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.

ST FRANCIS MEDICAL CENTER 309 JACKSON STREET MONROE, LA 71201 Jan. 31, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of staff written statements, Hospital Policy on Patient Rights and Responsibilities, Patient Grievance Policy, Patient Grievance/Activity Log and interviews with staff the hospital failed to meet the requirement of Condition of Participation related to Patient Rights for 2 of 2 (patients #2 and 3) patient in a total of 5 grievances reviewed as evidenced by:

1. Failing to ensure the patient has the right to receive care in a safe setting as evidenced by a physician (S15 MD) striking a patient during a procedure (patient #2). The hospital failed to protect the patient's emotional health and to promote respect, dignity and comfort that are components of an emotionally safe environment (patient #3). (See Tag A0144).

2. Failing to ensure the patient had the right to be free from all forms of abuse by failing to identify, investigate and/or follow their medical staff bylaws for allegations of disruptive behavior of a physician (S15 MD) for 2 of 2 patients in a total sample of 11 (#2, 3). (See Tag A0145)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of staff written statements, Hospital Policy on Patient Rights and Responsibilities, Patient Grievance Policy, Patient Grievance/Activity Log for patient #2 and interviews with staff the hospital failed to ensure the patient has the right to receive care in a safe setting as evidenced by a physician (S15 MD) striking a patient during a procedure (patient #2). The hospital failed to protect the patient's emotional health and to promote respect, dignity and comfort that are components of an emotionally safe environment (patient #3) for 2 of 2 patient in a total of 5 grievances reviewed. Findings:

Review of the Patient Rights and Responsibilities Policy provided to each patient upon treatment at St Francis Medical Center related to Respect and Dignity: you have the right to considerate, respectful care at all times and under all circumstances, with recognition of your individual dignity.....

Review of the Patient Grievance Policy effective 2/12 page 1 of 3: purpose- to provide a system for tracking patient and family grievance to determine trends and implement policies and procedures to prevent future recurrences.

1. Review of a written statement by S5 Surgical Tech revealed that S15 MD striked patient #2 during a procedure for severe nose bleed. Further review of the statement revealed S15 MD was in a hurry to begin suctioning the blood and examine patient #2, she started to scream and begged him to stop. Patient #2 attempted to rise from the table and S15 MD yelled at her to lay down and pushed her down forcefully back onto the OR bed. Patient #2 attempted to rise again and S15 MD hit her two or more times very forcefully to get her to lie down.

Review of a written statement by S6 Surgical Assistant revealed he was in the OR where patient #2 was being treated and she was crying and upset. Further review revealed S15 MD came into the room and told the patient to shut up and be quiet. He then shoved a sponge into her nose. Patient #2 began to holler "Don't do it" several times and S15 MD did not stop but punched the patient 3 times in the right shoulder.

Review of the written statement of S7 RN circulator revealed patient #2 was bleeding from her nose and mouth; was very anxious and scared. S7 RN stated she was monitoring patient #2 vital signs. S15 MD sprayed Cetacaine into patient #2's left nares and she did not tolerate it very well. Patient #2 yelled that the spray burned and hurt, as she attempted to rise and S15 MD tried to keep the patient on the table. S7 RN stepped out of the room to get extra suction tubing and when she returned S15 MD inserted the Rapid Rhino pack into patient #2's left nares but it did not stop the bleeding. S7 RN called for assistance. S15 MD left for another type of pack. When S15 MD left the room, patient #2 informed the nurse she did not want S15 MD to do anything else to her and that he had hit her to keep her from getting up. S7 RN received help from another RN, and left to call S4 Director of Surgery. During all of this S7 RN was able to administer IV sedation to help calm the patient down and convince the patient to allow S15 MD to complete the treatment.

Interview with S7 RN on 1/28/13 at 11:30 AM revealed patient #2 was very anxious when she got to the OR and when S15 MD sprayed her nose with Cetacaine spray, she became hysterical. S7 RN stated she understood patient #2 was talked with while she was in the holding area so was aware that she would be awake during the procedure. Patient #2 had been treated in the last 24 hours with packs to stop the bleed and S7 RN thought she knew what was going to happen. S7 RN stated she did ask S15 MD about anesthesia and he responded he had done thousands of these without sedation. S7 RN stated that as the treatment continued with patient #2 yelling, S15 MD conceded to IV sedation which she administered. S7 stated S15 MD asked for another type of pack but she was unsure of what he was asking for and she left the room to ask another colleague who did not know either. S15 MD left the OR himself and obtained the entire box of packs and found what he was looking for, inserted it but it did not stop the bleeding. S7 RN stated the pack he asked for was available but he was calling it something other than what the packet was labeled. Patient #2 was transferred to the Catheterization Lab for another procedure to stop the bleeding. S7 RN stated patient #2 reported to her while S15 MD was out of the room that he had hit her.

Interview with S5 Surgical Tech on 1/28/13 at 1:45 PM revealed patient #2 was already in the OR while she set up her surgical table. S5 Surgical Tech stated S15 MD came in, did not address patient #2, but sprayed Cetacaine spray into her nose. Patient #2 was hysterical to begin with and had blood all over her. Patient #2 was crying that her nose was burning. S15 MD proceeded to put a Rhino rocket into her nose. Patient #2 tried to sit from a supine position and S15 MD pushed her down-blood was running down her throat and she was spitting everywhere. When asked if patient #2 was restrained, S5 Surgical Tech stated there was a strap across her knees. S5 Surgical tech stated S15 MD forced her down to the table with his closed fist but only to keep her from falling off the table. Each time she attempted to rise he used the same manner to get her to lie down and told her to be quiet. S7 RN asked if she could sedate the patient and S15 MD agreed.

Interview with S6 Surgical Assistant on 1/28/13 at 2:15 PM revealed he was present during part of the treatment of patient #2 and witnessed S15 MD force the patient down to the table several times with his closed fist. S6 Surgical Assistant stated the incident was very upsetting and he had to leave the room. S6 Surgical Assistant also stated he had never seen S15 MD or any other doctor do that before.

Review of the written interview between S12 Social Worker, S8 Risk Manager, S10 Director of Emergency Services and Critical Care units and patient #2 revealed the interview took place on 1/17/13 in the patient's room. Further review of the interview revealed patient #2 told them that she became very upset in the OR due to the pain, S15 MD grabbed her, shook her, and put her back on the table. She stated he was not going to have that type of behavior in the OR. She stated she was very scared at that point. Patient #2 stated that that when she interacts with S15 MD she wanted to have a nurse or someone else in the room with her to make her more comfortable.

Review of a hand written note of an interview on 1/18/13 (no time) between S12 Social Worker and patient #2 revealed S12 Social Worker told patient #2 there was an open investigation and that DHH would be notified She stated that was good because what happened was horrible and should not happen again.

Review of the hand written notes of a meeting on 1/18/13 at 9:00 AM between the Administrator, S8 Risk Manager, S1 VP of Medical Affairs and S12 Social Worker revealed that all of the statements from all the staff invovled in the incident were reviewed. The concensus was that S15 MD struck the patient in an effort to restrain her.

2. Review of the Grievance/Activity Log-Issue comments/notes: patient #3 revealed he was seen by S15 MD ENT on 6/13/12 to perform a throat examination. After S15 MD sprayed Cetacaine in patient #3's throat, he proceeded to use a tongue depressor to view the back of his throat. Patient #3 gagged and S15MD told him his gagging was "in his head" and pushed against his forehead with 2 fingers. On 6/14/12, S15 MD visited patient #3 in his room. Patient #3 told him he was told by the hospitalist that gagging was a natural reaction and accused S15 MD of lying to him. S15 MD and patient #3 had words and S15 MD walked around the bed, put one hand on the patient's shoulder and the other hand in a fist and told patient #3 "you're lucky". The patient told S15 MD he was going to call the police and S15 MD told him to "go ahead, I used to be a police officer." S15 MD was also heard telling the patient that he is the physician and this is his hospital and he can do whatever he wants.

Interview with S11MD Patient Safety Advocate on 1/31/13 at 10:00 AM revealed he was aware of the incident between patient #3 and S15 MD. S11 MD Patient Safety Advocate stated he had just assumed that title and interviewed S15 MD. S11 MD Patient Safety Advocate stated his primary goal was to focus on patient care outcome, then to look at physicians. Review of a typed statement from S11MD Patient Safety Advocate to S8 Risk Manager, details of the interview were documented and that he and S8 Risk Manager and the unit manager and S12 social worker would meet again to further evaluate the complaint and to receive reports on the further care needs of patient #3 at that time. S11MD Patient Safety Advocate admitted he did not write a statement to document his findings to place in the credentialing file of S15 MD.

The surveyors asked hospital staff if there was documented evidence that either of presented to the QA committee by the Medical Executive staff who handles physician issues to determine if the hospital was identifying problems, evaluating those problems, and taking steps to ensure a safe patient evironment. No evidence was presented to the survey team prior to exit or during the exit conference.

In a telephone interview with S17 RN Quality Director on 2/3/13 confirmed the grievance filed by patient #3 on 6/15/12 did not get to the grievance committee and was not addressed by QA.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview the hospital failed to ensure the patient had the right to be free from all forms of abuse by failing to identify, investigate and/or follow their medical staff bylaws for allegations of disruptive behavior of a physician (S15MD) for 2 of 2 patients in a total sample of 11 (#2, 3). Findings:

Review of the hospital's Medical Staff ByLaws, Policies, and Rules and Regulations: Credentials Policy:6. B 1. reflected "Whenever a serious question has been raised, or where collegial efforts have not resolved an issue, regarding: (1) the clinical competence or clinical practice of any member of the Medical Staff, including the care, treatment or management of a patient or patients;. (2) the known or suspected violation by any member of the Medical Staff of applicable ethical standards or the Bylaws, polices, Rules and Regulations of the Hospital or the Medical Staff; and/or (3) conduct by any member of the Medical Staff that is considered lower than the standards of the Hospital or disruptive to the orderly operation of the Hospital or it's Medical Staff, including the inability of the member to work harmoniously with others, the matter may be referred to the Chief of Staff, the chair of the department, the chair of a standing committee, the CEO, or the Chair of the Board...(b) The person to whom the matter is referred will make sufficient inquiry to satisfy himself or herself that the question raised is credible and, if so, will forward it in writing to the Executive Committee. (c) No action taken pursuant to this Section will constitute an investigation."

Further review of the policy reflected "6.B.2. Initiation of Investigation: (a) When a question involving clinical competence or professional conduct is referred to, or raised by, the Executive Committee, the Executive Committee will review the matter and determine whether to conduct an investigation or to direct the matter to be handled pursuant to another policy, such as the Policy on Practitioner Health or the Code of Conduct Policy, or to proceed in another manner. In making this determination, the Executive Committee may discuss the matter with the individual. An investigation will begin only after a formal determination by the Executive Committee to do so...6.B.3 Investigative Procedure: (a) Once a determination has been made to begin an investigation, the Executive Committee will either investigate the matter itself, request that the Credentials Committee conduct the investigation, or appoint an individual or ad hoc committee to conduct the investigation..."


January 2013 Incident (Patient #2)

Review of a written statement by S5 Surgical Tech reflected an incident occurred during the treatment of patient #2 for severe a nose bleed. Review of the statement reflected the patient rolled in with blood all over her face and neck. Further review of the statement revealed S15 MD was in a hurry to get the patient on the OR bed to begin suctioning the blood and examine patient #2, she started to scream and begged him to stop. Patient #2 attempted to rise from the table and S15 MD yelled at her to lay down and pushed her down forcefuly back onto the OR bed. Patient #2 attempted to rise again and S15 MD hit her two or more times very forcefully to get her to lay down.

Review of a written statement by S6 Surgical Assistant revealed he was in the OR where patient #2 was being treated and she was crying and upset. Further review revealed S15 MD came into the room and told the patient to shut up and be quiet. He then shoved a sponge into her nose. Patient #2 began to holler "Don't do it" several times and S15 MD did not stop but punched the patient 3 times in the right shoulder.

Review of the written statement of S7 RN revealed patient #2 was bleeding from her nose and mouth; was very anxious and scared. S7 RN stated she was monitoring patient #2 vital signs. S15 MD sprayed Cetacaine into patient #2's left nares and she did not tolerate it very well. Patient #2 yelled that the spray burned and hurt, as she attempted to rise and S15 MD tried to keep the patient on the table. S7 RN stepped out of the room to get extra suction tubing and when she returned S15 MD inserted the Rapid Rhino pack into patient #2's left nares but it did not stop the bleeding. S7 RN called for assistance. S15 MD left for another type of pack. When S15 MD left the room, patietn #2 informed the nurse she did not want S15 MD to do anything else to her and that he had hit her to keep her from getting up. S7 RN received help from another RN, and left to call S4 Director of Surgery. During all of this S7 RN was able to administer IV sedation to help calm the patient down and convince the patient to allow S15 MD to complete the treatment.

Interview on 1/28/13 at 8:50 AM with S1 MD VP of Medical Affairs revealed that incidents that are reported through Nursing Services go to Risk Management and then to him. S1 MD VP of Medical Affairs stated he met with S8 Risk Manager and S12 Social Worker on 1/18/13 to discuss the incident. S1 MD VP of Medical Affairs stated that patient #2 did not want to change physicians during the course of hospital treatment. S1 MD VP of Medical Affairs stated he talked with S2 Chief of Staff and S3 Chief of Surgery who happened to also be an ENT, so he did not involve S3 Chief of Surgery since he was an ENT, and thought it would constitute a conflict of interest. S1MD VP of Medical Affairs also stated that S15 MD would be up for investigation by the medical executive committee if another incident arose.

S1MD VP of Medical Affairs stated he and S2 MD Chief of Staff reviewed the information gathered by S8 Risk Manager and felt that there was no need for further investigation due to the fact that there was a positive outcome for the patient. S1 MD VP of Medical Affairs further stated that he and S2 MD Chief of Staff talked with S15 MD on 1/24/13 about how he handled the patient and discussed that S15 MD could have done things differently. S1 MD VP of Medical Affairs confirmed there was no documentation of the meeting with S15 MD as of yet.


June, 2012 Incident (Patient #3)

Review of the "Louisiana Department of Health and Hospitals (DHH) Hospital Abuse/Neglect Initial Report" form prepared by S8, Director of Risk Management on 6/15/12 reflected an incident that occurred on 6/14/12 involving S15 MD and Patient #3. Further review revealed the description of the alleged incident reflected "Patient claims physician lied to him about previous gag reflex exam. Patient also alleges physician pushed on his head (during second gag reflex exam) and grabbed his shoulder without permission. Patient stated he was calling the police and suing the physician if he did not apologize."

Further review of the Initial Report Preview reflected the complaint issue was "Staff Attitude and Behavioral Issue", the nature was "Aggressive (Physical) Behavioral Issue and the Sub-nature was "Physician as Aggressor". Review of the Issue comments/notes reflected "According to the pt. the Dr. came by on 6/13 to do a procedure. The Dr. sprayed a yellow substance down his throat and the pt. was told this was going to numb his throat. The Dr. began his procedure and because he was pushing on the pts. tongue he began to gag. The dr. told the pt. that he shouldn't be gagging, and the pt. told the Dr. he couldn't help it. According to the pt. the Dr. used his finger and [pushed] back on his [forehead] and said 'you're gag reflex is here"... the pt. told the Dr. that he lied to him. The Dr. and the pt. had words and the Dr. came around the bed and put one hand on the pts. shoulder and the other hand in a fist and told the pt. "you're lucky". The pt. said that he was going to call the police and the Dr. said "go ahead, I used to be a police officer." The Dr. was also heard telling the pt. that he is the physician and this is his hospital and he can do whatever he wants."

Continued review of the report reflected an electronic mail (email) report completed by S16. Documentation reflected S16 "Went to room in response to the call light. Found Dr. [S15] at the foot of the bed having a verbal argument with the patient. Dr. [S15] was loudly stating "This man is crazy. You see that don't you. You see that man is crazy. I want you to testify to that, that this man is crazy." He [S15]said it several times...Dr. [S15] stated that he wasn't going to be called a [liar]. The patient stated, "You had no right to put your hands on me." The patient demonstrated putting his right hand on his left shoulder and squeezing it and [then]he took his first two fingers on his right hand and shoved his forehead back. Dr. [S15] stated, "I'm your doctor and you're my patient and this is my hospital, I have every right to touch you. I can do whatever I want."Dr. [S15] then stated, "If you think I assaulted you, then call the police; better yet I will call them for you, I'm a Monroe Policeman."...

Review reflected the initial actions taken were "Contacted VP of Patient Safety and Risk Management, initiated investigation per med staff disruptive physician protocols." Further review reflected the pt. wanted the Dr. taken off his case, and the issues to be addressed according to hospital's policies and procedures.


Review of a email transmission report, concerning the 6/2012 incident, completed by S11 MD Patient Safety Advocate reflected " I was notified................ that [Patient #3] had requested to file a complaint against [S15MD] regarding incidents in [Patient #3's] room...June 13 and 14...We did go to the patient unit, and I was able to encounter [S15MD] to talk with him about the incidents... I discussed with [S15MD] the patient's need for continued medical care either here at [hospital] or at another facility. [Patient #3] indicated his desire to stay here. [S18MD] was the "on call' ENT physician at [hospital] June 14, ...
She did not wish to become directly involved in the patient's care...but was helpful in explaining appropriate management...Another issue was the fact that [S15] will be the "on call" ENT physician Friday...any ENT care given this weekend at [hospital] will be given by [S15 MD]....

There was no documented evidence to reflect the Medical Staff Bylaws had been implemented and/or followed regarding disruptive behavior of a medical staff member.

During an interview with S11MD Patient Safety Advocate on 1/31/13 at approximately 9:50 a.m revealed he personally talked to Patient #3 and S15MD concerning the 6/2012 incident. S11MD Patient Safety Advocate stated the patient and S15MD apologized to each other. Further interview with S11 MD Patient Safety Advocate confirmed there was no documentation in the physician's credentialing file to reflect the 6/2012 incident and Medical Staff Bylaws related to disruptive behavior had been followed and/or provided to S15 MD.

During an interview with S8, Director of Risk Management on 1/31/13 at approximately 1:00 p.m. He confirmed the 6/2012 incident was addressed as a complaint/grievance and not as an allegation of abuse.
VIOLATION: QAPI Tag No: A0263
Based on record review and interview the hospital's governing body, medical staff, and administrative officials the hospital failed to meet the requirements for Conditions of Participation for Quality Assurance as evidenced by:

1. Failing to ensure clear expectations for safety were implemented for 2 of 2 patients (#2, 3) in a total sample of 11 who alleged aggressive behavior from a physician (S15).

2. The hospital failed to involve all hospital departments and services including medical staff in their QA program. The hospital also failed to ensure the adverse patient events are being tracked through the QA program. (A0286)
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview the hospital's governing body, medical staff, and administrative officials failed to ensure clear expectations for safety were implemented for 2 of 2 patients (#2, 3) in a total sample of 11 who alleged aggressive behavior from a physician (S15). The hospital also failed to ensure the adverse patient events were tracked.

Findings:

Review of the hospital's Complaints/Grievances revealed there were 2 grievances completed concerning S15 MD. Further review reflected both grievances involved physical and/or verbal aggression by the physician against patient #2 and Patient #3.

Interview on 1/28/13 at 8:50 AM with S1 MD VP of Medical Affairs revealed that incidents that are reported through Nursing Services go to Risk Management and then to him. S1 MD VP of Medical Affairs stated he met with S8 Risk Manager and S12 Social Worker on 1/18/13 to discuss the incident involving Patient #2. S1 MD VP of Medical Affairs stated that patient #2 did not want to change physicians during the course of hospital treatment. S1 MD VP of Medical Affairs tated he talked with S2 Chief of Staff and S3 Chief of Surgery who happened to also be an ENT, but did not involve S3 since he was an ENT, and thought it would constitute a conflict of interest. S1MD VP of Medical Affairs also stated that S15 MD would be up for investigation by the medical executive committee if another incident arose.

S1MD VP of Medical Affairs stated he and S2 MD Chief of Staff reviewed the information gathered by S8 Risk Manager and felt that there was no need for further investigation due to the fact that there was a positive outcome for the patient. S1 MD VP of Medical Affairs further stated that he and S2 MD Chief of Staff talked with S15 MD on 1/24/13 about how he handled the patient and discussed that S15 MD could have done things differently. S1 MD VP of Medical Affairs confirmed there was no documentation of the meeting with S15 MD as of yet.

During an interview with S11MD Patient Safety Advocate on 1/31/13 at approximately 9:50 a.m revealed he personally talked to Patient #3 and S15MD concerning the 6/2012 incident. S11MD Patient Safety Advocate stated the patient and S15MD apologized to each other. Further interview with S11 MD Patient Safety Advocate confirmed there was no documented evidence in the physician's Crendentialing/Quality file to reflect the 6/2012 incident; nor was there documented evidence to reflect the Medical Staff Bylaw related to disruptive behavior had been followed and provided to S15 MD.

Review of the Credentialing/Quality files for S15MD revealed there was no documented evidence of reports/incidents of disruptive behavior noted in the files.

Interview with S9 Quality Manager on 1/31/13 at approximately 11:10 a.m.revealed she maintained the "Quality files" for the medical staff. S9 stated there had been no reports/incidents regarding disruptive behaviors given to her to place in the Quality file for S15MD.

The surveyors asked hospital staff if there was documented evidence that the incidents with S15 MD and patient #2 and #3 were presented to the QA committee by the Medical Executive staff who handles physician issues to determine if the hospital was identifying problems, evaluating those problems, and taking steps to ensure a safe patient evironment. No evidence was presented to the survey team prior to exit or during the exit conference.

In a telephone interview with S17 RN Quality Director on 2/3/13 confirmed the grievance filed by patient #3 on 6/15/12 did not get to the grievance committee and was not addressed by QA.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on review of Medical Staff Bylaws, Rules and Regulations, medical record review and interview the hospital failed to ensure the medical staff enforced their bylaws by failing to ensure procedure for disruptive behavior by a physician was followed for 1 of 1 physician reviewed (S15 MD). Findings:

Review of the hospital's Medical Staff ByLaws, Policies, and Rules and Regulations: Credentials Policy:6. B 1. Initial Review: reflected "(a) Whenever a serious question has been raised, or where collegial efforts have not resolved an issue, regarding: (1) the clinical competence or clinical practice of any member of the Medical Staff, including the care, treatment or management of a patient or patients; (2) the known or suspected violation by any member of the Medical Staff of applicable ethical standards or the Bylaws, polices, Rules and Regulations of the Hospital or the Medical Staff; and/or
(3) conduct by any member of the Medical Staff that is considered lower than the standards of the Hospital or disruptive to the orderly operation of the Hospital or it's Medical Staff, including the inability of the member to work harmoniously with others, the matter may be referred to the Chief of Staff, the chair of the department, the chair of a standing committee, the CEO, or the Chair of the Board...(b) The person to whom the matter is referred will make sufficient inquiry to satisfy himself or herself that the question raised is credible and, if so, will forward it in writing to the Executive Committee. (c) No action taken pursuant to this Section will constitute an investigation.

6.B.2. Initiation of Investigation: (a) When a question involving clinical competence or professional conduct is referred to, or raised by, the Executive Committee, the Executive Committee will review the matter and determine whether to conduct an investigation or to direct the matter to be handled pursuant to another policy, such as the Policy on Practitioner Health or the Code of Conduct Policy, or to proceed in another manner. In making this determination, the Executive Committee may discuss the matter with the individual. An investigation will begin only after a formal determination by the Executive Committee to do so...6.B.3 Investigative Procedure: (a) Once a determination has been made to begin an investigation, the Executive Committee will either investigate the matter itself, request that the Credentials Committee conduct the investigation, or appoint an individual or ad hoc committee to conduct the investigation..."


June 2012 Incident

Review of the "Louisiana Department of Health and Hospitals (DHH) Hospital Abuse/Neglect Initial Report" form prepared by S8, Director of Risk Management on 6/15/12 reflected an incident that occurred on 6/14/12 involving S15 M.D. and Patient #3. Further review revealed the description of the alleged incident reflected "Patient claims physician lied to him about previous gag reflex exam. Patient also alleges physician pushed on his head (during second gag reflex exam) and grabbed his shoulder without permission. Patient stated he was calling the police and suing the physician if he did not apologize."

Further review of the Initial Report Preview reflected the complaint issue was "Staff Attitude and Behavioral Issue", the nature was "Aggressive (Physical) Behavioral Issue and the Sub-nature was "Physician as Aggressor". Review of the Issue comments/notes reflected "According to the pt. the Dr. came by on 6/13 to do a procedure. The Dr. sprayed a yellow substance down his throat and the pt. was told this was going to numb his throat. The Dr. began his procedure and because he was pushing on the pts. tongue he began to gag. The dr. told the pt. that he shouldn't be gagging, and the pt. told the Dr. he couldn't help it. According to the pt. the Dr. used his finger and [pushed] back on his [forehead] and said 'you're gag reflex is here"... the pt. told the Dr. that he lied to him. The Dr. and the pt. had words and the Dr. came around the bed and put one hand on the pts. shoulder and the other hand in a fist and told the pt. "you're lucky". The pt. said that he was going to call the police and the Dr. said "go ahead, I used to be a police officer." The Dr. was also heard telling the pt. that he is the physician and this is his hospital and he can do whatever he wants."

Continued review of the report reflected an electronic mail (email) report completed by S16. Documentation reflected S16 "Went to room in response to the call light. Found Dr. [S15] at the foot of the bed having a verbal argument with the patient. Dr. [S15] was loudly stating "This man is crazy. You see that don't you. You see that man is crazy. I want you to testify to that, that this man is crazy." He [S15]said it several times...Dr. [S15] stated that he wasn't going to be called a [liar]. The patient stated, "You had no right to put your hands on me." The patient demonstrated putting his right hand on his left shoulder and squeezing it and [then]he took his first two fingers on his right hand and shoved his forehead back. Dr. [S15] stated, "I'm your doctor and you're my patient and this is my hospital, I have every right to touch you. I can do whatever I want."Dr. [S15] then stated, "If you think I assaulted you, then call the police; better yet I will call them for you, I'm a Monroe Policeman."...

Review reflected the initial actions taken were "Contacted VP of Patient Safety and Risk Management, initiated investigation per med staff disruptive physician protocols." Further review reflected the pt. wanted the Dr. taken off his case, and the issues to be addressed according to hospital's policies and procedures.

Review of an email transmission report, concerning the 6/2012 incident, completed by S11 MD Patient Safety Advocate reflected " I was notified................ that [Patient #3] had requested to file a complaint against [S15MD] regarding incidents in [Patient #3's] room...June 13 and 14...We did go to the patient unit, and I was able to encounter [S15MD] to talk with him about the incidents... I discussed with [S15MD] the patient's need for continued medical care either here at [hospital] or at another facility. [Patient #3] indicated his desire to stay here. [S18MD] was the "on call' ENT physician at [hospital] June 14, ...
She did not wish to become directly involved in the patient's care...but was helpful in explaining appropriate management...Another issue was the fact that [S15] will be the "on call" ENT physician Friday...any ENT care given this weekend at [hospital] will be given by [S15]....

During an interview with S11MD Patient Safety Advocate on 1/31/13 at approximately 9:50 a.m revealed he personally talked to Patient #3 and S15MD concerning the 6/2012 incident. S11 MD Patient Safety Advocate stated the patient and S15MD apologized to each other. Further interview with S11 MD Patient Safety Advocate confirmed there was no documented evidence to reflect the 6/2012 incident and the Medical Staff Bylaws related to disruptive behavior had been followed and provided to S15 MD.


January 2013 Incident

Review of a written statement by S5 Surgical Tech reflected an incident occurred during the treatment of patient #2 for severe a nose bleed. Review of the statement reflected the patient rolled in with blood all over her face and neck. Further review of the statement revealed S15 MD was in a hurry to get the patient on the OR bed to begin suctioning the blood and examine patient #2, she started to scream and begged him to stop. Patient #2 attempted to rise from the table and S15 MD yelled at her to lie down and pushed her down forcefuly back onto the OR bed. Patient #2 attempted to rise again and S15 MD hit her two or more times very forcefully to get her to lie down.

Review of a written statement by S6 Surgical Assistant revealed he was in the OR where patient #2 was being treated and she was crying and upset. Further review revealed S15 MD came into the room and told the patient to shut up and be quiet. He then shoved a sponge into her nose. Patient #2 began to holler "Don't do it" several times and S15 MD did not stop but punched the patient 3 times in the right shoulder.

Review of the written statement of S7 RN revealed patient #2 was bleeding from her nose and mouth; was very anxious and scared. S7 RN stated she was monitoring patient #2 vital signs. S15 MD sprayed Cetacaine into patient #2's left nares and she did not tolerate it very well. Patient #2 yelled that the spray burned and hurt, as she attempted to rise and S15 MD tried to keep the patient on the table. S7 RN stepped out of the room to get extra suction tubing and when she returned S15 MD inserted the Rapid Rhino pack into patient #2's left nares but it did not stop the bleeding. S7 RN called for assistance. S15 MD left for another type of pack. When S15 MD left the room, patietn #2 informed the nurse she did not want S15 MD to do anything else to her and that he had hit her to keep her from getting up. S7 RN received help from another RN, and left to call S4 Director of Surgery. During all of this S7 RN was able to administer IV sedation to help calm the patient down and convince the patient to allow S15 MD to complete the treatment.

Interview on 1/28/13 at 8:50 AM with S1 MD VP of Medical Affairs revealed that incidents that are reported through Nursing Services go to Risk Management and then to him. The survey team asked what he recalled about an incident involving a patient who was being treated for a nose bleed in the OR (operating room) by S15 MD. S1 MD stated he met with S8 Risk Manager and S12 Social Worker on 1/18/13 to discuss an incident. S1 MD VP of Medical Affairs stated that patient #2 did not want to change physicians during the course of hospital treatment. S1 MD VP of Medical Affairs stated he talked with S2 Chief of Staff and S3 Chief of Surgery who happened to also be an ENT, but did not involve S3 since he was an ENT, and thought it would constitute a conflict of interest. S1MD VP of Medical Affairs also stated that S15 MD would be up for investigation by the medical executive committee if another incident arose.

S1MD VP of Medical Affairs stated he and S2 MD Chief of Staff reviewed the information gathered by S8 Risk Manager and felt that there was no need for further investigation due to the fact that there was a positive outcome for the patient. S1 MD VP of Medical Affairs further stated that he and S2 MD Chief of Staff talked with S15 MD on 1/24/13 about how he handled the patient and discussed that S15 MD could have done things differently. S1 MD VP of Medical Affairs confirmed there was no documentation of the meeting with S15 MD as of yet.

Review of the hospital's Credentialing /Quality file for S15MD revealed there was no documented evidence of any allegations of disruptive behaviors; nor, was there evidence of any investigations conducted concerning S15 MD noted in the file..