ensure that it had mechanisms and systems in place to prohibit and prevent sexual abuse, including conducting timely and thorough investigations of allegations of sexual abuse.

Findings include:

1. On 05/02/2011 Patient 1 alleged to hospital executive staff that Physician A, an anesthesiologist, had sexually abused him/her while he/she was sedated during a surgical procedure at the hospital. On 05/10/2011 those allegations of sexual abuse were reported to law enforcement. From 05/10/2011 through 07/28/2011 Physician A continued to practice at the hospital without knowledge that hospital executive staff knew of the allegations. Physician A provided anesthesia services in 133 surgical cases in the hospital during that time. No internal investigation by the hospital was initiated, nor has been as of the date of this survey. No actual changes in surgical/anesthesia procedures to protect patients were implemented. This placed patients vulnerable to, and at risk for abuse due to the sedating effects of anesthesia. Hospital executive staff did not report the allegations to the hospital's governing body or the state physician licensing board until after 07/28/2011, the date Physician A was arrested.

2. Refer to the deficiency cited at Tag A145, CFR 482.13(c), Patient' Rights, Privacy and Safety, which reflects the hospital's failure to protect patient's rights and investigate allegations of sexual abuse.

Based on observation, interviews, documentation in 8 of 8 medical records reviewed (Patient #s 1, 2, 3, 4, 5, 6, 7, 10), and review of policies, procedures, and other hospital records and documents, it was determined that the hospital failed to ensure that patients were free from sexual abuse. The hospital failed to ensure that it had mechanisms and systems in place to prohibit and prevent such abuse. It failed to identify and investigate events and occurrences that may have constituted or contributed to sexual abuse; it failed to protect patients after it had received what it considered "credible" allegations of sexual abuse; it failed to report the abuse to appropriate agencies; and it failed to plan and implement appropriate corrective actions to ensure that sexual abuse would not recur and patients were protected.

Findings include:

1. Review of a local media news article dated 08/23/2011 reflected the arrest of Physician A, an anesthesiologist who practiced at this hospital, Mid-Columbia Medical Center. The article reported that nine victims had come forward alleging sexual abuse while incapacitated under sedation or anesthesia administered by Physician A. The article reported that Physician A had been charged with first-degree rape and multiple counts of felony sexual abuse.

2. During interview with the Executive Vice President of Operations (VPO) which began at approximately 0900 on 09/14/2011, the VPO revealed that hospital staff were aware of media reports that several hospital patients had alleged that an anesthesiologist on the hospital's medical staff, Physician A, had sexually abused them while they were sedated for surgical procedures conducted at the hospital. The VPO acknowledged that the hospital was only aware of the identity of two of those patients.

The VPO stated that on 02/10/2011, Patient 2 had a surgical procedure performed at the hospital and was admitted after surgery for post-operative observation. At 1425 on that day, the VPO received a telephone call from Patient 2's surgeon, stating that Patient 2 had alleged to the surgeon that the anesthesiologist, Physician A, had inappropriately touched his/her breasts. The surgeon reported that he/she had already called the Vice President of Medical Affairs (VPMA) to report the allegation and that the VPMA had directed the surgeon to call the VPO. The VPO indicated that it was determined that the surgeon would speak to the patient again the next morning. The VPO stated that the following morning, on 02/11/2011, the surgeon visited Patient 2 in the hospital. Patient 2 reported to the surgeon that he/she had been hallucinating after surgery and that no inappropriate touching had occurred. The VPO stated that Patient 2 had refused to file a complaint and refused to speak with the VPO and that was the last he/she heard of or from Patient 2 until 07/29/2011. The VPO gave no indication that he/she had attempted to contact Patient 2 at that time in response to the report of allegations.

The VPO reported that he/she was contacted by a physician on 04/20/2011 who reported that he/she had received information which reflected that Patient 1, who is a hospital employee, had alleged "inappropriate touching" by Physician A during surgery. The physician sought direction from the VPO as he/she had not received the information from Patient 1 directly. The VPO stated he/she encouraged the physician to get a message to the person who had reported the information to the physician to request that Patient 1 come forward with this information. The VPO stated that he/she informed his/her supervisor, the hospital's Chief Executive Officer (CEO), of the allegation. The VPO gave no indication that any other actions were taken by the hospital at that time.

The VPO further reported that on 05/02/2011 Patient 1 contacted the VPO and requested a meeting to discuss an incident. The VPO stated that during the 05/03/2011 with Patient 1, Patient 1 was "very upset" and alleged that Physician A had inappropriately touched him/her while he/she was under the effects of anesthesia following a surgical procedure on 09/24/2007. Patient 1 reported that Physician A called him/her at home the day after surgery on 09/25/2007. Patient 1 reported that during that telephone conversation Physician A asked Patient 1 if he/she recalled anything about the surgery, and Patient 1 became fearful and said he/she did not recall anything about his/her experiences during the surgery. The VPO referred to this a "red flag" and stated that anesthesiologists do not call patients the day after surgery. The VPO stated that Patient 1 reported to the VPO that after his/her post-surgery return to work as a hospital employee Physician A visited the department he/she worked in several times, and that his/her perception was that Physician A "was flirtatious and fishing" for what he/she remembered about his/her surgery. The VPO stated that he/she encouraged Patient 1 to go to the police with this information and that Patient 1 said he/she would consider this advice. The VPO stated that he/she believed Patient 1 to be "credible" and reported this to the CEO. Handwritten notes from that meeting dated 05/03/2011 were reviewed and included "[Physician A] has made the comment in [the emergency department] [he/she] can do anything to a patient with the drugs [he/she] administers to a patient". The VPO gave no indication that the hospital contacted the police at that time in response to Patient 1's report.

The VPO reported that on 05/10/2011 Patient 1 met with the CEO and the VPO and stated that he/she was ready to file a report with the police. The VPO indicated that on that date, the CEO met with police and informed them of Patient 1's allegations and that Patient 1 also met with the police to file his/her report of allegations of sexual abuse. The VPO gave no indication that the hospital had initiated its own investigation into allegations of patient abuse.

The VPO reported that on 07/28/2011 Physician A was arrested after having disclosed during the police investigation that he/she had sexually abused a number of patients he/she had anesthetized at the hospital. He/she reportedly identified the names of a number of those patients. The VPO said that since Physician A's arrest a number of women had come forward with similar allegations. The VPO stated that "The touching usually happened after a vaginal surgery, or a knee surgery, or something where the bottom half of the body was draped", and "It usually happened under light sedation, not general anesthesia. I think [he/she] wanted them to be awake enough to know what [he/she] was doing. That's part of [his/her] pleasure. That's part of [his/her] sickness."

The VPO reported that after Physician A's arrest, a surgical staff member, Victim 9, came forward and reported to the VPO that on 07/24/2011, he/she had complained of a headache to Physician A while on duty. After the surgical cases had concluded for the day, Physician A had offered to "help [him/her] with [his/her] headache." Victim 9 stated that Physician A had started an intravenous line in his/her arm while in the operating room area, and that he/she "woke up forty minutes later" and alleged having been sexually assaulted by Physician A. The VPO stated that Victim 9 reported that he/she had been reluctant to come forward until after Physician A's arrest because Victim 9 had been a participant in "curbside medicine" which was "not an acceptable practice" per the VPO. The VPO defined curbside medicine as the practice of asking a physician for advice or a prescription without a patient record and without an official medical office visit.

The VPO indicated that the hospital did not conduct its own investigation into the allegations of patient abuse, and has not done so to the date of this investigation.

3. On 09/14/2011 in the early afternoon an interview was conducted with the Wasco County Chief Deputy District Attorney who provided "Indictment" documents which revealed the identity of ten victims who alleged sexual abuse by Physician A while they were "mentally incapacitated" and "physically helpless".

4. Review of medical records revealed that eight of those ten individuals identified in the indictment documents had surgery performed at the hospital on the date in the indictments of the alleged abuse and that anesthesia had been administered by Physician A in those cases:
Patient 1 had surgery on 09/24/2007;
Patient 5 had surgery on 04/02/2008;
Patient 4 had surgery on 01/18/2010;
Patient 7 had surgery on 01/26/2010;
Patient 3 had surgery on 04/05/2010;
Patient 10 had surgery on 12/20/2010;
Patient 6 had surgery on 01/03/2011; and
Patient 2 had surgery on 02/10/2011.

5. The only medical record which contained documentation of a potential related unusual occurrence or incident was the record for Patient 2, one of the cases which had been described by the VPO during interview of 09/14/11. The record reflected that Patient 2 was admitted on 02/10/11, underwent surgery on 02/10/11, and was discharged on 02/11/11. A form titled "Physician Progress Notes" was dated and timed "7/11/11 (sic) 0750" and was completed and signed by Patient 2's surgeon. It contained the following notes: "RN [Registered Nurse] [name] in room throughout interview and exam ...States everything went fine in OR [operating room] I must have been hallucinating. [No] complaints ... [Patient] given opportunity to discuss/bring up any problems/complaint/worries from perioperative experience. Offered opportunity to speak [with] non-physician administrator." There was no elaboration or context related to the remarks regarding "hallucinating" or "problems/complaint/worries" or "offered opportunity to speak with non-physician administrator." There was no additional information in the record related to this entry.

6. During the investigation the following hospital policies and procedures were reviewed:

The current policy and procedure titled "SURGICAL SERVICES SAFETY PRACTICES" with an original date of "1/04" reflected that "Patients receiving anesthesia medications will have at a minimum 2 people in attendance to ensure patient safety should emergency intervention/response be required."

The current policy and procedure titled "Patient Rights and Responsibilities" with an original date of "June 1985" reflected the patient's "right to receive care in a safe setting and to be free from all forms of abuse or harassment including free from mental, physical, sexual, and verbal abuse, neglect or exploitation."

The current policy and procedure titled "Sentinel Event and Root Cause Analysis" had an original date of "September 1997" and reflected that "Where a [Sentinel Event] occurs there shall be investigation and root cause analysis (RCA). The following events shall also result in investigation ...Rape or physical abuse in the hospital setting ...Any hospital event that results in ...serious psychological injury ..."

The policy and procedure titled "Adverse Sentinel Event or Potential Risk to Patient Safety" had an original date of "September 1997" and reflected that "Sentinel Event. An unexpected occurrence involving death or serious physical of psychological injury or the risk thereof ... The event is called 'sentinel' because it sends a signal or sounds a warning that requires immediate attention ...All events will be reported verbally and in writing ...to the Risk Manager. When an adverse event or potential risk is identified, an immediate investigation is initiated to determine the cause and to reduce the likelihood of occurrence/reoccurrence. The Risk Manager initiates the investigation by convening a multidisciplinary team of involved staff to conduct a root-cause analysis of the situation ... "

The current policy and procedure titled "OCCURRENCE REPORTING POLICY" had an original date of "July 1985" and reflected that an Occurrence Report was to be completed for "Conflicts between physicians and/or patients, families, employees or visitors...Conflict between employees and/or patients, families, visitors, or physicians ...Any other unusual occurrence involving a patient or visitor."

The policy and procedure titled "Employee Code of Conduct" had an original date of "11/19/2009." It reflected "MCMC requires all employees and other individuals in MCMC facilities or acting on behalf of MCMC to know and comply with all applicable laws, regulation and policies of MCMC ...Harassment or abusive treatment of others, sexual misconduct, or use of abusive, profane, or threatening language or gestures will not be tolerated ...Engaging in criminal activity on MCMC premises or off premises, if that activity affects the employee's work or workplace, involves violence, sexual misconduct, or otherwise potentially jeopardizes the health and safety of patient or other employees, will not be tolerated."

The policy and procedure titled "ANTI-HARASSMENT POLICY" had an original date of "10/23/2008" and reflected "Harassment of any kind is prohibited. This specifically includes sexual harassment and other harassment based on characteristics protected under the local, state and federal discrimination regulations ...Sexual harassment: Unwelcome sexual advances, requests for sexual favors or sexually suggestive conduct are sexual harassment when ...Such conduct or statements have the purpose or effect of interfering with the employee's work performance or creating an intimidating, hostile or offensive work environment ...Examples of harassment which may violate this policy also include ...Physical harassment such as assault, impeding or blocking movement, unauthorized touching or any physical interference with normal work or movement when directed at any individual ... Reports may be made anonymously and all reported incidents will be investigated by Human Resources ...Mid-Columbia Medical Center and its affiliated entities will not tolerate any form of harassment, nor will it tolerate (sic) any form of retaliation against an employee who brings a harassment issue forward."

The review of current Medical Staff Bylaws contained a section titled "ARTICLE SIXTEEN -CORRECTIVE ACTION PROCEDURES." The language at Article 16.1-1 reflected that "Whenever a practitioner with clinical membership and/or privileges engages in disruptive behavior, makes or exhibits acts, statements, demeanor or professional conduct, and the same is, or is reasonably likely to be detrimental to patient safety or to the delivery of quality patient care, corrective action may be initiated by any officer of the medical staff, by any clinical service chairmen, by the chief executive officer or by the board." Language at section 16.2-1 under "PRECAUTIONARY PRIVILEGE WITHDRAWAL" reflected "With reference to Article 16.1-1, if the act(s), statement(s), demeanor or conduct of the practitioner is/are perceived to represent a clear and imminent threat by the president of the medical staff or the hospital chief executive officer or the designate of either, then each of these persons shall have the authority to impose a precautionary privilege withdrawal."

7. The credentialing file for Physician A was reviewed. It reflected that Physician A had started providing anesthesiology services at the hospital in 2005. The file and disciplinary records included letters to Physician A dated 12/01/2006 and 07/20/2009 related to angry and inappropriate verbal behaviors exhibited by Physician A. There was no evidence that Physician A had been approached, investigated, or disciplined for any sexually or physically inappropriate behaviors or incidents involving patients or employees during his/her tenure at the hospital.

8. The CEO was interviewed on 09/14/2011 at 1605 hours. The CEO stated that the VPO made him/her aware that a physician had contacted the VPO on 04/20/2011 with reported allegations regarding Patient 1. The CEO stated that he/she called the physician and encouraged the physician to contact the individual who had reported the information to the physician to ask that Patient 1 come forward with information. The CEO stated that he/she had also spoken with the VPMA at this time to establish if there had been any concerns regarding Physician A and was informed that there were no concerns.

The CEO stated that he/she found Patient 1 to be "very credible" during an interview between himself and Patient 1 on 05/10/2011. The CEO stated "I know [he/she] believes [his/her allegations of abuse]." The CEO reported that Patient 1 asked what internal steps would be taken to prevent further patient abuse and the CEO stated "No provider would be allowed alone in OR suite with female patients."

The CEO stated that after the 05/10/2011 interview with Patient 1 procedures were followed to assure patient safety, in that two people were required to be with a "female" patient at all times. The CEO stated that after this interview, he/she met with the VPMA and that both decided that appropriate safety measures were already in place and being appropriately followed and that it was "essential that the [police investigation] be kept confidential as we were afraid [Physician A] would clam up."

The CEO reported that precautionary withdrawal of privileges for Physician A did not occur on 05/10/2011 in accordance with medical staff bylaws, until the "credible" charges against Physician A could be investigated. The CEO stated "We need to weigh the rights of the patient with the rights of the provider and the needs of the hospital. I can't just ruin a [person's] life like that" and "The police had no case until July twenty-eighth."

An undated document titled " POSSIBLE DISCIPLINARY ACTION: [PHYSICIAN A] As dictated by ...CEO of Mid-Columbia Medical Center " was provided by the CEO during the interview. It reflected that on 04/29/2011 "I had a telephone conversation with [physician name] regarding a phone call [he/she] had made approximately two weeks ago to [VPO]. The phone call to [VPO] was concerning a possible allegation of improper sexual conduct of [Physician A] toward to (sic) a patient ...I also mentioned to [physician name] that on Tuesday, April 26th, an anonymous letter had been delivered after hours to the administrative offices at MCMC with a fairly specific allegation against [Physician A] concerning inappropriate sexual conduct and contact with a patient during a gynecological operative procedures ...I plan on waiting until the end of next week to hear further developments from [physician name]. After that I will follow-up with [him/her] proactively to see if we have made progress in having this alleged victim come forward."

9. In an interview with the VPMA on 09/15/2011 at 0825 hours, The VPMA stated that the CEO scheduled a meeting with him/her and with the Chief of Anesthesiology (COA) in "late spring" of 2011 to make the VPMA and the COA aware that an individual, Patient 1, had decided to go to the police with an accusation that Patient 1 had been touched inappropriately while receiving anesthesia by Physician A. The VPMA stated, "We had to make sure our policies were in place, because now we were between a rock and a hard place. We couldn't say anything to anyone because of how it would impact the [police investigation] ...We had a meeting with [OR Director] and the OR staff to follow up with the updated policy. We reinforced what we were already doing. We asked [OR Director] to go in and out of the room more often when [Physician A] was doing a case."

The VPMA stated that the assault to Patient 1 as well as assaults to other victims who came forward since Physician A's arrest on 07/28/2011, did not happen in the preoperative area and did not happen in the postoperative area, but "In the OR, with us all around [Physician A] " . The VPMA added, "It probably happened in ten second's time under the drape, while a surgeon was busy at [his/her] end, while everyone else was busy." The VPMA was asked how the updated policy and procedure requiring two staff members to be with a patient at all times, which according to the VPMA was normal practice, would eliminate the possibility of another assault when the VPMA had previously acknowledged that the alleged assaults had occurred "with us all around them." The VPMA responded "We had to monitor [Physician A] without compromising the police investigation."

Information in sentinel event and occurrence reporting policies and procedures were reviewed with the VPMA. The VPMA stated that the report of an alleged assault to Patient 1, which had been reported to hospital Administration on 05/04/2011, had not been considered a sentinel event. The VPMA stated: "The term 'sentinel event' got lost in the fact that it became a criminal event." He/she stated that unusual occurrence reports had not been generated because "as [patient victims] came forward, they went to the police, and it became part of the police investigation."

During interview the VPMA referred to a report of inappropriate behavior by Physician A which had been made to him/her in May of 2010. The VPMA stated that he/she and the OR Director had approached Physician A with the concern that he/she had acted inappropriately toward two staff members of the OR. The VPMA stated that "[Physician A] acted surprised. [He/she] said that was never [his/her] intention to make someone uncomfortable and said that [his/her] actions were 'in jest.'" The VPMA stated "Behavior in the OR is different than on the floors. It's more relaxed. We use kidding and jousting about to relieve tension." He/she stated that "kidding and jousting about" sometimes included touching, and clarified that to mean "hugging", but that it did not usually include touching "underneath a blouse" and buttocks. The VPMA stated that he/she had never before seen unwanted touching of "under the blouse" and buttocks at the hospital, and that this behavior "would not be tolerated," and "There were no other concerns about Physician A. From a clinical point of view, [he/she] did a reasonably good job." When asked if the VPMA had documented anything about the confrontation with Physician A in May of 2010, he/she stated that he/she didn't think any documentation had occurred, and that "it was just grab-ass." When asked if he/she considered this incident with the employees in May 2010 similar to the report lodged with Administration by Patient 1 on 05/04/2011, the VPMA said, "We're talking about two different things here. I wouldn't put them in the same category, they are worlds apart. I don't think one leads to the other." When asked if he/she discussed this issue with the CEO, he/she stated "I may have mentioned it, but can't remember."

10. In an interview with the OR Director on 09/15/2011 at 1110 hours, the OR Director reported an incident involving Physician A which occurred in May of 2010. The OR Director described that he/she was approached by a staff RN, and the RN reported that two other staff members of the OR had informed the RN that Physician A had made "inappropriate contact" with the two other staff members. One of the two staff members cooperated with an interview with the OR Director and related details about the incident, which included reporting that Physician A "groped under [his/her] blouse" and then after being asked to stop he/she had placed his/her hands on the employee's buttocks. After the case, this staff member went into the utility room to process instruments, and Physician A followed him/her there and said, "So this is where you go to be alone." The second staff member who had reported information to the RN was uncooperative in an interview with the OR Director, and stated that he/she had already taken care of "the problem," and that the women who worked on-call in the OR had made a "safety pact never to leave any staff member alone in the evening with [Physician A]." The OR Director stated that he/she communicated the employee concerns to Human Resources, and then communicated the concern to the VPMA. The OR Director and the VPMA spoke with Physician A, who "claimed that [he/she] was surprised by the accusation, and promised that it would not happen again." The OR Director interviewed both employees approximately one month later, and was told by both employees that there were no further problems. The OR Director said, "But that was just 'grab-ass,' nothing like what [Physician A] is being accused of now". The OR Director further explained, "There's banter in the OR. It happens. This was a guy who exceeded the boundaries".

The OR Director stated that he/she first learned of allegations against Physician A "sometime in May" of 2011, in a meeting with the VPO and the VPMA. The OR Director stated that he/she had conducted a staff meeting after learning that there were "charges pending" against Physician A, but that "I had no idea of what the charges were, and I couldn't tell the staff anything." The OR Director stated that, as a result of the pending charges, a policy had changed to require two people to be with every patient at all times, and "From that point forward, I was in [the OR where Physician A was administering anesthesia] multiple times every case".

The OR Director referred to the policy and procedure "SURGICAL SERVICES SAFETY PRACTICES" which required that a minimum of 2 people be in attendance when patients are receiving anesthesia medication to ensure patient safety should emergency intervention/response be required. In addition an "INSERVICE SIGN-IN SHEET" dated 05/24/2011 was reviewed which contained a listing of with signatures of 12 surgical staff members. The OR Director stated that this policy had been updated to include the "2 people in attendance" section in response to the concerns about Physician A, and that he/she had explained to the staff the rationale for the updated policy and for the 05/24/2011 inservice in this way: "We lied, we told them [the staff members of the OR] that it was because of you, it was a new CMS requirement, because I couldn't tell them anything."

11. In an interview with an OR RN on 09/15/2011 at 1130 hours the OR RN stated that an "anthesthesiologist's screen" is used during all surgical procedures so that the anesthesiologist doesn't get "splattered" with blood/body fluids during the surgical procedure. The OR RN stated that some surgical procedures "have a lot of splatter" and described the anesthesiologist's screen as "standard of care." He/she stated that the screen was typically fastened at two points, one to the left and one to the right of the patient, and high enough to obscure the upper part of the body if the surgical procedure had involved the lower part of the body, and obscuring one side of the patient's body if the patient's neck or head had been the surgical site. The OR RN stated that the drape was low enough for the surgeon to make eye contact with the anesthesiologist in order to communicate the patient's condition and needs regarding anesthesia. The OR RN illustrated the equipment and personnel in a typical surgical case, with the patient bed, with two arm extenders, in the center of the OR. The OR RN drew the anesthesiologist's chair at the patient's head, with the anesthesiologist's "machine" at the right side of the patient's head, and the anesthesiologist's "cart" at the left side of the patient's head. The OR RN wrote "surgeon" between the patient's left arm and leg, and "assistant scrub" between the patient's right arm and leg. He/she drew the sterile instrument table at the patient's right foot, and the nurse's computer a distance away from the patient's left foot. The OR RN stated that these positions would change depending on the surgical site. The OR RN stated that in his/her role as a circulating nurse, he/she documented information on the computer, and he/she moved around the perimeter of the table and the sterile field to observe the patient, as well as to observe the progress and anticipate the needs of the staff members in the OR.

12. During follow-up interview with the VPO on 09/15/2011 at 1530 hours, the VPO was asked why revocation of hospital privileges did not occur immediately after he/she had heard a "credible" allegation of abuse, and why no internal investigation had taken place up to the day of this interview, which was six weeks after the arrest of Physician A. The VPO stated, "We could not compromise the police investigation, we would have had to involve the staff in an internal investigation. We have been told by our attorney and the police not to discuss or compromise the police investigation. Patients were not compromised once we set the trap. We had one chance, and one chance only, to get him."

The VPO stated that on 07/29/2011 an "emergent medical executive meeting" had been called to inform staff members of the arrest of Physician A. The VPO reported that also on 07/29/2011, he/she was speaking to Patient 2 regarding "mesh that had been used during [his/her] surgery that had been recalled." The VPO said he/she stated to Patient 2 "I have some unfortunate news to tell you. Physician A has been arrested." The VPO reported that Patient 2 replied "I knew it, I knew it," and told the VPO that Physician A had touched Patient 2 in the genital area.

13. In an interview with the COA on 09/22/2011 at 1130 hours, The COA stated, "The first I heard of any problem was when [CEO] called me in to say they had received a complaint in May [2011]. We were told we couldn't breathe a word of it out of fear that the investigation would be derailed. It was, after all, an allegation. In twenty-some years in practice, I've learned that some allegations aren't real. If you don't let it run its course, more damage could be done. There was no change in practice in the OR. I mean, how do you strike an appropriate balance? It was a police matter, and was being dealt with. Miscreants can't go unnoticed. We proceeded as we needed to." Asked specifically how the hospital proceeded, the COA replied, "We never let him be alone." Asked if Physician A had been alone with any patient prior to May of 2011, the COA stated that he/she didn't know and "You can't stop a ten second infraction." When asked if any practice change occurred after he/she found out about Physician A, he/she responded, "No, nothing we do could change."

When asked if the COA was aware of an incident in 2010 in which two staff members of the OR department alleged inappropriate behavior on the part of Physician A, the COA stated that he/she had no knowledge of this complaint. Asked, "If a physician were to have a complaint regarding inappropriate touching would an unusual occurrence report be filed?" The COA replied, "In regards to personal interactions, it is up to [the complainant] to fill out an [unusual occurrence report]. Damage to a patient is different and it has to be filled out. Unintended consequences to patients is not an option."

14. In a meeting with the Human Resources (HR) Director on 09/22/2011 at approximately 1600 hours, he/she stated that while original documentation regarding an incident that occurred in May of 2010 was lost, the following "recap" of events was accurate to the best of his/her knowledge. On 05/13/2010 "The OR Director indicated that an RN in the OR came to him/her indicating there were some problems brought up by two employees, [Employee 1] and [Employee 2], regarding concerns with Physician A's behavior toward them. The OR Director met with [Employee 1]. [Employee 1] explained the events of that day, and stated that he/she was not filing a formal complaint, and that he/she would 'take care of it.' He/she also indicated that staff members in OR 'on call' agreed not to be alone with Physician A. The OR Director also talked with [Employee 2], who was reluctant to discuss [his/her] concerns, and did not want to file a formal complaint."

The HR Director presented copies of typewritten notes to the HR Director from the OR Director which recounted the events of 05/13/2010. The OR Director's documentation of an interview between Employee 1 and himself contained the following: "[Employee 1] told me that while on call, [he/she] was in the OR beginning to set up a case. The circulator [circulating RN] was in the waiting area with the patient, and [Physician A] was setting up for the case in the room alone with [Employee 1]. [Employee 1] asked [Physician A] to tie [his/her] gown for [him/her]. [Physician A] approached [Employee 1] from behind, and put [his/her] hands under [his/her] blouse and began to "feel." [Em