HospitalInspections.org

Based on record review and interview, the medical staff failed to enforced the bylaws/rules/regulations/policy in regards to physician Peer review with allegations of physician misconduct, in that,

Patient #4 alleged physician (Personnel #6) misconduct on 6/05/17. The Peer Review was not completed and Patient #4 was not informed of an outcome.

Findings included

There was no Peer Review completed for Personnel #6 as a result of Patient #4's 6/05/17 allegations of physician misconduct.

There was no letter completed to inform Patient #4 of the outcome of the allegations of physician misconduct.

The 6/05/17 emailed complaint included physician misconduct allegations of "feared for the life of my unborn child and my own safety at the hands of the doctor who completely lost her temper, never introduced herself as a doctor...She yelled at my husband...and the yelled at me that he can't talk to me like that...I was scared she would harm me if I said anything...she ordered me to cut the cord...while this angry doctor was busy abusing me..."

The 1/10/17 Code of Conduct and Disruptive Behavior Policy required, "Managing suspected violations and violations of the Code of Conduct...Medical Staff...investigated by the CEO and the VP of Medical Affairs...submit the results of the investigation to the Medical Executive Committee...the individual who initiated the report will be notified that the report was received and that the issue was addressed."

The 10/11/16 Medical Staff Peer Review Policy required, "Circumstances requiring Peer Review...inappropriate professional conduct...Patient Complaints...Circumstances requiring external peer review...when dealing with the potential for a lawsuit..."

The 6/22/17 Patient Grievances ad Complaints Policy required, "If an employee is notified directly of a patient complaint...investigation & assuring final follow-up and complaint resolution...Grievances may be submitted verbally or in writing...alleged violation of patient rights...inappropriate behavior of staff or physician...Concerns will be investigated and outcome will be communicated to the patient in writing...steps taken on behalf of the patient to investigate the grievance, the results of the grievance process..."

During an interview on 12/04/17 ending at 2:54 PM, Personnel #1 was asked if there was a complaint logged for Patient #4's complaint on the discharge date. Personnel #1 stated, "No, I see what you are saying but it was treated as an incident through Risk until we received the letter (email)." Personnel #1 was asked if there was a Peer Review. Personnel #1 stated, "There was not a physician issue." Personnel #1 was informed the email complaint included allegations of physician misconduct.

During a telephone interview (He called the surveyor) on 12/06/17 ending at 1:47 PM, Personnel #4 was informed of the allegations of the 6/05/17 complaint and the specifics of the facility's above policies. Personnel #4 was asked if Peer Review occurred through MEC (Medical Executive Committee). Personnel #4 stated, "No."