The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SAINT THOMAS HICKMAN HOSPITAL 135 EAST SWAN STREET CENTERVILLE, TN 37033 June 3, 2015
VIOLATION: ORGANIZATIONAL STRUCTURE Tag No: C0240
Based on facility policy review, document review, medical record review, observation and interview, the hospital's Governing Body and the Chief Executive Officer (CEO) failed to assume responsibility for ensuring provision of patient care in a safe setting. Failure to protect patients from physician abuse resulted in a SERIOUS and IMMEDIATE THREAT to the HEALTH and SAFETY of Patient #1 and placed all Emergency Department patients in IMMEDIATE JEOPARDY and at risk for serious injury from abuse.

The findings included:

The hospital did not provide any evidence to demonstrate interventions had been implemented subsequent to abuse allegations made by EMS employees and Patient #1. Despite numerous complaints of abusive behavior and staff awareness of inappropriate and abusive behavior, Physician #1 was allowed to continue working in the Emergency Department without interventions or monitoring being implemented to ensure patient safety from abuse.
VIOLATION: GOVERNING BODY Tag No: C0241
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on facility policy review, document review, medical record review, observation and interview, the hospital's Governing Body and the Chief Executive Officer (CEO) failed to assume responsibility for ensuring provision of patient care in a safe setting for 3 of 5 (Patient #1, 2 and 3) sampled patients. Failure to protect patients from physician abuse resulted in a SERIOUS and IMMEDIATE THREAT to the HEALTH and SAFETY of Patient #1 and placed all Emergency Department patients in IMMEDIATE JEOPARDY and at risk for serious injury from abuse.

The findings included:

1. Review of the hospital's "Patient Rights and Responsibilities" policy revealed, "...Patient [Pt] Rights...You have the right to safe, high quality, compassionate healthcare, without fear of discrimination of any kind...You have the right to the most appropriate medical treatment available, delivered in a safe, considerate, and respectful manner...You have the right to be free from all forms of abuse, neglect and exploitation..."

Review of the hospital's "Standards of Conduct, SP-13" policy revealed, "...PURPOSE: The Standards of Conduct describe the behavior and conduct expected of [named healthcare company] associates, medical staff, Board Committee members and contractors to promote and protect the integrity of the Health Ministry...DEFINITIONS..."Standards of Conduct" means the principles of associate behavior that promote corporate responsibility... PROCEDURE/GUIDELINES: The following...Standards of Conduct... clearly state the [named healthcare company]'s expectations for how associates should conduct themselves to promote and protect the integrity of [named healthcare company]. Each associate is expected to act in a manner consistent with the Standards of Conduct... Deliver Clinically Excellent and Safe Patient Care: We deliver spiritually centered care to our patients that supports the physical, mental, emotional, social and spiritual needs of the person. Clinically excellent and safe care requires an organization that is highly reliable and dependent on each associate and medical staff member's participation in a culture of High Reliability. A High Reliability Organization is one that delivers on what it intends to do, putting in place systems, processes and behavior to build strong teams that will prevent errors and improve all areas of safety and experience for patients and associates..."

Review of the hospital's "Abuse" policy revealed, "...POLICY: It is the policy of [named healthcare company] and its associates to identify victims of abuse and neglect discovered in the course of providing patient care... PRINCIPLES/GUIDELINES...When an associate suspects that a patient is a victim of abuse, before or during hospitalization , the associate should immediately notify the patient's physician, the Patient Care Director, or House Supervisor...Adult and elderly abuse... Definition: Abuse means willful and unjustified infliction of pain, injury or mental anguish...Behavior symptoms may include...apprehension, fearfulness, helplessness... Psychological symptoms may be exhibited by irritability, exaggerated "startle" response, anxiety..."

Review of the hospital's "Associate Coaching, Counseling, and Corrective Action Guidelines, HR II-02" policy revealed, "...POLICY...It is expected that [named healthcare company] associates will, at all times, conduct themselves in a professional, efficient manner consistent with our mission and values... PURPOSE: The purpose of the corrective action process is to allow associates in most cases the opportunity to correct performance or behavioral issues before those issues have progressed to the point that the associate is terminated... CORRECTIVE ACTION GUIDELINES... Any act or omission...which in the judgment of management is not consistent with policy or the best interest of [named healthcare company] shall be grounds for corrective action up to and including termination, even for the first offense... Examples of infractions... Breach of internal or external customer service standards, or acting in a disrespectful manner to any patient, visitor, family member or co-worker... Threatening, intimidating, coercing, or using obscene and/or abusive language to a co-worker, patient, visitor or family member... Causing personal injury to self or others through willful acts, horseplay, or careless or negligent acts... Provoking or instigating a fight or disturbance, or threatening physical violence to another... Inappropriate behavior...Failure to follow safety...guidelines..."

Review of the hospital's "Patient Complaint and Grievance, SP-21" policy revealed, "...OBJECTIVE: To provide a centralized and systematic process for responding to a complaint or grievance filed by a patient or patient's representative in a timely and consistent manner... POLICY: [named healthcare company] recognizes that at times, patients or their representatives may be dissatisfied with the care, services and/or treatments provided to them... [named healthcare company] will respond to these grievances/complaints within the time frame prescribed by law, after appropriate review, analysis and action has been performed... DEFINITIONS...Grievances include the following... Allegations of abuse or neglect... All complaint/grievance investigations, recommendation and/or actions taken by [named healthcare company] are conducted for the purpose of quality improvement and peer review pursuant to Tennessee law... Management of Complaints...If there is a complaint of abuse, neglect and/or harm that complaint should be reported immediately the department manager, nursing supervisor, nursing director or guest relations representative and to the Risk Management Department. The staff should also follow [named healthcare company] policies in compliance with Tennessee state regulations regarding issues of abuse or neglect... Management of Grievances... Investigation findings will be communicated to Risk Management Department, who will be responsible for maintaining all information for use in QA/PI [quality assurance/performance improvement] activities..."

2. Review of a letter given to patients upon entering the hospital revealed, "...WE are committed to Providing Excellent Care... Our Promise to You...Treat you with RESPECT and DIGNITY...Be RESPONSIVE to you needs and make you COMFORTABLE while MANAGING your pain... Ensure COMFORTABLE, CLEAN and QUIET environment..."

3. Review of the hospital's "Medical Staff Bylaws" revealed, "... To insure a high level of professional performance of all staff members authorized to practice in the Hospital through the appropriate delineation of the clinical privileges that each staff member may exercise in the Hospital and through an ongoing review and evaluation of each practitioner's performance in the Hospital...To develop and enforce bylaws, rules and regulations and policies and procedures for self-governance of the Medical Staff... To provide a mechanism for accountability to the Governing Body regarding the appropriateness of patient care services and the professional and ethical conduct of each individual practitioner holding membership in the staff... To insure that all patients admitted to or treated in any of the facilities, departments or services of the Hospital shall receive quality care, observing at all times the following patient rights... Access to Care. Individuals shall be accorded impartial access to treatment or accommodations that are available or medically indicated...Respect and Dignity. The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his personal dignity... Personal Safety. The patient has the right to expect reasonable safety insofar as the Hospital practices and environment are concerned...ACTIVE MEDICAL STAFF... A physician shall be appointed to the Active Medical Staff of the [Hospital #1] will... Demonstrate professional competence in caring for his patients...full compliance with the ethical standards of his profession, and willingness to cooperate with other medical and Hospital personnel in establishing and maintaining a quality level of patient care..."

Review of the Physician's Job Summary revealed, "...Responsibilities... Evaluates and treats patients with appropriate medical diagnostic and treatment skills... participates in, and works to ensure... quality of care provided to patients... Respect and compassion for the dignity and diversity of life... Inspiring trust through personal leadership... Within scope of job, requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment..."

Review of the "CHIEF MEDICAL OFFICER ADDENDUM TO PHYSICIAN PRACTICE AGREEMENT" dated 7/24/13 with an effective date of 8/1/13 revealed, "... Initiates and assists in the organization and utilization of the Medical Staff and reviews the activities of the Medical Staff in accordance with ethical standards and the overall policies of the Hospital... Assists in the development and supervision, implementation, and operation of a quality assurance program as it relates to patient care... Responsible for the quality control of medical care...Is the lead physician of the Hospital's health care team... Participates in enforcing the Medical Staff Bylaws and all policies and procedures governing the Medical Staff, and oversees all instances when corrective action has been requested or taken against a Medical Staff member..."

4. Review of the Board (Governing Body) meeting minutes dated 6/27/13 through 4/23/15 revealed no documentation of complaints/grievances against Physician #1 or any monitoring of Physician #1's conduct.

Review of the Medical Executive Committee (MEC) meeting minutes dated 6/19/13 through 4/15/15 revealed no documentation of complaints/grievances against Physician #1 or any monitoring of Physician #1's conduct.

Review of the Quality Indicators monitored by the hospital dated July 2014 through March 2015 revealed no documentation that the complaints/grievances against Physician #1 had been incorporated into the hospital's Quality Assurance Performance Improvement Program.

During an interview in the Conference Room on 5/28/15 at 11:15 AM, while reviewing the meeting minutes and the Quality Indicators, the Chief Nursing Officer (CNO) stated that there was no information concerning the complaints/grievances against Physician #1 or any monitoring of Physician #1's conduct in these documents.

5. Review of credentialing documents for Physician #1 revealed a "Medical Staff Code of Conduct" dated 12/23/12 documenting, "...As a member of the...[Hospital #1]...I realize that I must treat others with respect, courtesy, and dignity, conducting myself in a professional and cooperative manner...I further understand that incidents of inappropriate conduct will be addressed and may become a matter for formal physician conduct review, possibly resulting in corrective action, suspension, or dismissal from the Medical Staff... While practicing at...[Hospital #1]...I agree to... Speak with kindness and courtesy to patients, families, hospital associates, and other physicians...Never engage in belittling, intimidating, threatening, or verbally attacking any person... Abstain from inappropriate physical contact with others... Abide by Medical Staff requirements as delineated in the Medical Staff Bylaws, Rules, and Regulations... working cooperatively and harmoniously with other members of the Medical and Hospital Staffs...Applicant's Signature [signed by Physician #1]..."

Review of Physician #1's Official Transcript dated from 6/14/11 through 5/28/15 revealed no documented training on patient abuse until 5/28/15 which was during the surveyor's visit to investigate this complaint.

6. Review of a complaint log provided by the hospital revealed, "...[Physician #1] Log...06-05-13...Pt [Patient #2] was seen in ED [Emergency Department] on 06-05-13. She stated that [Physician #1] yelled at her and said she was faking. She stated that he threw her file and said 'see.' She said that he told her she was going to get cancer if she continued to get CT [computerized tomography] scans, but then proceeded to order a CT..."

Medical record review for Patient #2 revealed an admitted to the ED of 6/5/13 with a chief complaint of abdominal pain. The History and Physical dated 6/5/13 documented, "...PAIN...Y...QUALITY...Sharp...TIMING...2 wks [weeks]...Present Now...[increasing]... Intermittent...ROS...Pain Sudden in Onset?...Y... Colicy?...Y... Nausea?...Y... GENITOURINARY... Dysuria?...Y...PHYSICAL EXAMINATION... GENERAL APPEARANCE...In Distress?...Y... NEURO/PSYCHIATRIC...Oriented x 3..." The physician's orders dated 6/5/13 documented, "...CT abd [abdomen] pelvis c [with] IV [intravenous] and oral contrast..." The nurses' note dated 6/5/13 documented, "...Dat [date]...06/5/13...Arrival Time: 1700 [5:00 PM]...CC(s) [chief complaint(s)]: Abdominal Pain...Acute/New... MENTAL STATUS...Alert... Oriented x3...ABDOMINAL PAIN...Onset...< 1 month... Type...Sharp...Burning... Throbbing... Constant... Changing Factors...Increases with...Palpation...Walking...Eating... Associated S/S [signs/symptoms]...SOB [shortness of breath]... N/V/D [nausea/vomiting/diarrhea]... Diaphoresis...dizzy... DISPOSITION... DISCHARGE... 6/5/13 2216 [10:16 PM]..."

Review of an "ASSOCIATE CONFERENCE REPORT" dated 7/18/13 revealed, "...ASSOCIATE NAME... [Physician #1]...SUPERVISOR/TITLE... [CNO/COO] [Chief Operating Officer]... TYPE OF MISCONDUCT OR PERFORMANCE PROBLEM... Inappropriate and unprofessional conduct that is disruptive and disrespectful... Action that harms goodwill between [named healthcare company] and its patients and the community we serve... SUPERVISOR'S REMARKS... An investigation revealed that you have made statements that were inappropriate and exhibited behavior that is not aligned with the [named healthcare company] mission, vision or values. Your behavior has left employees and patients feeling as though they were under attack and humiliated, which is unacceptable. Your failure to exercise prudence and discretion resulted in a patient being spiritually hurt when our primary purpose is to heal... Our expectation is that you exercise good judgment and interact with our patients and staff in a professional manner that is not confrontational or disruptive. You are being issued a Final Written Warning... You are also issued this notice that you must complete, at your own expense, [named professional course]. The central theme for the course is to provide physicians with disruptive behavior a safe, confidential environment where they can learn with their peers about the origins and consequences of their actions. Please submit proof of enrollment in the first available course and a detailed schedule for completing to Human Resources by 7/25/13. You [Your] employment is contingent on successful completion of these courses...Please know that any further incidents of this type of conduct may result in termination... ACTION TAKEN... Written Warning Final... [Physician #1's signature]... [CNO, COO's signature]..."

Review of the "Certificate of Attendance/Program for Distressed Physicians" revealed, "...[named medical school] certifies that [Physician #1] participated in the educational activity titled Program for Distressed Physicians at [named location] on August 28-30, 2013 and three follow-up sessions..."

During an interview in the Conference Room on 5/26/15 at 10:00 AM, the CNO confirmed the corrective action taken by the hospital in July 2013 was the direct result of the investigation for the complaint listed on Physician #1's Log dated 6/5/13. The CNO stated that if Physician #1 had not completed the course, he would have been fired. The CNO stated at that time, she was also the COO and responsible for the physicians. The CNO stated that the CMO took over that responsibility some time around the end of July 2013.

During an interview in the Chief Medical Officer's office on 5/26/15 at 10:30 AM, when asked about the corrective action taken against Physician #1 by the hospital in July 2013, the CMO stated, "...we had to send him to charm school... we've had no lawsuits against him which is a proxy for how one is doing..."

The hospital did not provide any documentation to evidence any steps taken by the hospital during the investigation to protect other patients or if and how the hospital monitored Physician #1 after he completed the required course to ensure patient safety from abuse.

7. Review of a complaint log provided by the hospital revealed, "...[Physician #1] Log...10-16-14...pt [Patient #3] complained to [named Nurse Practitioner], her PCP [primary care physician] at the clinic that she was seen in the ED here and [Physician #1] made her feel like a drug addict by the way he talked to her. Stated she came in here for anxiety and chest pain. She brought her medications with her and when she poured the bottles out [Physician #1] told her that right there's your problem. They ought to close those pain clinics. If you stop taking those medicines you will feel better. The patient was upset because she felt everyone in the ED could hear him yelling at her..."

Medical record review for Patient #3 documented an admitted to the ED of 9/21/14 with a chief complaint of sharp pain over head area. The History and Physical dated 9/21/14 documented, "...Physician: [Physician #1]... 09/21/14 7:41 PM... FINAL DIAGNOSES... Multiple complaints... Chronic pain... Anxiety..." The nurses' note dated 9/21/14 documented, "...Dat...09/21/14... Arrival Time: 1928 [7:28 PM]... NURSING ASSESSMENT... MENTAL STATUS... Awake...Alert... Oriented x3... Cooperative... CHEST...Pain... HEAD...Headache... RESPIRATORY... SOB...DISPOSITION... DISCHARGE...9/21/14...2035 [8:35 PM]..."

The hospital did not provide any documentation of an investigation of this complaint, any documented results of an investigation or any steps taken by the hospital to protect other patients from inappropriate physician behavior.

8. Review of a complaint log provided by the hospital revealed, "...[Physician #1]Log...02/06/15...[named long-term care facility] filed a complaint with [CNO]. A resident was transferred to the ED from [named long-term care facility]. The nurse complained that [Physician #1] was rude and screamed at her on the phone and hung up on her..."

The hospital did not provide any documentation of an investigation of this complaint or any documented results of an investigation.

9. Review of the complaint log for Physician #1 provided by the hospital revealed a complaint made by Patient #1 and Emergency Medical Services (EMS) concerning Physician #1 was not included in the document.

Medical record review for Patient #1 revealed the [AGE] year old patient was transported via EMS to Hospital #1 on 4/12/15 at 6:50 PM for a possible drug overdose. The History and Physical performed on 4/12/15 at 7:05 PM by Physician #1 documented, "...ROS [review of symptoms]... PSYCHIATRIC...Prior Psychiatric History?...Y [yes]... Depression... Bipolar... Anxiety... Drugs On Board?...Y... On Psychotropic Meds [medications]?...Y... Suicidal/Homicidal Ideation?... Voiced...Y... Recent Mood Change...Y... Confusion...N [no]...Agitation...Y... Hallucinations/Delusions?...N... PHYSICAL EXAMINATION... GENERAL APPEARANCE... In Distress?...N... Impaired LOC [level of consciousness]?...N... Responds to Voice?...Y...Pain?...Y... Cooperative?... N... Combative?...Y... PSYCHIATRIC...Oriented?...x3..." The physician's orders dated 4/12/15 documented, "...alcohol level...UDS [urine drug screen]..." The alcohol level was negative, and the UDS was positive for benzodiazepines, opiates and Oxycodone. The nurses' note dated 4/12/15 at 7:16 PM documented, "...Arrival Time: 1850 [6:50 PM]... NURSING ASSESSMENT... GENERAL...Distress...Severe... MENTAL STATUS...Awake... Alert... Combative...1855 [6:55 PM] Pt [patient] preferred not... [Physician #1] to take care of him for some reason...[signed by Nurse #2]..." The nurses' note dated 4/13/14 at 0:14 AM documented, "...DISPOSITION... TRANSFER to [Hospital #2]..."
Medical record review for Patient #1 from Hospital #2 revealed an admission date of [DATE] at 1:21 AM. The Consultation Report dated 4/13/15 documented, "...He [Patient #1] was brought to the emergency department [Hospital #1]. There, he states that he was somnolent and that he was struck by the emergency room physician, and this prompted him to be accused of suicidal ideation and transferred here for further care..." The "Neuro [neurological]/Behavioral Progress Note" dated 4/13/15 documented, "...Currently the patient endorses depressed and irritable mood, anger outbursts and easily provoked..." The Discharge Summary dated 4/13/15 documented, "...He [Patient #1] was cleared by Psychiatry and will be discharged home in stable condition..."

Review of the EMS' "Patient Care Record" for Patient #1 dated 4/12/15 revealed, "...UPON ARRIVAL TO [Hospital #1] WE TOOK PT IN ON STRETCHER. PT WAS CALM AND NOT HAVING TO BE RESTRAINED AT THIS TIME. [Physician #1] WALKED UP TO STRETCHER BEFORE WE MADE IT TO PTS ROOM AND BEGAN TO GIVE A VERY AGGRESSIVE STERNUM RUB. UPON ENTERING ROOM PT OPENED HIS EYES AT THIS TIME AND [Physician #1] STATED "I KNEW YOU WERE NOT HAVING A SEIZURE, I KNEW YOU WERE FAKING IT" THE STRETCHER WAS PRESSED UP TO THE HOSPITAL BED AND WE WERE GOING TO MOVE PT TO BED WHEN [Physician #1] AGAIN APPROACHED PT AND STARTED PUSHING THE PT TELLING PT TO "GET OVER ON THAT BED" PT DID NOT COMPLY AND [Physician #1] THEN STARTED PUSHING THE PTS HEAD WITH ONE HAND AND SHOULDER WITH THE OTHER. THE PT TOLD [Physician #1] TO STOP PUSHING HIM BUT [Physician #1] CONTINUED. THE PT LEANED AWAY FROM [Physician #1] and [Physician #1] ENDED UP GRABBING PTS HEAD AT ONE POINT AND THE PT WENT TO THE BED AND WAS ON HIS KNEES WITH HIS FISTS DRAWN AND [Physician #1] DREW HIS FISTS TELLING THE PT "I CAN TAKE YOU" DURING THIS ENTIRE INCIDENT THE PTS MOTHER WAS IN THE HALLWAY AND DOORWAY OF THE ROOM AND ASKING [Physician #1] TO PLEASE NOT HIT HER SON. AT THIS TIME I LEFT THE ER [emergency room /Department] DUE TO THE HOSTILITY OF THE SITUATION...Electronically Signed by: [EMS Employee #1]..."

10. Observations of the hospital's video recording revealed on 4/12/15 at approximately 6:58 PM, Patient #1 was brought to the emergency department escorted by EMS Employee #1 and 2. Patient #1 was sitting on the stretcher in a high Fowler's position. Patient #1 was awake and was turning his head as the stretcher entered through the doors. RN #1 met Patient #1 and EMS at the door and escorted them into the emergency department. Patient #1 disappeared from the camera's view as the stretcher turned the corner to enter the emergency department.

11. In the Conference Room on 5/5/15 at 2:45 PM, the CNO provided 4 pictures which she stated had been printed from her cellular phone. The CNO stated she received the pictures from Patient #1 on 4/15/15. She stated Patient #1 had taken the pictures of his chest with his cell phone some time after the altercation on 4/12/15 between Physician #1 and himself. Patient #1 sent the pictures to the CNO's cellular phone, and she printed the pictures from her phone.
Review of the pictures at this time revealed an area of discoloration on each side of the sternum.

During a phone interview on 5/27/15 at 10:30 AM, Patient #1 confirmed he sent pictures of his chest from his phone to the CNO's phone. Patient #1 stated the pictures were taken on Monday, 4/13/15 and show bruising caused by Physician #1 hitting his chest.

12. During a telephone interview on 5/6/15 at 1:50 PM, when asked to recount the incident, EMS Employee #1 stated, "...I picked him [Patient #1] up at home...an overdose...[Physician #1] met us at the door...said he [Patient #1] was faking...he got up on the cot...he did a very aggressive sternal rub...[in ED Trauma 1] we were setting up the stretcher to help the patient move over to the ER stretcher...[Physician #1] pushed him on the shoulder and head...kind of smacked him...the patient asked him to stop...[Physician #1] kept pushing him and telling him to get over on the stretcher...with the last push, the guy [Patient #1] got up on his hands and knees...[Physician #1] crouched down like he was going to fight...he raised his hands and balled his fists...he told the patient he could take him...he pushed him in the head and shoulder...I thought it was unprofessional...I called my supervisor...he [Patient #1] was lethargic [when they entered the ED]...we [EMS] gave him Narcan [on route to the ER]...he woke up and a little combative...he wasn't unresponsive...he was just lying there...the patient's mother came in and said [to Physician #1], "Don't hit my son, don't hit my son"...There have been issues in the past [about Physician #1]...it worried us [EMS Employee #1 and 2]...we felt like we needed to report...I want to be able to bring patients into the ER, but I can't do that in good conscience with the way he [Patient #1] was treated...it was not a good environment to bring a patient into...worried that this would happen again..."

During a telephone interview on 5/8/15 at 1:35 PM, when asked about the altercation between Physician #1 and Patient #1, EMS Employee #2 stated, "...We [EMS] brought him to the ER for an overdose... we gave him Narcan...he was agitated in the ambulance, but he calmed down... when we got to the ER... [Physician #1] started doing a sternal rub as hard as he could... before asking the patient anything... [Physician #1] said, "I knew you were faking"...we were pumping the stretcher to get it level with the ER stretcher... [Physician #1] started pushing him [Patient #1] and telling him "Get on over there"...the patient told him not to push him... [Physician #1] kept pushing him... patient rolled over on his knees and balled up his fists...[Physician #1] raised his hands and balled up his fists and said, "Come on, I can take you"...patient's mom... came in and said [to Physician #1], "Please don't hit my son"... [Physician #1] left the room... it was embarrassing and very unprofessional..." When asked if she was aware of any problems or concerns about Physician #1 prior to this incident, EMS Employee #2 stated, "...I've been here 5 years... yes...not as severe... he's rude with some patients... we want to provide help to people... [Physician #1] didn't provide help or a safe environment..." When asked where Physician #1 pushed Patient #1, EMS Employee #2 stated, "...pushed his shoulder and side of his head... contact was unjustified..." When asked why she felt the need to report the incident, EMS Employee #2 stated, "...my biggest concern is that [Physician #1] is going to cause harm... it's going to continue..."

During a telephone interview on 5/27/15 at 9:03 AM, when asked if he believed the allegations made by EMS Employee #1 and 2 concerning the altercation between Physician #1 and Patient #1, the EMS Director stated, "...yes, I believed them...I've known them for a long time..." When asked if he was aware of any prior problems or concerns with Physician #1's behavior, the EMS Director stated, "...At the first of the year, whenever we couldn't send an ambulance right away [to the ED], [Physician #1] would keep calling 911 or call here... and kind of yell at the crew... I told the Administrator that if he [Physician #1] had any problem with a decision we made about not sending an ambulance... because of tornadoes or ice storm... situation where it was not safe... or we didn't have an ambulance available because it was out on a call... he [Physician #1] needed to stop calling 911 or calling here and go through management..."

13. During an interview in the Conference Room on 5/6/15 at 10:40 AM, when asked to describe the altercation between Physician #1 and Patient #1, RN #1 stated, "...around shift change...over the radio...possible drug overdose...1st room on the right [Trauma 1]...most critical patients [patients typically placed in Trauma 1]...he [Patient #1] was somnolent..." RN #1 stated there were 2 EMS employees [EMS Employee #1 and 2] in the room who had transported Patient #1 to the ED and RN #2. RN #1 stated, "...[Physician #1] came in about the same time...doctor was shaking patient vigorously...[Physician #1] put his hand on patient's shoulder and pushed him vigorously...patient raised up and balled his fists...[Physician #1] crouched like he was going to fight...he told the patient to get over there [to the ED bed from the EMS stretcher]...his [Physician #1] voice was elevated...it was an angry "Get over there"...[Physician #1] said, "I'll take you down"...he [Physician #1] did make a threat [toward Patient #1]..." When asked about Physician #1 performing the sternal rub on Patient #1, RN #1 stated, "...it was a very vigorous sternal rub...went way beyond what was appropriate..." When asked if Patient #1 ever asked Physician #1 to stop pushing him, RN #1 stated, "...yes...he [Patient #1] was awake and told him [Physician #1] to stop..." When asked how Physician #1 responded, RN #1 stated, "...kept pushing him...that's when the patient balled up his fists..." When asked if anyone from administration had asked him about the incident, RN #1 stated, "...[CEO] did...he asked me if I thought this was a fireable offense...I told him I didn't know...maybe he [Physician #1] needed some counseling...[CEO] said that this has happened in the past..." When asked if he had experienced any problems or concerns with Physician #1 before, RN #1 stated, "...I've never seen anything physical before...he does raise his voice to patients and the nursing staff...this is the worst I've ever seen him [Physician #1]..."

14. During an interview in the Conference Room on 5/6/15 at 6:46 PM, when asked about the altercation between Physician #1 and Patient #1, RN #2 stated, "...at change of shift...[Physician #1] got a call from ambulance...questionable overdose...Klonopin and Meth...patient rolled in by ambulance...[Physician #1] did a sternal rub...heard him say, "Wake up and stop faking it"...[Physician #1] was pushing him to the other bed...patient was resistant and aggressive...said to [Physician #1], "Just stop it"...he was awake...the police came...he stayed here until midnight...sternal rub was out in the hallway...patient had been in ER before...patient said [to Physician #1], "I don't want you to lay your hands on me"...patient was in the bed when I went in between them..." When asked if Physician #1 told Patient #1 that he was under arrest, RN #2 stated, "...I heard that...[Physician #1] did apologize for his behavior...on 4/22 [2015] between 6 and 6:30 PM...[ED Director] was there...[RN #1], [RN #3] and [CEO]...they were going to have a meeting with the patient...the patient didn't show...he [Physician #1] apologized for his behavior for the incident..." When asked if she had ever witnessed this type of behavior before from Physician #1, RN #2 stated, "...yes...with patients with pain issues...patients with drug issues...he easily gets mad...I've heard him say [to a patient], "You're not going to get pain med"...he can be very furious..."

During a telephone interview on 5/28/15 at 1:05 PM, when asked how hard Physician #1 pushed Patient #1, RN #2 stated, "...I remember him [Physician #1] shoving him [Patient #1]..." When asked why she stepped between Physician #1 and Patient #1 during the altercation, RN #2 stated, "...just to stop it...the situation was getting worse... that's the worst I've seen him [Physician #1]...his face was red...his voice was trembling... I don't know what was going on with him..." When asked if she felt Physician #1's behavior was inappropriate, RN #2 stated, "...I think so..." When asked if the Administration had taken any action to address this incident, RN #2 stated, "...[CEO] said to help each other... watch each other..."

15. During an interview in the Conference Room on 5/6/15 at 11:06 AM, RN #3 stated she was at the nurses' station faxing paperwork for another patient when the altercation between Physician #1 and Patient #1 occurred. RN #3 stated she hit the panic button behind the desk which alerted the police on their radio. RN #3 stated she called the police dispatch, and the police arrived within a minute or two. RN #3 confirmed she was not in the room during the altercation but did hear Physician
VIOLATION: STAFFING AND STAFF RESPONSIBLITIES Tag No: C0250
Based on facility policy review, medical staff bylaws review, document review, medical record review, and interview, the hospital ' s Chief Medical Officer (CMO) failed to demonstrate medical direction, supervision and oversight of the health care activities in the Emergency Department by not ensuring appropriate physician staff behavior was demonstrated. Failure to ensure appropriate physician behavior resulted in a SERIOUS and IMMEDIATE THREAT to the HEALTH and SAFETY of Patient #1 and placed all Emergency Department patients in IMMEDIATE JEOPARDY and at risk for serious injury from abuse.

The findings included:

The hospital did not provide any evidence to demonstrate the medical staff leadership had ensured a thorough investigation concerning allegations of physician abuse, implemented any interventions subsequent to the abuse allegations made by EMS employees and Patient #1 to ensure patient safety or initiated direction, supervision and oversight of the care provided in the ED.
Despite numerous complaints of abusive behavior and medical staff awareness of inappropriate and abusive behavior, Physician #1 was allowed to continue working in the ED without interventions or monitoring being implemented by the medical staff leadership to ensure patient safety from abuse.
VIOLATION: RESPONSIBILITIES OF DOCTOR Tag No: C0257
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on facility policy review, medical staff bylaws review, document review, medical record review, and interview, the hospital ' s Chief Medical Officer (CMO) failed to demonstrate medical direction, supervision and oversight of the health care activities in the Emergency Department by not ensuring appropriate physician staff behavior was demonstrated for 3 of 5 (Patient #1, 2 and 3) sampled patients. Failure to ensure appropriate physician behavior resulted in a SERIOUS and IMMEDIATE THREAT to the HEALTH and SAFETY of Patient #1 and placed all Emergency Department patients in IMMEDIATE JEOPARDY and at risk for serious injury from abuse.

The findings included:

1. Review of the hospital's "Patient Rights and Responsibilities" policy revealed, "...Patient [Pt] Rights...You have the right to safe, high quality, compassionate healthcare, without fear of discrimination of any kind...You have the right to the most appropriate medical treatment available, delivered in a safe, considerate, and respectful manner...You have the right to be free from all forms of abuse, neglect and exploitation..."

Review of the hospital's "Standards of Conduct, SP-13" policy revealed, "...PURPOSE: The Standards of Conduct describe the behavior and conduct expected of [named healthcare company] associates, medical staff, Board Committee members and contractors... Each associate is expected to act in a manner consistent with the Standards of Conduct... Deliver Clinically Excellent and Safe Patient Care: We deliver spiritually centered care to our patients that supports the physical, mental, emotional, social and spiritual needs of the person. Clinically excellent and safe care requires an organization that is highly reliable and dependent on each associate and medical staff member's participation in a culture of High Reliability. "

Review of the hospital's "Associate Coaching, Counseling, and Corrective Action Guidelines, HR II-02" policy revealed, " ...PURPOSE: The purpose of the corrective action process is to allow associates in most cases the opportunity to correct performance or behavioral issues before those issues have progressed to the point that the associate is terminated... CORRECTIVE ACTION GUIDELINES... Any act or omission...which in the judgment of management is not consistent with policy or the best interest of [named healthcare company] shall be grounds for corrective action up to and including termination, even for the first offense... Examples of infractions... acting in a disrespectful manner to any patient, visitor, family member or co-worker... Threatening, intimidating, coercing, or using obscene and/or abusive language to a co-worker, patient, visitor or family member... Causing personal injury to self or others through willful acts ... Provoking or instigating a fight or disturbance, or threatening physical violence to another...

Review of the hospital's "Patient Complaint and Grievance, SP-21" policy revealed, "...OBJECTIVE: To provide a centralized and systematic process for responding to a complaint or grievance filed by a patient or patient's representative in a timely and consistent manner... [named healthcare company] will respond to these grievances/complaints within the time frame prescribed by law, after appropriate review, analysis and action has been performed... DEFINITIONS...Grievances include the following... Allegations of abuse or neglect... All complaint/grievance investigations, recommendation and/or actions taken by [named healthcare company] are conducted for the purpose of quality improvement and peer review pursuant to Tennessee law... Management of Complaints...If there is a complaint of abuse, neglect and/or harm that complaint should be reported immediately the department manager, nursing supervisor, nursing director or guest relations representative and to the Risk Management Department. The staff should also follow [named healthcare company] policies in compliance with Tennessee state regulations regarding issues of abuse or neglect... Management of Grievances... Investigation findings will be communicated to Risk Management Department, who will be responsible for maintaining all information for use in QA/PI [quality assurance/performance improvement] activities..."

2. Review of a letter given to patients upon entering the hospital revealed, "...WE are committed to Providing Excellent Care... Our Promise to You...Treat you with RESPECT and DIGNITY...Be RESPONSIVE to you needs and make you COMFORTABLE while MANAGING your pain... Ensure COMFORTABLE, CLEAN and QUIET environment..."

3. Review of the hospital's "Medical Staff Bylaws" revealed, "...PREAMBLE...Whereas, its [hospital] purpose is to provide for the health care needs of patients in all the services... Whereas, in furtherance of the Core Values of Respect and Quality Services, the Hospital is committed to carrying out its health ministry in a manner consistent with the [named healthcare system] and [named healthcare company] Mission, vision, values and Hospital's strategic plan, include adhering to a high standard of individual and organizational ethical and business practices... NAME...The name of the organization is the Medical Staff of the [named hospital]... PURPOSES...To assure that all patients admitted to or treated in any of the facilities, departments, or services of the Hospital shall receive the highest level of care attainable within the Hospital's means and circumstances... To insure a high level of professional performance of all staff members authorized to practice in the Hospital through the appropriate delineation of the clinical privileges that each staff member may exercise in the Hospital and through an ongoing review and evaluation of each practitioner's performance in the Hospital...To develop and enforce bylaws, rules and regulations and policies and procedures for self-governance of the Medical Staff... Subject to the authority and approval of the Governing Body, to exercise such power as is reasonably necessary to discharge its responsibilities under these bylaws... To provide a mechanism for accountability to the Governing Body regarding the appropriateness of patient care services and the professional and ethical conduct of each individual practitioner holding membership in the staff... To insure that all patients admitted to or treated in any of the facilities, departments or services of the Hospital shall receive quality care, observing at all times the following patient rights... Access to Care. Individuals shall be accorded impartial access to treatment or accommodations that are available or medically indicated...Respect and Dignity. The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his personal dignity... Personal Safety. The patient has the right to expect reasonable safety insofar as the Hospital practices and environment are concerned...ACTIVE MEDICAL STAFF... A physician shall be appointed to the Active Medical Staff of the [Hospital #1] will... Demonstrate professional competence in caring for his patients...full compliance with the ethical standards of his profession, and willingness to cooperate with other medical and Hospital personnel in establishing and maintaining a quality level of patient care..."

Review of the Physician's Job Summary revealed, "...Responsibilities... Evaluates and treats patients with appropriate medical diagnostic and treatment skills... participates in, and works to ensure... quality of care provided to patients... Respect and compassion for the dignity and diversity of life... Inspiring trust through personal leadership... Within scope of job, requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment..."

4. Review of the "CHIEF MEDICAL OFFICER ADDENDUM TO PHYSICIAN PRACTICE AGREEMENT" dated 7/24/13 with an effective date of 8/1/13 revealed, "...Covenants of Officer...Applicable Standards... Officer shall perform the Chief Medical Officer [CMO] Services in conformance with all requirements of Hospital Policies, Medicare Conditions of Participation, The Joint Commission, and all applicable federal and state statutes and regulations...Chief Medical Officer Services... Initiates and assists in the organization and utilization of the Medical Staff and reviews the activities of the Medical Staff in accordance with ethical standards and the overall policies of the Hospital... Formulates policies and objectives for medical programs and communicates these policies to appropriate staff for execution within an integrated team case management approach... Assists in developing the Hospital's clinical policies and formulating the mission, goals and philosophy of care... Oversight for annual and periodic evaluations of clinical providers... Recommends qualifications statements for credentialing, job descriptions, and evaluation standards for all clinical personnel... Assists in the development and supervision, implementation, and operation of a quality assurance program as it relates to patient care... Responsible for the quality control of medical care...Is the lead physician of the Hospital's health care team... Participates in enforcing the Medical Staff Bylaws and all policies and procedures governing the Medical Staff, and oversees all instances when corrective action has been requested or taken against a Medical Staff member..."

5. Review of the Board (Governing Body) meeting minutes dated 6/27/13 through 4/23/15 revealed no documentation of complaints/grievances against Physician #1 or any monitoring of Physician #1's conduct.

Review of the Medical Executive Committee (MEC) meeting minutes dated 6/19/13 through 4/15/15 revealed no documentation of complaints/grievances against Physician #1 or any monitoring of Physician #1's conduct.

Review of the Quality Indicators monitored by the hospital dated July 2014 through March 2015 revealed no documentation that the complaints/grievances against Physician #1 had been incorporated into the hospital's Quality Assurance Performance Improvement Program.

During an interview in the Conference Room on 5/28/15 at 11:15 AM, while reviewing the meeting minutes and the Quality Indicators, the Chief Nursing Officer (CNO) stated that there was no information concerning the complaints/grievances against Physician #1 or any monitoring of Physician #1's conduct in these documents.

6. Review of credentialing documents for Physician #1 revealed a "Medical Staff Code of Conduct" dated 12/23/12 documenting, "...As a member of the...[Hospital #1]...I realize that I must treat others with respect, courtesy, and dignity, conducting myself in a professional and cooperative manner...I further understand that incidents of inappropriate conduct will be addressed and may become a matter for formal physician conduct review, possibly resulting in corrective action, suspension, or dismissal from the Medical Staff... While practicing at...[Hospital #1]...I agree to... Speak with kindness and courtesy to patients, families, hospital associates, and other physicians...Never engage in belittling, intimidating, threatening, or verbally attacking any person... Abstain from inappropriate physical contact with others... Abide by Medical Staff requirements as delineated in the Medical Staff Bylaws, Rules, and Regulations... working cooperatively and harmoniously with other members of the Medical and Hospital Staffs...Applicant's Signature [signed by Physician #1]..."

During an interview in the Conference Room on 5/26/15 at 8:55 AM, when asked about Physician #1's training, the CNO stated Physician #1 had not had abuse training since 2009.

Review of Physician #1's Official Transcript dated from 6/14/11 through 5/28/15 revealed no documented training on patient abuse until 5/28/15 which was during the surveyor's visit to investigate this complaint.

7. Review of a complaint log provided by the hospital revealed, "...[Physician #1] Log...06-05-13...Pt [Patient #2] was seen in ED [Emergency Department] on 06-05-13. She stated that [Physician #1] yelled at her and said she was faking. She stated that he threw her file and said 'see.' She said that he told her she was going to get cancer if she continued to get CT [computerized tomography] scans, but then proceeded to order a CT..."

Review of an "ASSOCIATE CONFERENCE REPORT" dated 7/18/13 revealed, "...ASSOCIATE NAME... [Physician #1]...SUPERVISOR/TITLE... [CNO/COO] [Chief Operating Officer]... TYPE OF MISCONDUCT OR PERFORMANCE PROBLEM... Inappropriate and unprofessional conduct that is disruptive and disrespectful... Action that harms goodwill between [named healthcare company] and its patients and the community we serve... SUPERVISOR'S REMARKS... An investigation revealed that you have made statements that were inappropriate and exhibited behavior that is not aligned with the [named healthcare company] mission, vision or values. Your behavior has left employees and patients feeling as though they were under attack and humiliated, which is unacceptable. Your failure to exercise prudence and discretion resulted in a patient being spiritually hurt when our primary purpose is to heal... Our expectation is that you exercise good judgment and interact with our patients and staff in a professional manner that is not confrontational or disruptive. You are being issued a Final Written Warning... You are also issued this notice that you must complete, at your own expense, [named professional course]. The central theme for the course is to provide physicians with disruptive behavior a safe, confidential environment where they can learn with their peers about the origins and consequences of their actions. Please submit proof of enrollment in the first available course and a detailed schedule for completing to Human Resources by 7/25/13. You [Your] employment is contingent on successful completion of these courses...Please know that any further incidents of this type of conduct may result in termination... ACTION TAKEN... Written Warning Final... [Physician #1's signature]... [CNO, COO's signature]..."

Review of the "Certificate of Attendance/Program for Distressed Physicians" revealed, "...[named medical school] certifies that [Physician #1] participated in the educational activity titled Program for Distressed Physicians at [named location] on August 28-30, 2013 and three follow-up sessions..."

During an interview in the Conference Room on 5/26/15 at 10:00 AM, the CNO confirmed the corrective action taken by the hospital in July 2013 was the direct result of the investigation for the complaint listed on Physician #1's Log dated 6/5/13. The CNO stated that if Physician #1 had not completed the course, he would have been fired. The CNO stated at that time, she was also the COO and responsible for the physicians. The CNO stated that the CMO took over that responsibility some time around the end of July 2013.

During an interview in the Chief Medical Officer ' s office on 5/26/15 at 10:30 AM, when asked about the corrective action taken against Physician #1 by the hospital in July 2013, the CMO stated, "...we had to send him to charm school... we've had no lawsuits against him which is a proxy for how one is doing..."

The hospital did not provide any documentation to evidence any steps taken during the investigation to protect other patients or evidence to demonstrate medical staff leadership participated in oversight, supervision and monitoring of Physician #1 ' s behavior after he completed the required course in order to ensure patient safety from abuse.

8. Review of a complaint log provided by the hospital revealed, "...[Physician #1] Log...10-16-14...pt [Patient #3] complained to [named Nurse Practitioner], her PCP [primary care physician] at the clinic that she was seen in the ED here and [Physician #1] made her feel like a drug addict by the way he talked to her. Stated she came in here for anxiety and chest pain. She brought her medications with her and when she poured the bottles out [Physician #1] told her that right there's your problem. They ought to close those pain clinics. If you stop taking those medicines you will feel better. The patient was upset because she felt everyone in the ED could hear him yelling at her..."

The hospital did not provide any documentation of an investigation of this complaint, any documented results of an investigation, any steps taken to protect other patients from inappropriate physician behavior or any evidence of medical staff leadership involvement in this abuse allegation.

9. Review of a complaint log provided by the hospital revealed, "...[Physician #1] Log... 02/06/15... [named long-term care facility] filed a complaint with [CNO]. A resident was transferred to the ED from [named long-term care facility]. The nurse complained that [Physician #1] was rude and screamed at her on the phone and hung up on her..."

The hospital did not provide any documentation of an investigation of this complaint, any documented results of an investigation or any evidence of medical staff leadership involvement in this abuse allegation.

10. Review of the complaint log for Physician #1 provided by the hospital revealed there was no entry of a complaint made by Patient #1 and Emergency Medical Services (EMS) concerning Physician #1.

Medical record review for Patient #1 revealed the [AGE] year old patient was transported via EMS to Hospital #1 on 4/12/15 at 6:50 PM for a possible drug overdose. The History and Physical performed on 4/12/15 at 7:05 PM by Physician #1 documented, patient #1 had prior psychiatric history, drugs on board, on psychotropic medications, voiced suicidal or homicidal ideation, had recent mood change, agitation, responds to voice, combative and was not cooperative. The form documented the patient was oriented, not confused, did not have hallucinations or delusions, was not in distress, and did not have an impaired level of consciousness. The physician's orders dated 4/12/15 documented, "...alcohol level...UDS [urine drug screen]..." The alcohol level results were negative, and the UDS was positive for benzodiazepines, opiates and Oxycodone. The nurses' note dated 4/12/15 at 7:16 PM documented, the patient preferred not to have Physician #1 to take care of him. A nurses' note dated 4/13/14 at 0:14 AM documented the patient was transferred to Hospital #2.

Review of the medical record for Patient #1 from Hospital #2 revealed an admission date of [DATE] at 1:21 AM. The Consultation Report dated 4/13/15 documented, "...He [Patient #1] was brought to the emergency department [Hospital #1]. There, he states that he was somnolent and that he was struck by the emergency room physician, and this prompted him to be accused of suicidal ideation and transferred here for further care..."

Review of the Emergency Medical Services (EMS) "Patient Care Record" for Patient #1 dated 4/12/15 revealed, "...UPON ARRIVAL TO [Hospital #1] WE TOOK PT IN ON STRETCHER. PT WAS CALM AND NOT HAVING TO BE RESTRAINED AT THIS TIME. [Physician #1] WALKED UP TO STRETCHER BEFORE WE MADE IT TO PTS ROOM AND BEGAN TO GIVE A VERY AGGRESSIVE STERNUM RUB. UPON ENTERING ROOM PT OPENED HIS EYES AT THIS TIME AND [Physician #1] STATED "I KNEW YOU WERE NOT HAVING A SEIZURE, I KNEW YOU WERE FAKING IT" THE STRETCHER WAS PRESSED UP TO THE HOSPITAL BED AND WE WERE GOING TO MOVE PT TO BED WHEN [Physician #1] AGAIN APPROACHED PT AND STARTED PUSHING THE PT TELLING PT TO "GET OVER ON THAT BED" PT DID NOT COMPLY AND [Physician #1] THEN STARTED PUSHING THE PTS HEAD WITH ONE HAND AND SHOULDER WITH THE OTHER. THE PT TOLD [Physician #1] TO STOP PUSHING HIM BUT [Physician #1] CONTINUED. THE PT LEANED AWAY FROM [Physician #1] and [Physician #1] ENDED UP GRABBING PTS HEAD AT ONE POINT AND THE PT WENT TO THE BED AND WAS ON HIS KNEES WITH HIS FISTS DRAWN AND [Physician #1] DREW HIS FISTS TELLING THE PT "I CAN TAKE YOU" DURING THIS ENTIRE INCIDENT THE PTS MOTHER WAS IN THE HALLWAY AND DOORWAY OF THE ROOM AND ASKING [Physician #1] TO PLEASE NOT HIT HER SON. AT THIS TIME I LEFT THE ER [emergency room /Department] DUE TO THE HOSTILITY OF THE SITUATION...Electronically Signed by: [EMS Employee #1]..."

11. In the Conference Room on 5/5/15 at 2:45 PM, the CNO provided 4 pictures which she stated had been printed from her cellular phone. The CNO stated she received the pictures from Patient #1 on 4/15/15. She stated Patient #1 had taken the pictures of his chest with his cell phone some time after the altercation on 4/12/15 between Physician #1 and himself. Patient #1 sent the pictures to the CNO's cellular phone, and she printed the pictures from her phone.
Review of the pictures revealed an area of discoloration on each side of the sternum.

During a telephone interview on 5/27/15 at 10:30 AM, Patient #1 confirmed he sent pictures of his chest from his phone to the CNO's phone. Patient #1 stated the pictures were taken on Monday, 4/13/15 and show bruising caused by Physician #1 hitting his chest.

12. During a telephone interview on 5/6/15 at 1:50 PM, EMS Employee #1 stated Physician #1 said Patient #1 was faking, he got up on the cot, he did a very aggressive sternal rub. Physician #1 pushed the patient on the shoulder and head, kind of smacked him, the patient asked him to stop, Physician #1 kept pushing him and telling him to get over on the stretcher, with the last push the patient got up on his hands and knees, Physician #1 crouched down like he was going to fight. The physician raised his hands and balled his fists and told the patient he could take him. Physician #1 pushed the patient in the head and shoulder. EMS Employee #1 stated, " I thought it was unprofessional... I called my supervisor... he [Patient #1] was lethargic [when they entered the ED]...we [EMS] gave him Narcan [on route to the ER]...he woke up and a little combative...he wasn't unresponsive...he was just lying there...the patient's mother came in and said [to Physician #1], ' Don't hit my son, don't hit my son ' ...There have been issues in the past [about Physician #1]...it worried us [EMS Employee #1 and 2]...we felt like we needed to report...I want to be able to bring patients into the ER, but I can't do that in good conscience with the way he [Patient #1] was treated...it was not a good environment to bring a patient into...worried that this would happen again..."

During a telephone interview on 5/8/15 at 1:35 PM, when asked about the altercation between Physician #1 and Patient #1, EMS Employee #2 stated when they arrived at the ED Physician #1 started doing a sternal rub as hard as he could before asking the patient anything. Physician #1 said, ' I knew you were faking ' . Physician #1 started pushing Patient #1 and telling him to " Get on over there " and the patient told him not to push him. Physician #1 kept pushing him and the patient rolled over on his knees and balled up his fists. Physician #1 raised his hands and balled up his fists and said, " Come on, I can take you. " The patient's mother came in and said to Physician #1, "Please don't hit my son." EMS Employee #2 stated, " it was embarrassing and very unprofessional..." When asked if she was aware of any problems or concerns about Physician #1 prior to this incident, EMS Employee #2 stated, "...I've been here 5 years... yes...not as severe... he's rude with some patients... we want to provide help to people... [Physician #1] didn't provide help or a safe environment..." When asked where Physician #1 pushed Patient #1, EMS Employee #2 stated, "...pushed his shoulder and side of his head... contact was unjustified..." When asked why she felt the need to report the incident, EMS Employee #2 stated, "...my biggest concern is that [Physician #1] is going to cause harm... it's going to continue..."

During a telephone interview on 5/27/15 at 9:03 AM, when asked if he believed the allegations made by EMS Employee #1 and 2 concerning the altercation between Physician #1 and Patient #1, the EMS Director stated, "...yes, I believed them...I've known them for a long time..." The EMS Director stated, "...At the first of the year, whenever we couldn't send an ambulance right away [to the ED], [Physician #1] would keep calling 911 or call here... and kind of yell at the crew... I told the Administrator that if he [Physician #1] had any problem with a decision we made about not sending an ambulance he needed to stop calling 911 or calling here and go through management..."

13. During an interview in the Conference Room on 5/6/15 at 10:40 AM, RN #1 stated Patient #1 was somnolent, there were 2 EMS employees and RN #2 in the room. Physician #1 was shaking the patient vigorously. Physician #1 put his hand on Patient #1 ' s shoulder and pushed him vigorously. The patient raised up and balled his fists. Physician #1 crouched like he was going to fight. Physician #1 told the patient to get over there [to the ED bed from the EMS stretcher] Physician #1 voice was elevated, it was an angry, "Get over there." RN #1 stated Physician #1 said to Patient #1, ' I'll take you down ' [Physician #1] did make a threat [toward Patient #1]..." When asked about Physician #1 performing the sternal rub on Patient #1, RN #1 stated, "...it was a very vigorous sternal rub...went way beyond what was appropriate..." When asked if Patient #1 ever asked Physician #1 to stop pushing him, RN #1 stated, "...yes...he [Patient #1] was awake and told him [Physician #1] to stop..." When asked how Physician #1 responded, RN #1 stated, "...kept pushing him...that's when the patient balled up his fists..." When asked if anyone from administration had asked him about the incident, RN #1 stated the CEO did asked him if he thought this was a fireable offense and RN #1 told the CEO he didn't know, maybe Physician #1 needed some counseling. RN #1 stated the CEO said that this has happened in the past. When asked if he had experienced any problems or concerns with Physician #1 before, RN #1 stated, "...I've never seen anything physical before...he does raise his voice to patients and the nursing staff...this is the worst I've ever seen him [Physician #1]..."

14. During an interview in the Conference Room on 5/6/15 at 6:46 PM, RN #2 stated Physician #1 did a sternal rub on Patient #1 and she heard him say, "Wake up and stop faking it." Physician #1 was pushing the patient to the other bed and the patient was resistant and aggressive and said to Physician #1, "Just stop it." The RN stated the patient was awake and that the police came. She stated the patient said to Physician #1, "I don't want you to lay your hands on me" and that the patient was in the bed when she went in between them. When asked if Physician #1 told Patient #1 that he was under arrest, RN #2 stated, "...I heard that...[Physician #1] did apologize for his behavior...on 4/22 [2015] between 6 and 6:30 PM...[ED Director] was there...[RN #1], [RN #3] and [CEO]...they were going to have a meeting with the patient...the patient didn't show...he [Physician #1] apologized for his behavior for the incident..." When asked if she had ever witnessed this type of behavior before from Physician #1, RN #2 stated, "...yes...with patients with pain issues...patients with drug issues...he easily gets mad...I've heard him say [to a patient], "You're not going to get pain med"...he can be very furious..."

During a telephone interview on 5/28/15 at 1:05 PM, when asked how hard Physician #1 pushed Patient #1, RN #2 stated, "...I remember him [Physician #1] shoving him [Patient #1]..." When asked why she stepped between Physician #1 and Patient #1 during the altercation, RN #2 stated, "...just to stop it...the situation was getting worse... that's the worst I've seen him [Physician #1]...his face was red...his voice was trembling... I don't know what was going on with him..." When asked if she felt Physician #1's behavior was inappropriate, RN #2 stated, "...I think so..." When asked if Administration had taken any action to address this incident, RN #2 stated, "...[CEO] said to help each other... watch each other..."

15. During an interview in the Conference Room on 5/6/15 at 11:06 AM, RN #3 stated she was at the nurses' station faxing paperwork for another patient when the altercation between Physician #1 and Patient #1 occurred. RN #3 stated she hit the panic button behind the desk which alerted the police on their radio. RN #3 stated she called the police dispatch, and the police arrived within a minute or two. RN #3 confirmed she was not in the room during the altercation but did hear Physician #1 telling Patient #1, "...You're faking it..."

16. During an interview in the Conference Room on 5/6/15 at 2:35 PM, the ED Charge Nurse stated Patient #1 stated he didn't want Physician #1 in his room, he wanted to go to another hospital. He said, "I don't want that doctor." There was an officer in the patient ' s room. Physician #1 told the patient he was under arrest." When asked if she was aware of any prior problems or concerns about Physician #1's behavior, the ED Charge Nurse stated, "...yes...verbally...he [Physician #1] would respond in kind [to how the patients or employees behaved]...I've seen him restrain a patient...he could tone it down..."

17. During a telephone interview on 5/27/15 at 10:30 AM, Patient #1 stated, "...I've been going there [ED Department] all my life... I went to the doctor at [behavioral healthcare facility]... swapped my medication to Paxil... had an adverse effect... mother thought I had overdosed... I was having difficulty breathing and [Physician #1] came over and started hitting me on the chest...he said, "There's nothing wrong with you" ...he smacked me on the side of the head and told me to get over there... from the gurney to the ER bed... he said I was faking a seizure... he pushed me by the face, and I told him to stop... he pushed me again, and I told him if he did we would go at it... he raised his hands up and balled up his fists and said, "I'll knock you out"... he was rude... he was treating me like a drug addict... he said, "You're one of those pill mill junkies"... When asked how the hospital responded to his allegations, Patient #1 stated, "...doctor [ED Director] and head nurse [CNO] met with me... they said they would look into it... [CEO] told me that the hospital bills would be taken care of... [CEO] asked me to come in so [Physician #1] could apologize to me... I told him no disrespect, but I didn't want to have any contact with him [Physician #1]...I've been back to the ER...had some broken ribs from a machine falling on me...I asked my mother to call to see if he was there...[Physician #1] wasn't there, so I went in and was treated fine..." Patient #1 stated he would not go to Hospital #1's ED if Physician #1 was on duty there. He stated he would either have to travel to somewhere else or not seek treatment at all. Patient #1 stated he was afraid of the way he would be treated by Physician #1 if he went to Hospital #1's ED, and Physician #1 was on duty.

18. During a telephone interview on 5/28/15 at 2:45 PM, Patient #1's Family Member #1 stated, "... he [Patient #1] had been there before and [Physician #1] accused him of coming there just to get drugs... his chest was hurting...he had an upper respiratory infection...[Physician #1] doesn't believe in giving people pain medication...he [Patient #1] didn't want to deal with him [Physician #1]...when I went in [Trauma 1], [Patient #1] was standing up...he was agitated with him [Physician #1]...he did have marks on him [on his chest]...his shirt was torn when I went in...it wasn't when they loaded him in the ambulance...[Physician #1] told me he was faking something...I don't remember what it was...they were moving him from the ambulance bed to the other bed...[Patient #1] told him several times not to touch him... I told [Physician #1] that something had to be wrong... I wanted to make sure everything was done... they took his blood and urine...nothing showed except the meds [medications] he was on... when the Crisis Team got there, they said they couldn't do anything because there wasn't anything in his system... when we got to Nashville, we found out the medication they had put him on [Paxil according to Patient #1] threw him back like he was when he was taking meth... I don't think he [Physician #1] really done right with the way he
VIOLATION: PROVISION OF SERVICES Tag No: C0270
Based on facility policy review, document review, medical record review, and interview, the hospital ' s Chief Nursing Officer (CNO) failed to ensure the Emergency Department nursing staff were adequately trained, oriented and aware of the facility abuse policy reporting requirements. Failure to ensure nursing staff knowledge of and adherence to the abuse policy resulted in the abusive situation involving Patient #1 not being immediately reported and placed all Emergency Department patients in IMMEDIATE JEOPARDY and at risk for serious injury from abuse.

The findings included:

The hospital did not provide any evidence to demonstrate nursing staff followed its policy for reporting abuse despite numerous complaints of abusive behavior and staff awareness of inappropriate and abusive behavior by Physician #1.
VIOLATION: NURSING SERVICES Tag No: C0294
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on facility policy review, document review, medical record review, and interview, the hospital ' s Chief Nursing Officer (CNO) failed to ensure the Emergency Department nursing staff were adequately trained, oriented and aware of the facility abuse policy reporting requirements 1 of 5 (Patient #1) sampled patients. Failure to ensure nursing staff knowledge of and adherence to the abuse policy resulted in the abusive situation involving Patient #1 not being immediately reported and placed all Emergency Department patients in IMMEDIATE JEOPARDY and at risk for serious injury from abuse.

The findings included:

1. Review of the hospital's "Patient Rights and Responsibilities" policy revealed, "...Patient [Pt] Rights...You have the right to safe, high quality, compassionate healthcare, without fear of discrimination of any kind...You have the right to the most appropriate medical treatment available, delivered in a safe, considerate, and respectful manner...You have the right to be free from all forms of abuse, neglect and exploitation..."

Review of the hospital's "Abuse" policy revealed, "...POLICY: It is the policy of [named healthcare company] and its associates to identify victims of abuse and neglect discovered in the course of providing patient care... PRINCIPLES/GUIDELINES...When an associate suspects that a patient is a victim of abuse, before or during hospitalization , the associate should immediately notify the patient's physician, the Patient Care Director, or House Supervisor...Adult and elderly abuse... Definition: Abuse means willful and unjustified infliction of pain, injury or mental anguish...Behavior symptoms may include...apprehension, fearfulness, helplessness... Psychological symptoms may be exhibited by irritability, exaggerated "startle" response, anxiety..."

Review of a letter given to patients upon entering the hospital revealed, "...WE are committed to Providing Excellent Care... Our Promise to You...Treat you with RESPECT and DIGNITY...Be RESPONSIVE to you needs and make you COMFORTABLE while MANAGING your pain... Ensure COMFORTABLE, CLEAN and QUIET environment..."

2. Review of a complaint log provided by the hospital revealed:

a) "...[Physician #1] Log...06-05-13...Pt [Patient #2] was seen in ED [Emergency Department] on 06-05-13. She stated that [Physician #1] yelled at her and said she was faking. She stated that he threw her file and said 'see.' She said that he told her she was going to get cancer if she continued to get CT [computerized tomography] scans, but then proceeded to order a CT..."

b) "...[Physician #1] Log...10-16-14...pt [Patient #3] complained to [named Nurse Practitioner], her PCP [primary care physician] at the clinic that she was seen in the ED here and [Physician #1] made her feel like a drug addict by the way he talked to her. Stated she came in here for anxiety and chest pain. She brought her medications with her and when she poured the bottles out [Physician #1] told her that right there's your problem. They ought to close those pain clinics. If you stop taking those medicines you will feel better. The patient was upset because she felt everyone in the ED could hear him yelling at her..."

c) " ...[Physician #1]Log...02/06/15...[named long-term care facility] filed a complaint with [CNO]. A resident was transferred to the ED from [named long-term care facility]. The nurse complained that [Physician #1] was rude and screamed at her on the phone and hung up on her..."

d) The complaint log for Physician #1 provided by the hospital did not document a complaint made in May 2015 by Patient #1 and Emergency Medical Services (EMS) concerning Physician #1.

3. Review of an "ASSOCIATE CONFERENCE REPORT" dated 7/18/13 revealed, "...ASSOCIATE NAME... [Physician #1]...SUPERVISOR/TITLE... [CNO/COO] [Chief Operating Officer]... TYPE OF MISCONDUCT OR PERFORMANCE PROBLEM... Inappropriate and unprofessional conduct that is disruptive and disrespectful... Action that harms goodwill between [named healthcare company] and its patients and the community we serve... SUPERVISOR'S REMARKS... An investigation revealed that you have made statements that were inappropriate and exhibited behavior that is not aligned with the [named healthcare company] mission, vision or values. Your behavior has left employees and patients feeling as though they were under attack and humiliated, which is unacceptable. Your failure to exercise prudence and discretion resulted in a patient being spiritually hurt when our primary purpose is to heal... Our expectation is that you exercise good judgment and interact with our patients and staff in a professional manner that is not confrontational or disruptive. You are being issued a Final Written Warning... You are also issued this notice that you must complete, at your own expense, [named professional course]. The central theme for the course is to provide physicians with disruptive behavior a safe, confidential environment where they can learn with their peers about the origins and consequences of their actions. Please submit proof of enrollment in the first available course and a detailed schedule for completing to Human Resources by 7/25/13. You [Your] employment is contingent on successful completion of these courses...Please know that any further incidents of this type of conduct may result in termination... ACTION TAKEN... Written Warning Final... [Physician #1's signature]... [CNO, COO's signature]..."

Review of the "Certificate of Attendance/Program for Distressed Physicians" revealed, "...[named medical school] certifies that [Physician #1] participated in the educational activity titled Program for Distressed Physicians at [named location] on August 28-30, 2013 and three follow-up sessions..."

During an interview in the Conference Room on 5/26/15 at 10:00 AM, the CNO confirmed the corrective action taken by the hospital in July 2013 was the direct result of the investigation for the complaint listed on Physician #1's Log dated 6/5/13. The CNO stated that if Physician #1 had not completed the course, he would have been fired. The CNO stated at that time, she was also the COO and responsible for the physicians. The CNO stated that the CMO took over that responsibility sometime around the end of July 2013.

During an interview in the CMO's office on 5/26/15 at 10:30 AM, when asked about the corrective action taken against Physician #1 by the hospital in July 2013, the CMO stated, "...we had to send him to charm school... we've had no lawsuits against him which is a proxy for how one is doing..."

4. Medical record review for Patient #1 revealed the [AGE] year old patient was transported via EMS to Hospital #1 on 4/12/15 at 6:50 PM for a possible drug overdose. The nurses' note dated 4/12/15 at 7:16 PM documented the patient did not want Physician #1 to take care of him. The nurses' note dated 4/13/14 at 0:14 AM documented the patient was transferred to Hospital #2.

Review of the medical record from Hospital #2 for patient #1 revealed an admission date of [DATE] at 1:21 AM. The Consultation Report dated 4/13/15 documented, "...He [Patient #1] was brought to the emergency department [Hospital #1]. There, he states that he was somnolent and that he was struck by the emergency room physician, and this prompted him to be accused of suicidal ideation and transferred here for further care..."

5. Review of the Emergency Medical Services (EMS) "Patient Care Record" for Patient #1 dated 4/12/15 revealed, "...UPON ARRIVAL TO [Hospital #1] WE TOOK PT IN ON STRETCHER. PT WAS CALM AND NOT HAVING TO BE RESTRAINED AT THIS TIME. [Physician #1] WALKED UP TO STRETCHER BEFORE WE MADE IT TO PTS ROOM AND BEGAN TO GIVE A VERY AGGRESSIVE STERNUM RUB. UPON ENTERING ROOM PT OPENED HIS EYES AT THIS TIME AND [Physician #1] STATED "I KNEW YOU WERE NOT HAVING A SEIZURE, I KNEW YOU WERE FAKING IT" THE STRETCHER WAS PRESSED UP TO THE HOSPITAL BED AND WE WERE GOING TO MOVE PT TO BED WHEN [Physician #1] AGAIN APPROACHED PT AND STARTED PUSHING THE PT TELLING PT TO "GET OVER ON THAT BED" PT DID NOT COMPLY AND [Physician #1] THEN STARTED PUSHING THE PTS HEAD WITH ONE HAND AND SHOULDER WITH THE OTHER. THE PT TOLD [Physician #1] TO STOP PUSHING HIM BUT [Physician #1] CONTINUED. THE PT LEANED AWAY FROM [Physician #1] and [Physician #1] ENDED UP GRABBING PTS HEAD AT ONE POINT AND THE PT WENT TO THE BED AND WAS ON HIS KNEES WITH HIS FISTS DRAWN AND [Physician #1] DREW HIS FISTS TELLING THE PT "I CAN TAKE YOU" DURING THIS ENTIRE INCIDENT THE PTS MOTHER WAS IN THE HALLWAY AND DOORWAY OF THE ROOM AND ASKING [Physician #1] TO PLEASE NOT HIT HER SON. AT THIS TIME I LEFT THE ER [emergency room /Department] DUE TO THE HOSTILITY OF THE SITUATION...Electronically Signed by: [EMS Employee #1]..."

During a telephone interview on 5/6/15 at 1:50 PM, when asked to recount the incident, EMS Employee #1 stated, "...I picked him [Patient #1] up at home...an overdose...[Physician #1] met us at the door...said he [Patient #1] was faking...he got up on the cot...he did a very aggressive sternal rub...[in ED Trauma 1] we were setting up the stretcher to help the patient move over to the ER stretcher...[Physician #1] pushed him on the shoulder and head...kind of smacked him...the patient asked him to stop...[Physician #1] kept pushing him and telling him to get over on the stretcher...with the last push, the guy [Patient #1] got up on his hands and knees...[Physician #1] crouched down like he was going to fight...he raised his hands and balled his fists...he told the patient he could take him...he pushed him in the head and shoulder...I thought it was unprofessional...I called my supervisor...he [Patient #1] was lethargic [when they entered the ED]...we [EMS] gave him Narcan [on route to the ER]...he woke up and a little combative...he wasn't unresponsive...he was just lying there...the patient's mother came in and said [to Physician #1], "Don't hit my son, don't hit my son"...There have been issues in the past [about Physician #1]...it worried us [EMS Employee #1 and 2]...we felt like we needed to report...I want to be able to bring patients into the ER, but I can't do that in good conscience with the way he [Patient #1] was treated...it was not a good environment to bring a patient into...worried that this would happen again..."

During a telephone interview on 5/8/15 at 1:35 PM, when asked about the altercation between Physician #1 and Patient #1, EMS Employee #2 stated, "...We [EMS] brought him to the ER for an overdose... we gave him Narcan...he was agitated in the ambulance, but he calmed down... when we got to the ER... [Physician #1] started doing a sternal rub as hard as he could... before asking the patient anything... [Physician #1] said, "I knew you were faking"...we were pumping the stretcher to get it level with the ER stretcher... [Physician #1] started pushing him [Patient #1] and telling him "Get on over there"...the patient told him not to push him... [Physician #1] kept pushing him... patient rolled over on his knees and balled up his fists...[Physician #1] raised his hands and balled up his fists and said, "Come on, I can take you"...patient's mom... came in and said [to Physician #1], "Please don't hit my son"... [Physician #1] left the room... it was embarrassing and very unprofessional..." When asked if she was aware of any problems or concerns about Physician #1 prior to this incident, EMS Employee #2 stated, "...I've been here 5 years... yes...not as severe... he's rude with some patients... we want to provide help to people... [Physician #1] didn't provide help or a safe environment..." When asked where Physician #1 pushed Patient #1, EMS Employee #2 stated, "...pushed his shoulder and side of his head... contact was unjustified..." When asked why she felt the need to report the incident, EMS Employee #2 stated, "...my biggest concern is that [Physician #1] is going to cause harm... it's going to continue..."

During a telephone interview on 5/27/15 at 9:03 AM, when asked if he believed the allegations made by EMS Employee #1 and 2 concerning the altercation between Physician #1 and Patient #1, the EMS Director stated, "...yes, I believed them...I've known them for a long time..." When asked if he was aware of any prior problems or concerns with Physician #1's behavior, the EMS Director stated, "...At the first of the year, whenever we couldn't send an ambulance right away [to the ED], [Physician #1] would keep calling 911 or call here... and kind of yell at the crew... I told the Administrator that if he [Physician #1] had any problem with a decision we made about not sending an ambulance... he [Physician #1] needed to stop calling 911 or calling here and go through management..."

6. In the Conference Room on 5/5/15 at 2:45 PM, the CNO provided 4 pictures which she stated had been printed from her cellular phone. The CNO stated she received the pictures from Patient #1 on 4/15/15. She stated Patient #1 had taken the pictures of his chest with his cell phone some time after the altercation on 4/12/15 between Physician #1 and himself. Patient #1 sent the pictures to the CNO's cellular phone, and she printed the pictures from her phone.
Review of the pictures at this time revealed an area of discoloration on each side of the sternum.

During a phone interview on 5/27/15 at 10:30 AM, Patient #1 confirmed he sent pictures of his chest from his phone to the CNO's phone. Patient #1 stated the pictures were taken on Monday, 4/13/15 and show bruising caused by Physician #1 hitting his chest.

7. During an interview in the Conference Room on 5/6/15 at 10:40 AM, when asked to describe the altercation between Physician #1 and Patient #1, RN #1 stated, "...around shift change...over the radio...possible drug overdose...1st room on the right [Trauma 1]...most critical patients [patients typically placed in Trauma 1]...he [Patient #1] was somnolent..." RN #1 stated there were 2 EMS employees [EMS Employee #1 and 2] in the room who had transported Patient #1 to the ED and RN #2. RN #1 stated, "...[Physician #1] came in about the same time...doctor was shaking patient vigorously...[Physician #1] put his hand on patient's shoulder and pushed him vigorously...patient raised up and balled his fists...[Physician #1] crouched like he was going to fight...he told the patient to get over there [to the ED bed from the EMS stretcher]...his [Physician #1] voice was elevated...it was an angry "Get over there"...[Physician #1] said, "I'll take you down"...he [Physician #1] did make a threat [toward Patient #1]..." When asked about Physician #1 performing the sternal rub on Patient #1, RN #1 stated, "...it was a very vigorous sternal rub...went way beyond what was appropriate..." When asked if Patient #1 ever asked Physician #1 to stop pushing him, RN #1 stated, "...yes...he [Patient #1] was awake and told him [Physician #1] to stop..." When asked how Physician #1 responded, RN #1 stated, "...kept pushing him...that's when the patient balled up his fists..." When asked if anyone from administration had asked him about the incident, RN #1 stated, "...[CEO] did...he asked me if I thought this was a fireable offense...I told him I didn't know...maybe he [Physician #1] needed some counseling...[CEO] said that this has happened in the past..." When asked if he had experienced any problems or concerns with Physician #1 before, RN #1 stated, "...I've never seen anything physical before...he does raise his voice to patients and the nursing staff...this is the worst I've ever seen him [Physician #1]..."

8. During an interview in the Conference Room on 5/6/15 at 6:46 PM, when asked about the altercation between Physician #1 and Patient #1, RN #2 stated, "...at change of shift...[Physician #1] got a call from ambulance...questionable overdose...Klonopin and Meth...patient rolled in by ambulance...[Physician #1] did a sternal rub...heard him say, "Wake up and stop faking it"...[Physician #1] was pushing him to the other bed...patient was resistant and aggressive...said to [Physician #1], "Just stop it"...he was awake...the police came...he stayed here until midnight...sternal rub was out in the hallway...patient had been in ER before...patient said [to Physician #1], "I don't want you to lay your hands on me"...patient was in the bed when I went in between them..." When asked if Physician #1 told Patient #1 that he was under arrest, RN #2 stated, "...I heard that...[Physician #1] did apologize for his behavior...on 4/22 [2015] between 6 and 6:30 PM...[ED Director] was there...[RN #1], [RN #3] and [CEO]...they were going to have a meeting with the patient...the patient didn't show...he [Physician #1] apologized for his behavior for the incident..." When asked if she had ever witnessed this type of behavior before from Physician #1, RN #2 stated, "...yes...with patients with pain issues...patients with drug issues...he easily gets mad...I've heard him say [to a patient], "You're not going to get pain med"...he can be very furious..."

During a telephone interview on 5/28/15 at 1:05 PM, when asked how hard Physician #1 pushed Patient #1, RN #2 stated, "...I remember him [Physician #1] shoving him [Patient #1]..." When asked why she stepped between Physician #1 and Patient #1 during the altercation, RN #2 stated, "...just to stop it...the situation was getting worse... that's the worst I've seen him [Physician #1]...his face was red...his voice was trembling... I don't know what was going on with him..." When asked if she felt Physician #1's behavior was inappropriate, RN #2 stated, "...I think so..." When asked if the Administration had taken any action to address this incident, RN #2 stated, "...[CEO] said to help each other... watch each other..."

9. During an interview in the Conference Room on 5/6/15 at 11:06 AM, RN #3 stated she was at the nurses' station faxing paperwork for another patient when the altercation between Physician #1 and Patient #1 occurred. RN #3 stated she hit the panic button behind the desk which alerted the police on their radio. RN #3 stated she called the police dispatch, and the police arrived within a minute or two. RN #3 confirmed she was not in the room during the altercation but did hear Physician #1 telling Patient #1, "...You're faking it..."

10. During an interview in the Conference Room on 5/6/15 at 2:35 PM, when asked about the altercation between Physician #1 and Patient #1, the ED Charge Nurse stated, "...I wasn't here when he [Patient #1] arrived...I met him in Trauma 1...he stated he didn't want [Physician #1] in his room...he wanted to go to another hospital...he said, "I don't want that doctor"...there was an officer in his room...[Physician #1] told him he was under arrest..." When asked if she was aware of any prior problems or concerns about Physician #1's behavior, the ED Charge Nurse stated, "...yes...verbally...he [Physician #1] would respond in kind [to how the patients or employees behaved]...I've seen him restrain a patient...he could tone it down..."


11. During a telephone interview on 5/27/15 at 10:30 AM, when asked about the altercation between Physician #1 and himself, Patient #1 stated, "...[Physician #1] came over and started hitting me on the chest...he said, "There's nothing wrong with you" ...he smacked me on the side of the head and told me to get over there... from the gurney to the ER bed... he said I was faking a seizure... he pushed me by the face, and I told him to stop... he pushed me again, and I told him if he did we would go at it... he raised his hands up and balled up his fists and said, "I'll knock you out"... he was rude... he was treating me like a drug addict... he said, ' You're one of those pill mill junkies ' ... he just treated me really bad... " When asked how the hospital responded to his allegations, Patient #1 stated, "...doctor [ED Director] and head nurse [CNO] met with me... they said they would look into it... [CEO] told me that the hospital bills would be taken care of... [CEO] asked me to come in so [Physician #1] could apologize to me... I told him no disrespect, but I didn't want to have any contact with him [Physician #1]...I've been back to the ER...had some broken ribs from a machine falling on me...I asked my mother to call to see if he was there...[Physician #1] wasn't there, so I went in and was treated fine..." Patient #1 stated he would not go to Hospital #1's ED if Physician #1 was on duty there. He stated he would either have to travel to somewhere else or not seek treatment at all. Patient #1 stated he was afraid of the way he would be treated by Physician #1 if he went to Hospital #1's ED, and Physician #1 was on duty.

12. During a telephone interview on 5/28/15 at 2:45 PM, when asked about the altercation between Physician #1 and Patient #1, Patient #1's Family Member #1 stated, "... [Patient #1] had been there before and [Physician #1] accused him of coming there just to get drugs...his chest was hurting... he had an upper respiratory infection...[Physician #1] doesn't believe in giving people pain medication... he [Patient #1] didn't want to deal with him [Physician #1]... when I went in [Trauma 1], [Patient #1] was standing up... he was agitated with him [Physician #1]... he did have marks on him [on his chest]...his shirt was torn when I went in... it wasn't when they loaded him in the ambulance... [Physician #1] told me he was faking something... I don't remember what it was... they were moving him from the ambulance bed to the other bed... [Patient #1] told him several times not to touch him... I told [Physician #1] that something had to be wrong... I don't think he [Physician #1] really done right with the way he talked to him...the way [Physician #1] was treating him...I've heard other people complain about how rude he was to them..."

13. During an interview in the Conference Room on 5/5/15 at 10:30 AM, the CNO stated Patient #1 called her on Tuesday, 4/14/15 [2 days later] to tell her that he had been mistreated by Physician #1. The CNO stated she asked him to come to the hospital to discuss the incident. Patient #1 met with the CNO and the ED Director on 4/17/15. The CNO stated Patient #1 told the exact same story when he met with them. The CNO stated that the Chief Executive Officer (CEO), Chief Medical Officer (CMO) and the ED Director took responsibility for investigation of the complaint.

During an interview in the Conference Room on 5/5/15 at 11:00 AM, the CNO identified Physician #1 as an employee of the hospital.

During an interview in the Conference Room on 5/26/15 at 8:55 AM, when asked the nursing staff's responsibility when an employee abused or demonstrated inappropriate behavior toward a patient or another staff member, the CNO stated, "...report it immediately to their supervisor..." The CNO stated that she found out about the allegations of abuse and mistreatment from Patient #1 on Tuesday, 4/14/15 (2 days after the incident). The CNO stated the CEO was informed about the incident on Tuesday, 4/14/15 from the EMS Director. The CNO confirmed nursing staff failed to report the incident to her or the CEO.

14. During an interview in the Conference Room on 5/26/15 at 8:20 AM, Physician #1 stated Patient #1 was acting like he was having a seizure and he rubbed the patient ' s chest which was a time-honored way to assess alertness. The patient woke up and started cussing, he swung his arm around and " I was trying to help him over [from EMS stretcher to ED stretcher]... he came around...he swung back... I pushed his head away from me...he wanted to leave... his mother came in and told him, "Let [Physician #1] treat you"..." When asked how he handled aggressive or combative patients, Physician #1 stated, "...try to calm them down... sometimes you have to restrain..." When asked if he had ever seen the patient before, Physician #1 stated, "...I had seen him on 2 previous occasions... once for bronchitis, once for flank pain... [on the visit for flank pain] there was some blood in his urine, but CT didn't reveal any kidney stones... I didn't give him any pain medication... he's a well-known drug person..." When asked if he told Patient #1 that he was under arrest, Physician #1 stated, "...I may have...he's my responsibility... to keep him from leaving..." When asked if he raised his hands to Patient #1 or told him that he could take him, Physician #1 stated, "...When I pulled back I said, "Come on"...if he wanted to fight then ok..."

15. During an interview in the Conference Room on 5/6/15 at 5:28 PM, when asked about the altercation between Physician #1 and Patient #1, the CEO stated, "...On Tuesday, April 14th, I received a text to give [EMS Director] a buzz...spoke with him on the phone...about a situation Sunday evening [4/12/15]...alleged behavior by [Physician #1]...[CNO] received a phone call by [Patient #1]...I was on the phone with [EMS Director] when she was on the phone with [Patient #1]...about aggressive behavior by rubbing on the chest hard. When asked to define abuse, the CEO stated, "...[physical abuse] striking, hitting...could potentially cause harm...[verbal abuse] loud, disrespectful..." When asked when staff should notify him about concerns of inappropriate behavior or abuse, the CEO stated, "...people should notify me as quick as they can..."


The hospital did not provide any evidence to demonstrate nursing staff followed its policy for reporting abuse despite numerous complaints of abusive behavior and staff awareness of inappropriate and abusive behavior by Physician #1.

REFER TO C-241
VIOLATION: PERIODIC EVALUATION & QA REVIEW Tag No: C0330
Based on facility policy review, document review, medical record review, and interview, the hospital failed to demonstrate an effective Quality Assessment Performance Improvement (QAPI) program that identified and took action to minimize the likelihood of patient abuse in the Emergency Department. Failure to identify and implement protective interventions for complaints of abusive physician behavior resulted in a SERIOUS and IMMEDIATE THREAT to the HEALTH and SAFETY of Patient #1 and placed all Emergency Department patients in IMMEDIATE JEOPARDY and at risk for serious injury from abuse.

The findings included:

The hospital did not provide any evidence to demonstrate the QAPI program was involved in any of the complaint allegations of abuse. Despite numerous complaints of abusive behavior and staff awareness of inappropriate and abusive behavior, the QAPI program provided no evidence of identified opportunities to improve patient safety from abuse, implementation of any interventions or monitoring subsequent to the abuse allegations made by EMS employees to ensure patient safety from abuse.
VIOLATION: QUALITY ASSURANCE Tag No: C0337
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on facility policy review, document review, medical record review, and interview, the hospital failed to demonstrate an effective Quality Assessment Performance Improvement (QAPI) program that identified and took action to minimize the likelihood of patient abuse for 1 of 2 (Physician #1) sampled Emergency Department (ED) physicians. Failure to identify and implement protective interventions for complaints of abusive physician behavior resulted in a SERIOUS and IMMEDIATE THREAT to the HEALTH and SAFETY of Patient #1 and placed all Emergency Department patients in IMMEDIATE JEOPARDY and at risk for serious injury from abuse.

The findings included:

1. Review of the hospital's "Patient Rights and Responsibilities" policy revealed, "...Patient [Pt] Rights...You have the right to safe, high quality, compassionate healthcare, without fear of discrimination of any kind...You have the right to the most appropriate medical treatment available, delivered in a safe, considerate, and respectful manner...You have the right to be free from all forms of abuse, neglect and exploitation..."

Review of the hospital's "Patient Complaint and Grievance, SP-21" policy revealed, "...OBJECTIVE: To provide a centralized and systematic process for responding to a complaint or grievance filed by a patient or patient's representative in a timely and consistent manner... POLICY: [named healthcare company] recognizes that at times, patients or their representatives may be dissatisfied with the care, services and/or treatments provided to them... [named healthcare company] will respond to these grievances/complaints within the time frame prescribed by law, after appropriate review, analysis and action has been performed... DEFINITIONS...Grievances include the following... Allegations of abuse or neglect... All complaint/grievance investigations, recommendation and/or actions taken by [named healthcare company] are conducted for the purpose of quality improvement and peer review pursuant to Tennessee law... Management of Complaints...If there is a complaint of abuse, neglect and/or harm that complaint should be reported immediately the department manager, nursing supervisor, nursing director or guest relations representative and to the Risk Management Department. The staff should also follow [named healthcare company] policies in compliance with Tennessee state regulations regarding issues of abuse or neglect... Management of Grievances... Investigation findings will be communicated to Risk Management Department, who will be responsible for maintaining all information for use in QA/PI [quality assurance/performance improvement] activities..."

2. Review of the "CHIEF MEDICAL OFFICER ADDENDUM TO PHYSICIAN PRACTICE AGREEMENT" dated 7/24/13 with an effective date of 8/1/13 revealed, "... Officer shall perform the Chief Medical Officer [CMO] Services in conformance with all requirements of Hospital Policies, Medicare Conditions of Participation, The Joint Commission, and all applicable federal and state statutes and regulations...Chief Medical Officer Services... Initiates and assists in the organization and utilization of the Medical Staff and reviews the activities of the Medical Staff in accordance with ethical standards and the overall policies of the Hospital... Formulates policies and objectives for medical programs and communicates these policies to appropriate staff for execution within an integrated team case management approach... Assists in developing the Hospital's clinical policies and formulating the mission, goals and philosophy of care... Oversight for annual and periodic evaluations of clinical providers... Recommends qualifications statements for credentialing, job descriptions, and evaluation standards for all clinical personnel... Assists in the development and supervision, implementation, and operation of a quality assurance program as it relates to patient care... Responsible for the quality control of medical care...Is the lead physician of the Hospital's health care team... Participates in enforcing the Medical Staff Bylaws and all policies and procedures governing the Medical Staff, and oversees all instances when corrective action has been requested or taken against a Medical Staff member..."

3. Review of a complaint log for Physician #1 provided by the hospital revealed:

a) "...[Physician #1] Log...06-05-13...Pt [Patient #2] was seen in ED [Emergency Department] on 06-05-13. She stated that [Physician #1] yelled at her and said she was faking. She stated that he threw her file and said 'see.' She said that he told her she was going to get cancer if she continued to get CT [computerized tomography] scans, but then proceeded to order a CT..."

b) "...[Physician #1] Log...10-16-14...pt [Patient #3] complained to [named Nurse Practitioner], her PCP [primary care physician] at the clinic that she was seen in the ED here and [Physician #1] made her feel like a drug addict by the way he talked to her. Stated she came in here for anxiety and chest pain. She brought her medications with her and when she poured the bottles out [Physician #1] told her that right there's your problem. They ought to close those pain clinics. If you stop taking those medicines you will feel better. The patient was upset because she felt everyone in the ED could hear him yelling at her..." The hospital failed to provide any documentation to evidence investigation of this complaint.

c) " ...[Physician #1]Log...02/06/15...[named long-term care facility] filed a complaint with [CNO]. A resident was transferred to the ED from [named long-term care facility]. The nurse complained that [Physician #1] was rude and screamed at her on the phone and hung up on her..." The hospital failed to provide any documentation to evidence investigation of this complaint.

d) The complaint log for Physician #1 provided by the hospital did not document a complaint made in May 2015 by Patient #1 and Emergency Medical Services (EMS) concerning Physician #1.

4. Review of credentialing documents for Physician #1 revealed a "Medical Staff Code of Conduct" dated 12/23/12 documenting, "...As a member of the...[Hospital #1]...I realize that I must treat others with respect, courtesy, and dignity, conducting myself in a professional and cooperative manner...I further understand that incidents of inappropriate conduct will be addressed and may become a matter for formal physician conduct review, possibly resulting in corrective action, suspension, or dismissal from the Medical Staff... While practicing at...[Hospital #1]...I agree to... Speak with kindness and courtesy to patients, families, hospital associates, and other physicians...Never engage in belittling, intimidating, threatening, or verbally attacking any person... Abstain from inappropriate physical contact with others... Abide by Medical Staff requirements as delineated in the Medical Staff Bylaws, Rules, and Regulations... working cooperatively and harmoniously with other members of the Medical and Hospital Staffs...Applicant's Signature [signed by Physician #1]..."

Review of an "ASSOCIATE CONFERENCE REPORT" dated 7/18/13 revealed, "...ASSOCIATE NAME... [Physician #1]...SUPERVISOR/TITLE... [CNO/COO] [Chief Operating Officer]... TYPE OF MISCONDUCT OR PERFORMANCE PROBLEM... Inappropriate and unprofessional conduct that is disruptive and disrespectful... Action that harms goodwill between [named healthcare company] and its patients and the community we serve... SUPERVISOR'S REMARKS... An investigation revealed that you have made statements that were inappropriate and exhibited behavior that is not aligned with the [named healthcare company] mission, vision or values. Your behavior has left employees and patients feeling as though they were under attack and humiliated, which is unacceptable. Your failure to exercise prudence and discretion resulted in a patient being spiritually hurt when our primary purpose is to heal... Our expectation is that you exercise good judgment and interact with our patients and staff in a professional manner that is not confrontational or disruptive. You are being issued a Final Written Warning... You are also issued this notice that you must complete, at your own expense, [named professional course]. The central theme for the course is to provide physicians with disruptive behavior a safe, confidential environment where they can learn with their peers about the origins and consequences of their actions. Please submit proof of enrollment in the first available course and a detailed schedule for completing to Human Resources by 7/25/13. You [Your] employment is contingent on successful completion of these courses...Please know that any further incidents of this type of conduct may result in termination... ACTION TAKEN... Written Warning Final... [Physician #1's signature]... [CNO, COO's signature]..."

Review of the "Certificate of Attendance/Program for Distressed Physicians" revealed, "...[named medical school] certifies that [Physician #1] participated in the educational activity titled Program for Distressed Physicians at [named location] on August 28-30, 2013 and three follow-up sessions..."

During an interview in the Conference Room on 5/26/15 at 10:00 AM, the CNO confirmed the corrective action taken by the hospital in July 2013 was the direct result of the investigation for the complaint listed on Physician #1's Log dated 6/5/13. The CNO stated that if Physician #1 had not completed the course, he would have been fired. The CNO stated at that time, she was also the COO and responsible for the physicians. The CNO stated that the CMO took over that responsibility sometime around the end of July 2013.

During an interview in the CMO's office on 5/26/15 at 10:30 AM, when asked about the corrective action taken against Physician #1 by the hospital in July 2013, the CMO stated, "...we had to send him to charm school... we've had no lawsuits against him which is a proxy for how one is doing..."

The hospital did not provide any documentation to evidence the inclusion of abusive behaviors in the QAPI program or any steps taken by the QAPI program to protect other patients and monitor for inappropriate and abusive behavior subsequent to the 7/18/13 action taken against Physician #1.


5. Medical record review for Patient #1 revealed the [AGE] year old patient was transported via EMS to Hospital #1 on 4/12/15 at 6:50 PM for a possible drug overdose. The nurses' note dated 4/12/15 at 7:16 PM documented the patient did not want Physician #1 to take care of him. The nurses' note dated 4/13/14 at 0:14 AM documented the patient was transferred to Hospital #2.

Review of the medical record from Hospital #2 for patient #1 revealed an admission date of [DATE] at 1:21 AM. The Consultation Report dated 4/13/15 documented, "...He [Patient #1] was brought to the emergency department [Hospital #1]. There, he states that he was somnolent and that he was struck by the emergency room physician, and this prompted him to be accused of suicidal ideation and transferred here for further care..."

In the Conference Room on 5/5/15 at 2:45 PM, the CNO provided 4 pictures which she stated had been printed from her cellular phone. The CNO stated she received the pictures from Patient #1 on 4/15/15. She stated Patient #1 had taken the pictures of his chest with his cell phone sometime after the altercation on 4/12/15 between Physician #1 and himself. Patient #1 sent the pictures to the CNO's cellular phone, and she printed the pictures from her phone.
Review of the pictures revealed an area of discoloration on each side of the sternum.

During a phone interview on 5/27/15 at 10:30 AM, Patient #1 confirmed he sent pictures of his chest from his phone to the CNO's phone. Patient #1 stated the pictures were taken on Monday, 4/13/15 and show bruising caused by Physician #1 hitting his chest.


6. Review of the Emergency Medical Services (EMS) "Patient Care Record" for Patient #1 dated 4/12/15 revealed, "...UPON ARRIVAL TO [Hospital #1] WE TOOK PT IN ON STRETCHER. PT WAS CALM AND NOT HAVING TO BE RESTRAINED AT THIS TIME. [Physician #1] WALKED UP TO STRETCHER BEFORE WE MADE IT TO PTS ROOM AND BEGAN TO GIVE A VERY AGGRESSIVE STERNUM RUB. UPON ENTERING ROOM PT OPENED HIS EYES AT THIS TIME AND [Physician #1] STATED "I KNEW YOU WERE NOT HAVING A SEIZURE, I KNEW YOU WERE FAKING IT" THE STRETCHER WAS PRESSED UP TO THE HOSPITAL BED AND WE WERE GOING TO MOVE PT TO BED WHEN [Physician #1] AGAIN APPROACHED PT AND STARTED PUSHING THE PT TELLING PT TO "GET OVER ON THAT BED" PT DID NOT COMPLY AND [Physician #1] THEN STARTED PUSHING THE PTS HEAD WITH ONE HAND AND SHOULDER WITH THE OTHER. THE PT TOLD [Physician #1] TO STOP PUSHING HIM BUT [Physician #1] CONTINUED. THE PT LEANED AWAY FROM [Physician #1] and [Physician #1] ENDED UP GRABBING PTS HEAD AT ONE POINT AND THE PT WENT TO THE BED AND WAS ON HIS KNEES WITH HIS FISTS DRAWN AND [Physician #1] DREW HIS FISTS TELLING THE PT "I CAN TAKE YOU" DURING THIS ENTIRE INCIDENT THE PTS MOTHER WAS IN THE HALLWAY AND DOORWAY OF THE ROOM AND ASKING [Physician #1] TO PLEASE NOT HIT HER SON. AT THIS TIME I LEFT THE ER [emergency room /Department] DUE TO THE HOSTILITY OF THE SITUATION...Electronically Signed by: [EMS Employee #1]..."

During a telephone interview on 5/6/15 at 1:50 PM, EMS Employee #1 verified the verbal and physical inappropriate and abusive behavior toward Patient #1 by Physician #1 did occur on 4/12/15.

During a telephone interview on 5/8/15 at 1:35 PM, EMS Employee #2 verified the verbal and physical inappropriate and abusive behavior toward Patient #1 by Physician #1 did occur on 4/12/15.

7. During an interview in the Conference Room on 5/6/15 at 10:40 AM, RN #1 verified the verbal and physical inappropriate and abusive behavior toward Patient #1 by Physician #1 did occur on 4/12/15.

8. During an interview in the Conference Room on 5/6/15 at 6:46 PM, RN #2 verified the verbal and physical inappropriate and abusive behavior toward Patient #1 by Physician #1 did occur on 4/12/15.

9. During an interview in the Conference Room on 5/6/15 at 11:06 AM, RN #3 verified the verbal inappropriate and abusive behavior toward Patient #1 by Physician #1 did occur on 4/12/15.

10. During a telephone interview on 5/27/15 at 10:30 AM, Patient #1 verified the verbal and physical inappropriate and abusive behavior toward him by Physician #1 did occur on 4/12/15 and stated, " I've been back to the ER...had some broken ribs from a machine falling on me...I asked my mother to call to see if he was there...[Physician #1] wasn't there, so I went in and was treated fine..." Patient #1 stated he would not go to Hospital #1's ED if Physician #1 was on duty there. He stated he would either have to travel to somewhere else or not seek treatment at all. Patient #1 stated he was afraid of the way he would be treated by Physician #1 if he went to Hospital #1's ED, and Physician #1 was on duty.

11. During a telephone interview on 5/28/15 at 2:45 PM, Patient #1's Family Member #1 stated, "... [Patient #1] had been there before and [Physician #1] accused him of coming there just to get drugs...his chest was hurting... he had an upper respiratory infection...[Physician #1] doesn't believe in giving people pain medication... he [Patient #1] didn't want to deal with him [Physician #1]... when I went in [Trauma 1], [Patient #1] was standing up... he was agitated with him [Physician #1]... he did have marks on him [on his chest]...his shirt was torn when I went in... it wasn't when they loaded him in the ambulance... [Physician #1] told me he was faking something... I don't remember what it was... they were moving him from the ambulance bed to the other bed... [Patient #1] told him several times not to touch him... I told [Physician #1] that something had to be wrong... I don't think he [Physician #1] really done right with the way he talked to him...the way [Physician #1] was treating him...I've heard other people complain about how rude he was to them..."

12. During an interview in the Conference Room on 5/5/15 at 10:30 AM, the CNO stated Patient #1 called her on Tuesday, 4/14/15 [2 days later] to tell her that he had been mistreated by Physician #1. The CNO stated she asked him to come to the hospital to discuss the incident. Patient #1 met with the CNO and the ED Director on 4/17/15. The CNO stated Patient #1 told the exact same story when he met with them. The CNO stated that the Chief Executive Officer (CEO), Chief Medical Officer (CMO) and the ED Director took responsibility for investigation of the complaint.

13. During an interview in the Conference Room on 5/26/15 at 8:20 AM, Physician #1 stated Patient #1 was acting like he was having a seizure and he rubbed the patient ' s chest which was a time-honored way to assess alertness. The patient woke up and started cussing, he swung his arm around and " I was trying to help him over [from EMS stretcher to ED stretcher]... he came around...he swung back... I pushed his head away from me...he wanted to leave... his mother came in and told him, "Let [Physician #1] treat you"..." When asked how he handled aggressive or combative patients, Physician #1 stated, "...try to calm them down... sometimes you have to restrain..." When asked if he had ever seen the patient before, Physician #1 stated, "...I had seen him on 2 previous occasions... once for bronchitis, once for flank pain... [on the visit for flank pain] there was some blood in his urine, but CT didn't reveal any kidney stones... I didn't give him any pain medication... he's a well-known drug person..." When asked if he told Patient #1 that he was under arrest, Physician #1 stated, "...I may have...he's my responsibility... to keep him from leaving..." When asked if he raised his hands to Patient #1 or told him that he could take him, Physician #1 stated, "...When I pulled back I said, "Come on"...if he wanted to fight then ok..."

14. During an interview in the Conference Room on 5/6/15 at 5:28 PM, when asked about the altercation between Physician #1 and Patient #1, the CEO stated, "...On Tuesday, April 14th, I received a text to give [EMS Director] a buzz...spoke with him on the phone...about a situation Sunday evening [4/12/15]...alleged behavior by [Physician #1]...[CNO] received a phone call by [Patient #1]...I was on the phone with [EMS Director] when she was on the phone with [Patient #1]...about aggressive behavior by rubbing on the chest hard. When asked to define abuse, the CEO stated, "...[physical abuse] striking, hitting...could potentially cause harm...[verbal abuse] loud, disrespectful..." When asked when staff should notify him about concerns of inappropriate behavior or abuse, the CEO stated, "...people should notify me as quick as they can..."

15. Review of the ED Physician Staffing Schedule for April, May and June 2015 revealed Physician #1 was scheduled on 4/12/15, 4/13/15, 4/15/15, 4/16/15, 4/17/15, 4/24/15 and 4/25/15 [during the two week period 4/12/15-4/25/15]. The schedule had Physician #1 marked off on 4/16/15 and 4/17/15. Physician #1 was scheduled from 4/25/15 through the end of June 2015 from 1-4 times weekly.

16. Review of the Quality Indicators monitored by the hospital dated July 2014 through March 2015 revealed no documentation that the allegations of abusive behavior in the complaints/grievances against Physician #1 had been incorporated into the hospital's Quality Assurance Performance Improvement Program.


During an interview in the Conference Room on 5/28/15 at 11:15 AM, while reviewing the meeting minutes and the Quality Indicators, the Chief Nursing Officer (CNO) stated that there was no information concerning the complaints/grievances against Physician #1 or any monitoring of Physician #1's conduct in the documents.


The hospital did not provide any evidence to demonstrate the QAPI program was involved in any of the complaint allegations of abuse. Despite numerous complaints of abusive behavior and staff awareness of inappropriate and abusive behavior, the QAPI program provided no evidence of identified opportunities to improve patient safety from abuse, implementation of any interventions or monitoring subsequent to the abuse allegations made by EMS employees to ensure patient safety from abuse.

REFER TO C-241