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Based on document review and interview, the facility failed to ensure grievances were investigated and resolved in a timely manner and in accordance with the facility's policy in 5 (#1 through #5) of 12 (#1 through #12) patient grievance records reviewed.
A review of patient #1's grievance record revealed the following information:

The facility received the grievance on 7/28/2016, from patient #1's brother regarding his care and treatment in the Emergency Department (ED). Patient #1, a 33 year old male, sought treatment at the ED, on 7/26/2016, with nausea, vomiting, and shortness of breath. Patient #1 was treated and released from the ED the morning of 7/27/2016. The patient died from cardiac arrest less than 2 hours after leaving the ED.
The initial acknowledgement of grievance receipt letter, from the Director of Patient Relations (staff #4) was sent to the complainant on 7/28/2016.
A second letter, dated 8/5/2016, from staff #4, provided the investigation progress.
A third letter, dated 10/6/2016, from staff #4, apologized for the investigation delay.
A fourth letter, dated 1/10/2017, from the Chief Medical Officer (CMO), staff #5, detailed the patient's course of treatment in the ED and the following conclusion statement, "When we review issues, complaints, or concerns we always review our processes and medical care and this was done in your Brother's case." There was no investigation results provided to the complainant.

An interview, conducted on 3/1/2017, with staff #4, in reference to the excessive time taken by the facility to investigate and resolve patient #1's grievance initiated by the brother of patient #1.
Staff #4, provided the following information:
The complaint was received on 7/28/2016. It was sent to staff #8, the ED Medical Director, for review, then was sent to the facility's Grievance Committee Meeting on 8/5/2016.

A review of the 8/5/2016, Grievance Committee Meeting Minutes revealed the following statement:
" ...(Patient #1): This complaint was referred to the Grievance Committee by the ED Medical Staff Director. Mr. (patient #1's brother), lodged a complaint on behalf of his deceased brother (patient #1). According to Mr. (patient #1's brother), his brother presented to the ED via ambulance experiencing shortness of breath, nausea and vomiting. He was discharged and died at 8:00 a.m. the same day of release. Mr. (patient #1's brother) shared that his brother discharge paper list him as non-compliant; this was the result of documentation in his record by Drs. (staff #12 or #13). Mr. (patient #1's brother) alluded to the physicians having a preconceived idea about the patient as the result of the other physician's documentation.
Dr. (staff #8), ED Leadership and Patient Relations discussed and reviewed Mr. (patient #1's brother) concern. Staff #8 reviewed the record; he stated treatment was appropriate. However, for a second look; he requested the complaint go to the grievance committee. The Committee discussed the findings of the record and the feedback reported from staff #8 and concluded that this should be kicked up to the Medical Staff Officer for review and resolution."

Staff #4 provided computer documented notes titled, "Patient Relations Worksheet", that revealed the following tracking timeline for patient #1's grievance:
"8/5/2016 11:42 AM by (staff #4) --- This complaint was taken to the Grievance Committee for review. After review and discussion it was decided that this complaint should be referred to the Medical Staff Office and Emergency Services Medical Staff Director. I a (sic) sending a letter to Mr. (patient #1's brother) acknowledging that his concern is being referred for Medical Staff review.
...9/1/2016 01:17 PM by (staff #6) --- (patient #1's brother) called the Patient Relations office this morning wondering the status of his complaint. He stated that he received two letters that stated his complaint is being investigated. He has not made contact with anyone from the Medical Staff Office. I (staff #6) informed (patient #1's brother) that someone will be contacting him regarding the findings to his complaint. He would like everything in writing; however, his phone number is ...
9/1/2016 01:24 PM by (staff #6) --- Resent this complaint and updated Dr (staff #5), Dr. (staff #14), Dr. (staff #8), (staff #7) and (staff #4) of resent (sic) conversation with (patient #1's brother). Sent email today.
9/9/2016 01:16 PM by (staff #6) --- Resent this complaint to (staff #7) today.
10/5/2016 04:01 PM by (staff #6) --- (patient #1's brother) contacted (staff #15), Patient Access Manager, today wanting to know the outcome of the investigation. I (staff #6) resent this complaint again today to (staff #5) and the Grievance Committee members for update and resolution.
10/6/2016 04:31 PM by (staff #6) --- Sent a letter today to (patient #1's brother) stating the complaint is currently under investigation.
10/7/2016 01:11 PM by (staff #6) --- Resent this complaint today to (staff #5) for resolution.
10/26/2016 03:27 PM by (staff #6) --- Resent this complaint today to (staff #5) for resolution.
11/2/2016 08:49 AM by (staff #6) --- Met Monday, October 31, 2016, with (staff #5), (staff #4), and myself to discuss this complaint. (Staff #5) will compose a RL (resolution letter) to brother, (patient #1's brother). He will send us a copy upon completion.
11/18/2016 03:21 PM by (staff #6) --- Requested today a copy of RL from (staff #5).
12/9/2016 01:11 PM by (staff #6) --- (Staff #4) requested a copy of RL from (staff #5's) administrative assistant.
1/9/2017 04:32 PM by (staff #4) --- Hi (staff #5) and (staff #16), (patient #1's brother) called today; he stated he has been tolerant and patient (sic) to allow us to conduct our investigation. However, this has been going on since July 2016. He wants an answer to his complaint. He stated we are; but we are not communicating with him and he needs answers. He was nice, but I would hear his frustration. Has the letter to (patient #1's brother) gone out? (Staff #4)
1/12/2017 04:36 PM by (staff #6) --- Received signed copy of resolution letter today from (staff #16), (staff #5's) administrative assistant.
An interview conducted on 3/1/2017, with staff #5 revealed the following information:
Staff #5 stated, "Over time, I found out the ED Medical Director (staff #8) was not going to send the resolution letter. I was told their Risk Management advised them not to respond to the grievance ....I think that was sometime late in November (2016). It sat on my desk for about 3 weeks, which was my fault ...I just forgot about it."

The grievance "resolution" letter was sent to the complainant 166 days after the initial grievance was received.




A review of patient #2's grievance record revealed the following information:
The facility received the grievance on 9/26/2016, from patient #2, a 36 year old female, regarding an attending physician's conduct towards the patient during a hospital stay.
The initial acknowledgement of grievance receipt letter, from staff #4, was sent to the complainant on 9/26/2016.
A second letter, dated 10/27/2016, from staff #4, provided the investigation progress.
A third letter, dated 1/10/2017, from the CMO, staff #5, informed the complainant he would discuss the issue with the physician and apologized for the "experience" the patient had.
The grievance "resolution" letter was sent to the complainant 106 days after the initial grievance was received.

A review of patient #3's grievance record revealed the following information:
The facility received the grievance on 9/12/2016, from patient #3's husband regarding the care and treatment received as a patient in the facility. Patient #3, a 68 year old female, was scheduled for a cardiac catheterization procedure. After waiting most of the day, the patient was informed the physician that was scheduled to conduct the procedure, was out of town.
The initial acknowledgement of grievance receipt letter, from staff #4, was sent to the patient on 9/12/2016.
A second letter, dated 9/13/2016, from the facility's Chief Hospitalist, staff #11, stated the investigation was completed on 9/13/2016, and included the course of action taken to prevent a recurrence of the issue.
A third letter, dated 1/10/2017, from the CMO, staff #5, contained an explanation for the erroneous procedure scheduling with a physician that was not available at the time, in addition to an apology to the patient.
The grievance "resolution" letter was sent to the complainant 120 days after the initial grievance was received.

A review of patient #4's grievance record revealed the following information:
The facility received the grievance on 1/18/2017, from patient #4's daughter regarding the care and treatment patient #4 received in the facility's ED. Patient #4, an 80 year old female, was seen in the ED with nausea and vomiting. Patient #4's daughter complained the ED physician did not see the patient for 7 hours after arrival. In addition, the ED physician discharged the patient home and told her she had a "bug". Patient #4 returned to ED the next day and was found to have a perforated colon. She was admitted and had emergency surgery to repair the colon perforation.
The initial acknowledgement of grievance receipt letter, from staff #4, was sent to the patient on 1/18/2017.
A second letter, dated 2/27/2017, from staff #4, stated the grievance was still under investigation.
As of 3/1/2017, the date of this surveyor's review, a grievance "resolution" letter had not been sent to the complainant or the patient. The grievance was received 42 days prior to the surveyor's review.

A review of patient #5's grievance record revealed the following information:
The facility received the grievance on 7/26/2016, from patient #5 regarding the care and treatment received in the facility's ED. Patient #5, a 37 year old female, was seen in the ED after her abdominal surgical staples came out, resulting in an open wound. Patient #5's surgeon in Plano, Texas, was contacted by the ED physician. The surgeon advised the ED physician on how to treat the patient's wound. Patient #5 complained the ED physician did not follow the surgeon's advice and when she followed up with the surgeon, she was found to have a wound infection, resulting in an 11 day hospital stay. In addition, patient #5 initiated a second complaint in reference to her minor son's ED care and treatment on a separate date. Both of the complaints were processed together.
The initial acknowledgement of grievance receipt letter, from staff #4, was sent to the patient on 7/26/2016.
A second letter, dated 8/3/2016, from the facility's ED Director, staff #10, included a summary of the ED Medical Director's investigation. The letter also stated, " ...After investigation and follow-up, it is the decision of (facility name) that this complaint has been resolved ...."
A third letter, dated 9/22/2016, from staff #4, informed patient #5, the complaint was still under investigation.
A 4th letter, dated 10/20/2016, from staff #4 stated, " ...An investigation was conducted and concluded on October 18, 2016 ....". It further explained the process of the investigation and included the results.
The grievance "resolution" letter was sent to the complainant 86 days after the initial grievance was received.

A review of the facility's policy titled, "Complaint/Grievance Procedure", revealed the following information:
" ...Every effort will be made to investigate grievances, identify corrective actions and bring the grievance or concern to resolution. ...The Board of Directors has delegated (in writing) the responsibility to review and resolve grievances to the Grievance Committee as set forth by this policy.
...5. All grievances shall be acknowledged within 7 days of receipt of the grievance; the initial acknowledgement letter to the patient or patient representative shall be generated by the Customer Service Department. However, most issues are acknowledged immediately upon receipt.

6. If additional communication regarding the investigation of the grievance is required the investigating manager/director shall provide the patient or representative with a letter of resolution within 30 days of receipt of the grievance.

7. All grievances related to care/services shall receive written follow-up from the person conducting the investigation. If a resolution from the above process is unsatisfactory to a patient/designee, the complainant will be informed of his or her right to further review. In addition, the letter of resolution should provide, at a minimum the following information:

a. the name of the hospital contact person;
b. steps taken on behalf of the patient to investigate the grievance;
c. results of the investigation and follow-up actions; and
d. the date of completion ..."

Based on record review and interview the facility failed to participate in, and document the Emergency Department's Grievance Committee meetings.

A review of the facility's policy titled, "Complaint/Grievance Procedure", revealed the following information:
" ...POLICY:
It is the policy of CHRISTUS St. Michael Health System to provide a reasonable and consistent approach to addressing patient complaints/grievances and family or visitor concerns. Every effort will be made to investigate grievances, identify corrective actions and bring the grievance or concern to resolution. CSMSH recognizes the importance of such actions in maintaining patient satisfaction, reducing corporate liability and identifying opportunities to improve care and service quality. The Board of Directors has delegated (in writing) the responsibility to review and resolve grievances to the Grievance Committee as set forth by this policy ....


GRIEVANCE COMMITTEE:
The hospital's Board of Directors is responsible for the effective operation of the Grievance process. The Board delegates responsibility for reviewing and responding to patient complaints/grievances to the Grievance Committee as a sub-committee of the Performance Improvement Council (PIC). Patient grievances may be submitted to CHRISTUS St. Michael Grievance Committee (Administrative Staff, Quality Management, and Customer Service and Risk Management) for review and resolution if the concern cannot be resolved through CHRISTUS St. Michael standard grievance process as outlined previously in this policy.

a. The Customer Service Manager will serve as the chairperson of the Grievance Committee.
b. The Customer Service Manager will maintain a confidential log with appropriate documentation of all referred complaints/grievances, actions taken and resolutions attempted.
c. The Grievance Committee will report to the PIC quarterly. The PIC shall report biannually to the Local Governing Board ...."


An interview conducted on 3/1/2017, with staff #4 revealed the facility's Emergency Department (ED) had their own Grievance Committee. The ED Grievance Committee meeting minutes were requested by the surveyor. Staff #4 stated the ED Grievance Committee meetings did not include the facility's Risk Management or Patient Relations Department and the facility's administration was not aware if any of the ED Grievance Committee meetings were documented.

An interview conducted on 3/1/2017, with staff #1 and staff #2 confirmed the above information from staff #4. Staff #1 explained the Emergency Department physician's group was contracted by the facility to staff the Emergency Department physicians. The ED physician's group had their own Risk Management Department, separate from the facility's Risk Management.

Based upon record review and interview, the medical staff failed to address and initiate a corrective plan of action for recurring conduct and care complaints against an ED physician (staff #18) in 6 (patients #1, #6, #8, #9, #10 and #12) of 12 (patients #1 through #12) patient complaints/grievances reviewed.

Patient #1 was a 33 year old male that presented to the facility's ED on 7/26/2016.

A review of the facility's "Patient Relations Worksheet", revealed the following information documented upon receipt of the grievance lodged by patient #1's brother:

" ...7/28/2016 11:12 AM by (staff #6) --- (Patient #1's brother) called the Patient Relations Department stating his brother (patient #1) came to the ED (Emergency Department) on 07/26/2016 with shortness of breath, nausea/vomiting and the ED did nothing for him and sent him home. On the drive home, the patient was sleeping, but (patient #1's brother) stated the patient was weak and fatigued. (Patient #1) died at home yesterday morning, July 27, 2016 approximately 8:00am. According to (patient #1's brother) the cause of death was a heart attack. He came to the ED with all the symptoms, but wasn't treated for them. (Patient #1's brother) stated the patient's discharge paperwork stated he was non-compliant, which isn't true. The patient came in for shortness of breath and should've been treated for such, instead of being discharged. (Patient #1's brother) stated his brother has been using (facility) for the past year for his medical needs. And the patient's nephrologist (either Dr. (staff #12) or Dr. (staff #13)) documented in his medical records that the patient was non-compliant and ever since this documentation, the other physicians make up their minds that (patient #1) is non-compliant, which is false. According to (patient #1's brother), the patient was going to Shreveport for dialysis. At the end of the conversation, (patient #1's brother) stated at this time, he is only concerned with the patient's ED visit from July 26th. (Patient #1's brother) stated he has contacted the Texas Department of Human Health Services about this situation ...."

There was no resolution letter sent to patient #1's brother at the time of the surveyor's investigation (3/1/2017).



Patient #6 was a 56 year old female that presented to the facility's ED on 2/1/2017.

A review of the facility's "Patient Relations Worksheet", revealed the following information documented upon receipt of the grievance lodged by patient #6:

" ...2/3/2017 11:08 AM by (staff #17) --- (Patient #6) spoke with (staff #4). She stated that Dr. (staff #18) treated her so poorly, like a drug seeker and a welfare case, was generally rude and mean to her. He stated, "I want to know when you are going to quit smoking?" He looks in the computer and said to her, "You have been in here quite frequently." She explained that she had a deep vein thrombosis.
He told her he was going to give her a steroid patch. She asked him if they could help her with getting a ride home, as she was brought in an ambulance. He told her no, she explained she is on a fixed income. He stated, "I don't care what you live on, you need to start bringing money with you. This is not a charity hospital." She was humiliated and felt like a bum. She cried and asked her nurse to take her IV out so she could leave. As bad as she was hurting, she walked home.

..."3/1/2017 09:39 AM by (staff #6) --- Comments from ED Medical Director from 2/19/2017: "(Patient #6) Pt with COPD (chronic obstructive pulmonary disease) who was seen and treated in the ED. Medicine was good. Recommend making Dr. (staff #18) aware of complaint."

A review of the resolution letter, dated 2/21/2017, sent to patient #6, contained the following information:
" ...In summary your concern was that the physician treated you poorly and told you that he could not help you get a ride home while you were in the Emergency Department.
Your record was reviewed by the Emergency Department leadership team on February 7, 2017. It was found during our review that steroids and a breathing treatment were ordered for you before you left against medical advice. I would like to sincerely apologize for the perception that the doctor was rude during your visit. The Emergency Department Medical Director will be following up with the physician involved in your care in reference to his interaction with you.
After investigation and follow-up, it is the decision of (facility) that this complaint has been resolved ....Sincerely, (staff #9) ..."

The facility was unable to provide any evidence that staff #8 followed up with staff #18 in regards to patient #6's perception of the physician's rudeness.



Patient #8 was a 46 year old female that presented to the facility's ED on 1/10/2016.

A review of the facility's "Patient Relations Worksheet", revealed the following information documented upon receipt of the grievance lodged by patient #8:

" ...1/11/2016 11:25 AM by (staff #17) --- (Patient #8) called and spoke with (staff #6). She came to the ER (Emergency Room) last night with stomach pain that she had been having since August. She waited three hours in pain, she did have a CT Scan and saw Dr. (staff #18). Dr. (staff #18) was very hateful and at some point told her "Do not come back to (facility)". He described her pain as phantom pain. This confused her, so she was asking him questions, and this only seemed to make him more angry. His face was read and was "boiling hot mad".
Also, she was nauseous and the nurse asked twice for Phenergan (anti-nausea medication). He wouldn't give her anything for nausea. He did give her a pain shot and sent her home. She was still in pain and nauseous however ...."

A review of the resolution letter, dated 1/26/2016, sent to patient #8, contained the following information:
" ...In summary your concern is that you felt that the physician that treated you was rude and would not listen to your concerns. You also felt that you should have received Phenergan for your nausea. I apologize for your experience. The medical director did review your chart and complaints and there was no emergency condition identified and he recommends any further treatment must be pursued through your primary care physician.
After investigation and follow-up, it is the decision of (facility) that this complaint has been resolved ....Sincerely, (staff #10) ..."

Even though the resolution letter addressed the care provided to patient #8, there was no acknowledgement in the letter regarding the patient's grievance related to the physician's rudeness. There was no evidence provided that the Medical Director had addresssed staff #18's behavior.



Patient #9 was a 42 year old male that presented to the facility's ED on 9/17/2016.

A review of the facility's "Patient Relations Worksheet", revealed the following information documented upon receipt of the grievance lodged by patient #9:

"9/21/2016 10:38 AM by (staff #17) --- The patient came to the ED on 9/17/2016 because he was urinating blood and severe pain. Dr. (staff #18) judged and discriminated against the patient. Dr. (staff #18) walked into the room and the first thing he said was, "I got a bad feeling about you, I'm not going to give you anything for pain." The patient stated he discriminated against him because of the multiple tattoos on his arms and the way he looks. The doctor treated him like s***. (Patient #9) stated that he has a hernia and kidney stones in both kidneys. He's trying to see a surgeon, but in the meantime, he's in a lot of pain. The patient stated that he was peeing blood in front of the nurse; therefore, something was wrong. The patient did state that Dr. (staff #18) wanted to order an MRI (Magnetic Resonance Imaging), but he was told by his previous doctor not to have another MRI because of the over exposure to the radiation. (Patient #9) completely misjudged him because he's a 13 year veteran with the State Narcotic Office and he will be contacting the State Medical Board and filing a formal complaint against Dr. (staff #18). (Patient #9) did not receive any discharge paper work and no prescriptions. The patient wants to know if there is anything in his medical records that a physician wrote that stated anything derogatory about him ....

9/22/2016 12:41 PM by (staff #6) --- Resent this complaint to the ED Team today. This complaint was discussed today with the ED Grievance Committee Meeting today. Documentation shows that Dr. (staff #18) wanted patient to receive CT (computerized tomography) Scan to assess for any significant pathology. Physician did order Bentyl (anticholinergic used to relieve spasms in the stomach and intestines) and Ibuprofen for patient. Patient refused CT Scan during this visit and left. It was decided that (staff #10) will send a resolution letter to patient."

A review of the resolution letter, dated 9/22/2016, sent to patient #9, contained the following information:
" ...In summary your concern is that you felt that your treating physician judged you on your appearance and did not give you any prescriptions for your pain. Also, you would like to know if he wrote anything derogatory about you in his notes. Our Medical Director did review your chart. Dr. (staff #18) wanted to do further testing prior to giving you any narcotics. You became upset and left the emergency department without your discharge instructions. If you would like a copy of your medical records, you can request them from Health Information Management from 8-4pm, Monday through Friday.
After investigation and follow-up, it is the decision of (facility) that this complaint has been resolved ....Sincerely, (staff #10) ..."

The resolution letter addressed the care issues identified in the grievance but did not address the comments and behavior of the physician. There was no evidence that the ED Medical Director addressed the comments and behavior of staff #18.



Patient #10 was a 32 year old male that presented to the facility's ED on 8/14/2016.

A review of the facility's "Patient Relations Worksheet", revealed the following information documented upon receipt of the grievance lodged by patient #10:

"8/17/2016 10:52 AM by (staff #17) --- (Patient #10) spoke with (staff #19). He stated that he came in to the ER with chest pain and shortness of breath. He stated that Dr. (staff #18) was very rude with him. He could barely speak and Dr. (staff #18) was frustrated by that. He told the nurse to give him a shot for pain. Blood work was done and a chest x-ray. One hour later Dr. (staff #18) came back, said "Airways are clear, nothing wrong with the airways, stop looking at your girlfriend and talk to me" in a very rude tone. When the bloodwork came back he was cleared for discharge and when he got up started vomiting and was sent home with no prescription and was still in pain.
Also, the RN ...was rude. She was very rough doing a throat swab. When he move his head she told him "You know you have the right to refuse". He was not refusing, she was just being very rough ...

8/18/2016 09:56 AM by (staff #6) --- Additional comments from Dr. (staff #8): "Discussed with Dr. (staff #18) - reviewed chart - pneumomediastinum (abnormal presence of air or gas in the mediastinum/center chest area) and free air in the neck missed on initial xray. We contacted patient and they came back and were admitted. While patient was in the ER (second visit) I discussed with them and the primary complaint was Dr. (staff #18's) rudeness. I advised I would discuss with Dr. (staff #18) which I did. Also reviewed chest and neck films with him. Can generate letter apologizing for rudeness and miss on initial xray which was caught on overread. (Staff #10) to address with nurse."

A review of the resolution letter, dated 8/25/2016, sent to patient #10, contained the following information:
" ...In summary your concern is you felt that your treating physician in the emergency department was rude to you. Also, you felt that the nurse involved in your care was very rough when swabbing your throat. The Medical Director reviewed your chart and was able to follow up with you during your second visit to the emergency department. He did follow up with Dr. (staff #18) with reference to his rudeness. I am following up with the nurse whom you felt was also rude. I sincerely apologize and hope that you are doing well at this time.
After investigation and follow-up, it is the decision of (facility) that this complaint has been resolved ....Sincerely, (staff #10) ..."

The resolution letter addressed the rudeness of staff #18, however the facility provided no evidence that the Medical Director followed up with staff #18 with reference to his rudeness.




Patient #12 was a 28 year old female that presented to the facility's ED on 7/20/2016.

A review of the facility's "Patient Relations Worksheet", revealed the following information documented upon receipt of the grievance lodged by patient #12's mother:

" ...7/25/2016 08:52 AM by (staff #17) --- This was an email from (staff #20): I received a call from (patient #12's mother), mother of (patient #12). (Patient #12's mother) stated that her daughter, (patient #12), was in the ER last night and saw Dr. (staff #18) for an earache, an ear infection, vaginal bleeding, and cramping. (Patient #12) is 28 years old, and 5 weeks pregnant, per (patient #12's mother). (Patient #12's mother) stated that she called all around in the ER trying to check on her daughter and everyone was rude. (Patient #12's mother) stated that she wanted to inform me "in case I didn't know, that (facility) and (other local facility) both have bad reputations and that's why everyone has to go out of town." (Patient #12's mother) was very angry. She stated that when Dr. (staff #18) came in to see her daughter, "he looked like he either didn't get enough sleep or he was on something he shouldn't be on." (Patient #12's mother) stated that Dr. (staff #18) was very rude and told her daughter that she was having a miscarriage but that he couldn't see any infection in her ear. She also stated that Dr. (staff #18) gave her daughter Keflex (antibiotic), but "he didn't even want to do that, and today she has green bloody drainage coming from her ear.
(Patient #12's mother) also stated that Dr. (staff #18) told her daughter that she was 2 to 3 days pregnant and it could be a tubal pregnancy. (Patient #12's mother) stated that her daughter's ear was hurting her and she was cramping really bad and she wanted to file a formal complaint about this. I told her I would send an email to the ER Director. (Patient #12's mother) stated that "if someone didn't call her back within a reasonable time, she would be coming up to the hospital." ...

A review of the resolution letter, dated 8/3/2016, sent to patient #12, contained the following information:
"In summary your concern is that you felt that your treating physician was rude and told you that you did not have an ear infection and that you were having a miscarriage. Our Medical Director did review your visit for 7/20/16. You were seen by Dr. (staff #18) who ordered lab and an ultrasound. He did prescribe an antibiotic for your ear infection. It appears that you initially did not want the prescription when the nurse was discharging you. She asked Dr. (staff #18) to talk with you again which he did and you were given a prescription. You were also instructed to follow up with your physician for follow up lab work. I do hope you had your lab work repeated. I sincerely apologize that you felt your medical needs weren't met.
After investigation and follow-up, it is the decision of (facility) that this complaint has been resolved ....Sincerely, (Staff #10) ..."

The resolution letter gave an explanation of the medical treatment provided but did not address the rudeness of staff #18. No evidence was provided that the ED Medical Director addressed staff #18 related to his behavior towards the patient.

A review of staff #18's physician credential file revealed no documentation related to the above complaints or any other complaints referencing staff #18.

All 6 (patient #1, #6, #8, #9, #10 and #12) of the complainants cited (staff #18's) rude behavior towards the patients. The facility received 4 (patient #1, #9, #10 and #12) of the complaints citing (staff #18's) behavior, between the dates of 7/25/2016 and 9/21/2017, a 58 day period.

A review of the facility's Medical Staff Bylaws and Rules and Regulations, revealed the following information:
" ...4.2 Qualifications for Membership. All applicants to the Associate, Active, Courtesy, Consulting, or Active-Affiliate Medical Staff must satisfy the following conditions to qualify for initial Medical Staff membership and reappointment:

g. must adhere to the ethics of their profession; and

h. must possess good reputation and character, including stable mental, physical, and emotional health sufficient to perform the essential functions of their professional duties with or without reasonable accommodations and ability to work harmoniously with others, with or without reasonable accommodation ....


9. Practitioner Health Committee. The functions of the Practitioner Health Committee shall include the following:

Addressing Practitioner health as it relates to patient safety;
Educating the Medical Staff regarding illness and impairment recognition issues specific to Practitioners;
Encouraging self-referral by Practitioners and referral by other members of the Medical Staff and Administration;
Evaluating the credibility of a complaint, allegation, or concern;
Determining whether a Practitioner's problem is best addressed through a disciplinary measure or via the physician-health route; ..."