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Based on review of hospital approved policy and procedure, Medical Staff Bylaws, staff interview, and review of patient records, the hospital failed to report a health care practitioner (anesthesiologist-MD #1) to the Department of Health based on a credible report of inappropriate touching or sexual misconduct with 2 patients (Patients #1 and #2).

Failure to report health care practitioners as required to the Department risked patient health and safety.

Findings:

Patient and hospital records were reviewed. Patients #1 and #2 had had surgical procedures at the hospital on Thursday, 4/1/2010. Operating Room staff on both cases included the identified anesthesiologist (MD #1), and the same surgeon and surgical technician. On Friday, 4/2/2010, the surgical technician reported he/she had observed MD #1 fondling both patients' breasts after putting them under general anesthesia.

Administrative anesthesiology staff contacted MD #1 by telephone on Monday, 4/5/2010 and confronted him with the allegation of inappropriate patient touching. He denied the inappropriate intent of the touching and immediately resigned.

Interview with administrative staff on 5/3/2010 revealed that the hospital (via the surgeon) had notified the patients of the incidents and had cooperated with the local police investigation of MD #1.

Medical Staff Bylaws were reviewed on 5/3/2010. Section 14.4, "Reporting Requirements" read, "The President and Chief Executive Officer or President of the Medical Staff, as appropriate, will report actions to professional bodies and state and federal governmental agencies to the extent required by law."

Interview with administrative staff on 5/3/2010 verified that the hospital did not report MD #1 to the Department of Health.

Administrative interview on 5/3/2010 revealed that the Administration understood and anticipated that the police detective investigating the case would forward his investigation to the Washington State Department of Health and Medical Quality Assurance Commission. They also understood and anticipated that the local police would notify the Colorado state health department regarding the allegations against MD #1 (where MD #1 was reportedly residing at the time of this investigation).

Per administrative staff interview on 5/3/2010, the hospital had already received a reference request for MD #1 from a Colorado hospital.

The right to privacy and safety of any future patients was not assured by assuming another agency would report to the proper authorities. Disclosure to the patients regarding the incidents and cooperating with the local police investigation did not absolve the hospital's responsibility to report MD #1 to the Department of Health/Medical Quality Assurance Commission.

Failure to report to the Department of Health and follow hospital approved policy and procedure and the intent of the law placed the health and safety of future patients at risk;
prevented public agencies with legal jurisdiction to provide needed practitioner oversight; prevented timely notification of other public agencies; and prevented crucial tracking and monitoring of healthcare practitioners to protect the health and safety of future patients.