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.

PALESTINE REGIONAL MEDICAL CENTER 2900 S LOOP 256 PALESTINE, TX 75801 Nov. 6, 2014
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to provide the complainant with a written notice of the decision made the facility for 1 of 3 complaints that had been reported to the facility about the Cath-Lab Unit.


A review of the record titled, "Tracking Log" for the facility complaint log revealed complainant had filed a complaint to the facility on [DATE]. The log revealed a complainant's name, staff member responsible, date sent, but the final outcome and the follow-up date was left blank. A review of the complaint book where all complaint responses are kept and letters to the complainant with a resolution revealed no evidence for this complaint.


A phone interview with patient #9 on 11/18/2014, at approximately 5:00 PM, revealed the patient was never notified that the complaint had been investigated nor had the patient received any letter informing the complainant that the complaint had been investigated.


An interview with Staff #3 on 11/5/2014, at 2:00 PM, confirmed the complaint book did not have any documentation about the complaint filed on 8/13/2014.
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
Based on observations, records review and interviews, the facility failed to ensure that staff working in the Cardiac Cath-Lab were qualified for 2 (#7 and # 9) of 8 staff members.


A review of the facility's Job description titled, "Cardiac Cath-Lab Tech (RCIS, CVT)" Date of Origin: 1/2012 and dated and signed by staff #7 on 7/21/2014 revealed the following:


"Special Qualifications
RCIS (optional)
Current ACLS/BLS
-Experience in Cath lab, angiography, special procedures
-Experience in complex physiological monitoring systems
-Knowledge of stents, balloons, wires, catheters, needle, packs, IABP, IV systems
Written and verbal communication skills-Compassion for high quality patient care"


A review of the facility's Job description titled, "Criteria-Based Performance Evaluation/Job Description system" dated and signed by staff #7 on 7/9/2014 revealed the following:


"Certification in BLS and ACLS required."


On observation tour of a patient through the Cath- lab on 11/5/2014 observed staff #7 scrubbed in and providing care to a patient.


A review of #7"s personnel file revealed no current certifications in ACLS (Advanced Cardiac Life Support) or BLS (Basic Life Support), and no documentation that she had any prior experience in angiography, special procedures, complex physiological monitoring systems, and any knowledge of stents, balloons, wires, catheters, needle, packs, IABP, IV systems. Staff #7 was hired 7/21/2014. The personnel file contained (2) different job descriptions which were signed by Staff #7 one was dated 7/9/2014 and the other was signed 7/21/2014, both job descriptions required the current certifications of BLS/ACLS.


An interview with Staff #10 on 11/5/2014 at 5:00 PM confirmed staff #7 does not have BLS or ACLS certifications.


An interview with the Director of Human Resources #5 on 11/5/2014 at 4:00 PM confirmed staff #7 does not have BLS/ACLS certifications in her file which is required per the facility job descriptions. Staff #5 was asked why staff #7 is allowed to work, when the job description says it must be current. Staff #5 stated, "We give employees a 90 day grace period for BLS and 6 months grace period on ACLS. Staff #5 was asked is this a written policy regarding the grace periods. Also, Staff #5 was asked if the 90 day grace period was up on October 21, 2014. Staff #5 stated, "No it's not written in a policy and yes the 90 day grace period is up."


An interview with Staff #3 on 11/5/2014 at 5:00 PM, who was in the conference room assisting with personnel files, confirmed the above findings.


An interview with #8 on 11/5/2014 at 12:00 PM reported that staff #9 was performing Cardiac Catheterizations on patients without physician #15 in the Cath-Lab Room. Staff #8 bragged on how fast they could do a Diagnostic Heart Catheterization. Staff #8 stated, "We can do a Diagnostic Cath in '6 minutes'."


An interview with Staff #10 on 11/5/2014 at 5:00 PM reported staff #9 was performing Cardiac Catheterizations on patients without physician #15 in the Cath-Lab Room.


A review of Staff #9 file revealed his title was a Registered Cardiovascular Invasive Specialist (RCIS).


A review of the Scope of Practice for a RCIS revealed the following:


"The RCIS should not assume responsibilities for which they are not adequately educated or trained. It is the obligation of the employing institution to validate an employee's credentials, preparation and knowledge base for which he/she is hired to assume. Medication administration and certain medical imaging functions may be restricted for an RCIS who does not have RN (Registered Nurse) or RT (Radiology Technician) license in some states. Operates and maintains all diagnostic and therapeutic equipment. Operates under the direct supervision of a board certified or eligible physician with privileges to perform invasive cardiovascular procedures at their medical facility."

An interview with Staff #6 on 11/6/2014 at approximately 1:00 PM confirmed administration was aware Staff #9 was performing Cardiac Catheterizations.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on records review and interviews, the governing body failed to:

A. provide an effective oversight for the operation of the hospital and provide a safe enviroment for patient care. The disruptive conduct of the practitioner poses a threat to patient care and abuse of staff members.

Interviews with the facility staff members during the day of 11/4/2014 revealed the following:

An interview with Staff #2 (Ethics Compliance Officer) on 11/4/2014, at approximately 8:30 AM, reported that the facility had received a complaint through the Corporate Compliance Hotline on October 23, 2014.

A review of the record from the Corporate Compliance Hotline revealed the following:

"1. Medical Staff.

Reporter:Identity: Anonymous

Summary: The caller believes a cardiologist's negative comments towards the staff cause a hostile work environment.

Details: Facility "A" Hospital


The caller stated that for the last six months, Physician #15, cardiologist, has voiced negative comments towards the Cath-lab staff. The caller stated in general, Physician #15 is a nice person, but approximately twice a week, he will voice a negative comment towards the staff such as, 'No one knows what they are doing here,' which causes a hostile work environment.


The caller stated he/she is understanding to the fact that working as a cardiologist is a stressful profession and knows Physician#15 is important to the hospital, but would like him to treat the staff as part of his team.


The caller believes Physician #15 should be reminded to show the Cath-lab staff respect because 'we are here to assist him'. "

Staff #2 was asked if there has been anything discussed or implemented for this occurrence. Staff #2 stated, "No."

An interview with Staff #17 CEO (Chief Executive Officer) on 11/4/2014, at approximately 9:30 AM, reported that there had been an occurrence with the Cath-Lab team about a year ago where Physician #15 had lashed out at the Cath-Lab team. Staff #17 was asked if anything was written up on the occurrence. Staff #17 stated, "No." Staff #17 stated, "The second occurrence took place in August (2014) and was reported to me by the Risk Management (Staff #4). There were two female employees working in Radiology that felt uncomfortable with the text messages they had received from Physician #15. There were several e-mails exchanged between Human Resource Director, Radiology, Risk Management, and myself concerning the occurrences. "Staff #17 reported he had a conversation with Physician #15 about the occurrence. Staff #17 was asked if the Chief of Staff or MEC (Medical Executive Committee) had been informed of the disruptive behavior. Staff #17 stated, "No, but I think I will need to inform him of the occurrences."

An interview with the Chairman of the Credentialing Committee (Physician #16) on 11/4/2014, revealed he was not aware of physician #15 disruptive and unprofessional behavior with staff members. Furthermore he was not aware that the physician #15 had previous disruptive behavior prior to being granted privileges at the present facility.

A review of the written conversation between Physician #15 and Staff #17 on 8/22/2014 revealed the following:

"I met with Physician #15 on the afternoon of August 22, 2014, at approximately 3:30 PM, to let him know that Human Resources had received complaints against him from employees that he was texting after hours and that it was making them uncomfortable. Physician #15 seemed surprised about the complaint. He stated that he had several employees that texted him and that it was a two way communication. I explained to him that some of the text messages to him were work related and the ones that he was sending was of a more personal nature. I explained that this was making employees uncomfortable. I explained that unless he was 100% sure that the employee wanted personal text messages that he should refrain from sending personal texts. I further told him that I was not going to identify the individual that complained because they did not want to hurt the work relationship. He expressed his understanding and stated that he would be more careful in the future."


Staff #17 was asked had the compliance hotline issue been addressed. Staff #17 stated, "No."


An interview with the Human Resource Director on 11/4/2014 revealed the following:

Issue #1 reported during the interview with the Human Resource Director on 11/4/2014 at 10:00 AM.

Staff #5 was asked if there had been any issues with the Cath-Lab Department. Staff #5 stated, "About two (2) years ago (2) male employees that worked in radiology had come to Human Resources saying they don't want to work in the Cath-Lab. The atmosphere is very demeaning, the physician was very critical of their work. They had requested from the Radiology Department manager to be transferred out of the unit." Staff #5 was asked was the incident written up. Staff #5 stated, "No, I just mentioned the issues to the CEO (Chief Operating Officer)." Staff #5 was asked what happened to the employees. Staff #5 stated, "One of the employees no longer works at the facility and the other employee was transferred back to radiology department."

Issue #2 reported during the interview with the Human Resource Director on 11/4/2014 at 10:00 AM.

Staff #5 reported the second issue of inappropriate texting that occurred in August of 2014. Physician # 15 (who is the Cath-Lab Medical Director) had texted two (2) female employees in the Radiology department with inappropriate text messages that made the employees feel uncomfortable. The employees had reported the issues to the Radiology department manager, who then reported to the Risk Management Department, and Risk Management had reported the issue to Human Resources. Staff #5 was asked was there a report written. Staff #5 stated, "Staff #4 (Risk Management) had written the occurrences."

Issue #3 reported during the interview with the Human Resource Director on 11/4/2014 at 10:00 AM.

Staff #5 reported 4-5 months ago Employee #8 came to Human Resources reporting that Physician #15 was calling him "stupid" and was very demeaning to him. He was requesting to be transferred out of the Cath Lab Department. The other occurrence occurred about 2 weeks ago Employee # 11 had requested to be transferred out due to the negative atmosphere and inconsistency of long hours in the Cath Lab. Staff #5 was asked had this been written up. Staff #5 stated, "No, but it was mentioned to the CCO (Chief Clinical Officer)."

An interview with Vendor #18 (who was requested by physician #15 to speak with the surveyor) on 11/4/2014, at 10:30 AM, reported the following.

Vendor #18 was asked how the physician and staff work together during the Cath- Lab procedures. Vendor #18 stated, "The Cath-lab unit seems 'dysfunctional'. I have been here for 3 weeks and the staff members seem to have lack of knowledge for the Cath-Lab procedures."

An interview with Staff #3 (Quality Director) on 11/4/2014, at 11:00 AM, reported the following:

Staff #3 was asked if she had heard of any occurrences in the Cath-Lab. Staff #3 stated, "I interviewed Staff #11(she is a Cath -Lab member) for a position in the Quality Department. Staff #11 told me she needed to be transferred out of the Cath-Lab because of inconsistency of long hours and physician #15 had been talking about her to other staff members. Physician #15 was saying she should not be allowed to study and take test for nurse practitioner on the computer at work. Staff #11 had been cleared to use the computer for testing. I know she went to the Human Resource department within the last 2 weeks."

An interview with Staff #1 (Assistant CNO) on 11/4/2014, at 11:30 AM, reported the following:

Staff #1 was asked if she had heard of any occurrences in the Cath-Lab. Staff #1 stated, "I know the Cath-Lab members don't like the long hours in the Cath-Lab, but they were made aware of the hours when they applied for the position."

An interview with Staff #14 on 11/4/2014, at 12:00 PM, reported the following:

Staff #14 was asked if she had heard Physician #15 call Cath -Lab staff names or belittle the staff. Staff #14 stated, "Yes Physician #15 calls the staff F...Ups, stupid, idiots, and is this the first day you have ever worked here." Staff #14 reported the Director of the Cath-Lab had interviewed all Cath-Lab members last Thursday. I typed the report. Staff #14 was asked why you typed the report. Staff #14 stated, "I guess he didn't want it to be in his handwriting." Staff #14 was asked why the interviews were conducted. Staff #14 stated, "The working environment has been really bad the last 2 weeks. Physician #15 has threatened the staff that he is going to get us fired and he will black ball us." Staff #14 was asked what black ball means. Staff #14 stated, "He will not speak to you. The patient care is inconsistent at times. Some of the patients are waiting for discharge for several hours. Like sometimes the patient can be up in 3 hours and sometimes it will be 6 hours before he lets the patient get up and it will be the identical type of procedure. The Director of the Cath-Lab was supposed to go to administration with all the problems in the Cath-Lab, but he has not been back to work." Staff #14 was asked where the report was. Staff #14 stated, "I gave it to Staff #10 this morning."

An interview with Staff #12 on 11/4/2014, at 1:45 PM, reported the following:

Staff #12 was asked if there were issues in the Cath-Lab. Staff #12 stated, "There has been conflict in the Cath-Lab for the last 6 months. Physician #15 calls me 'useless and a moron'. "Staff #12 was asked did you report this. Staff #12 stated, "I followed my chain of command, but the Director of the Cath -Lab told me to 'deal with it or find another job'. I liked my job, but I'm tired of being belittled and afraid of retaliation."

An interview with Staff #13 on 11/4/2014, at 2:00 PM, reported the following:

Staff #13 was asked if there were any issues in the Cath-Lab. Staff #13 stated, "About a month ago he got real loud with me, because I put a catheter plug in the wrong place. I have not had any issues with physician #15, except I have heard him belittle the other staff members and call them F ... ups. Sometimes it gets very uncomfortable. The scrub technicians get the worse of it from physician #15. Physician #15 is inappropriate with the scrubs and it has gotten very uncomfortable in the Cath-Lab since the Director of the Cath-Lab has been gone." Staff #13 was asked does this type of behavior happen in front of the patient. Staff #13 stated, "Yes and the patients are lying on the table for an hour waiting on Physician #15. This hour wait is a regular occurrence. If the issues are not resolved I will not stay." Staff #13 was asked did you report this type of conduct. Staff #13 stated, "The Director of the Cath-lab has been there when it happens and nothing has been done."

An interview with Staff #11 on 11/4/2014, at 2:30 PM, reported the following:

Staff #11 was asked if there were any issues in the Cath-Lab. Staff #11 stated, "I went to Human Resources (HR) about 2 weeks ago and talked with the Director. I was fearful for my job and fearful of Physician #15. Physician #15 was talking to the Cath-Lab staff about me using the computer at the hospital while at work and that I should be fired for that. I was taking a test on the hospital computer (I had been given permission from Human Resources as long as I was off the clock and I was.) I applied for another position in the hospital and was fearful if the Director of Cath-Lab #9 and the Medical Director #15 found out, they would fire me. So, that is why I went to HR for fear of retaliation. I have heard Physician #15 call Staff #8 'stupid' and he treats Staff #8 like a dog."

Staff #11 also had reported inconsistencies in patient care. Staff #11 stated, "I was taking care of a patient that Physician #15 had told the family the patient would have to be admitted after the procedure. Patient came down to post-op after the procedure. At 2:00 PM, patient and family were requesting to go to the floor, so I called the Physician #15 to see if patient could go to the floor and he said, 'I will be down to see him'. At 6:00 PM, Physician #15 had still not showed up. I called the physician again. Physician #15 called back at 7:00 PM, and said 'what patient'. He then gave me orders to admit the patient to the floor. "

An interview with Staff #7 on 11/4/2014, at 3:15 PM, reported the following:

Staff #7 was asked if there were any issues in the Cath-Lab. Staff #7 stated, "I have heard Physician #15 uses the F ... word, stupid and moron toward the staff working in the Cath-Lab. Physician #15 is very direct when he speaks to me, but I am new to the scrub position." Staff #7 was asked if the foul language was used in front of patients and if patients were on the table waiting for the Physician #15. Staff #7 stated, "Yes."

An interview with Staff #10 on 11/4/2014, at 3:15 PM, reported the following:

Staff #10 was asked if there were any issues in the Cath-Lab. Staff #10 stated, "The hours are very long on Wednesdays, sometimes over 16 hours. Staff #10 was asked have you heard Physician #15 call the staff names. Staff #10 stated, "I heard him call the staff 'stupid and moron'." Staff #10 was asked did you report to anyone since you are the charge nurse in the Cath-Lab. Staff #10 stated, "I reported it to Director #9 and all he said was 'this is how it is and if you don't like it you can leave'. I have also reported this to Staff #1." Staff #10 was asked about the interview that Staff #9 (Cath-Lab Director) conducted. Staff #10 stated, "I was present during the interview with the staff and basically they all said the same thing that they were tired of being called names, and being belittled. Physician #15 has a way of demeaning the staff."

An interview with Staff #8 on 11/5/2014, at approximately 12:15 PM, reported the following:

Staff #8 was asked if there were any issues in the Cath-Lab. Staff #8 stated, "Physician #15 is very demeaning, he calls me an F ...Up, idiot, and stupid in front of the Cath-Lab staff. I went to Human Resources couple of months ago trying to get a transfer out of the Cath-Lab to anywhere in the hospital. I wrote all of this on the hospital survey and I reported it to the Director of the Cath-Lab." The Director of the Cath-Lab told me that he had gone to administration, but that they wouldn't back him and he said, "It is what it is". Staff #8 was asked did the foul language get used in front of the patients and did the patients stay on the table for long periods. Staff #8 stated, "Yes."

During the interview process it was reported by Staff #14 that the Director of the Cath-Lab had conducted interviews with staff members #7, 8, 11, 12, 13, and 14 on October 30, 2014. A review of the interviews documented by the Director noted the same complaints voiced by staff members #7, 8, 11, 12, 13, and 14 when the complaint survey was conducted.


An interview with the administrative Staff #1, 6, and 17 revealed no indication that any action had been taken place to resolved the complaints voiced by the staff members #7, 8, 10, 11, 12, 13, and 14 for the demeaning behavior that physician #15 had displayed toward the staff in the present of patients.



B. ensure the Medical Staff Bylaws were followed concerning a physician's disruptive behavior.

Refer to Tag: A0049
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on record review and interview, the governing body failed to ensure that the Medical Staff Bylaws were followed concerning a physician's disruptive behavior.


An interview with Staff #2 (Ethics Compliance Officer) on 11/4/2014, at approximately 8:30 AM, reported the facility had received a complaint through the Corporate Compliance Hotline on October 23, 2014.

A review of the record from the Corporate Compliance Hotline revealed the following:

"1. Medical Staff.

Reporter: Identity: Anonymous

Summary: The caller believes a cardiologist's negative comments towards the staff cause a hostile work environment.

Details: Facility "A" Hospital


The caller stated for the last six months, Physician #15, cardiologist, has voiced negative comments towards the Cath-lab staff. The caller stated in general, Physician # 15 is a nice person, but approximately twice a week he will voice a negative comment towards the staff such as, 'No one knows what they are doing here.,' which causes a hostile work environment.


The caller stated he/she is understanding to the fact working as a cardiologist is a stressful profession and knows Physician#15 is important to the hospital, but would like him to treat the staff as part of his team.


The caller believes Physician #15 should be reminded to show the Cath- lab staff respect because 'we are here to assist him'."

Staff #2 was asked has anything been discussed or implemented for this occurrence. Staff #2 stated, "No."

An interview with Staff #17 CEO (Chief Executive Officer) on 11/4/2014, at approximately 9:30 AM, reported there had been an occurrence with the Cath -Lab team about a year ago where Physician #15 had lashed out at the Cath-Lab team. CEO was asked if anything was written up on the occurrence. Staff #17 CEO stated, "No." Staff #17 stated, "The second occurrence took place in August (2014) and was reported to me by the Risk Management (Staff #4). There were two female employees working in Radiology that felt uncomfortable with the text messages they had received from Physician #15. There were several e-mails exchanged between Human Resource Director, Radiology, Risk Management, and myself concerning the occurrences. "Staff #17 reported he had a conversation with Physician #15 about the occurrence. Staff #17 CEO was asked had the Chief of staff been notified of the disruptive behavior. CEO stated, "No, but I will be speaking to the Chief of Staff since the second occurrence has occurred."

A review of the written conversation between CEO and Physician #15 on 8/22/2014 revealed the following:

"I met with Physician #15 on the afternoon of August 22, 2014, at approximately 3:30 pm, to let him know that Human Resources had received complaints against him from employees that he was texting after hours and that it was making them uncomfortable. Physician #15 seemed surprised about the complaint. He stated that he had several employees that texted him and that it was a two way communication. I explained to him that some of the text messages to him were work related and the ones that he was sending was of a more personal nature. I explained that this was making employees uncomfortable. I explained that unless he was 100% sure that the employee wanted personal text messages that he should refrain from sending personal texts. I further told him that I was not going to identify the individual that complained because they did not want to hurt the work relationship. He expressed his understanding and stated that he would be more careful in the future."


Staff #17 was asked has the compliance hotline issue been addressed that was reported on October 23, 2014. CEO stated, "No."

A review of the record titled, "Medical Staff Bylaws Appendix 'C' Hospital policy regarding Practitioner's Conduct" revealed the following:


"It is the policy of the hospital for all individuals working in the hospital to treat others with respect, courtesy, and dignity, and to conduct themselves in a professional, cooperative manner, and in compliance with the code of conduct for facility. This policy sets forth the requirement that all physicians and Allied Health Professionals who work in the hospital will act in a professional and respectful manner at all times. Furthermore, this policy defines disruptive conduct, and outlines how it should be reported and addressed.


The objectives of this policy are to ensure quality patient care by promoting a safe, cooperative, and professional healthcare environment, and to provide hospital employees and physicians with a work environment based on respect and one that encourages personal and professional growth.


II. Disruptive Conduct

For purposes of this policy, "disruptive conduct" is any conduct that disrupts the smooth operation of the hospital, adversely affects the abilities of others to perform their jobs appropriately, poses a threat or potential threat to safe quality patient care or exposes the hospital or medical staff to potential liability. Such disruptive conduct may include, but is not limited to, behavior such as:

1. Abusive behavior or comments to hospital personnel, other practitioners, hospital visitors, and patients or their families.

2. Attacks, verbal or physical, directed at other practitioners, hospital personnel, patients or visitors that are: personal, inappropriate, irrelevant, or beyond the bounds of fair professional conduct.


VI. MEETING WITH THE PRACTITIONER

A first confirmed incident of disruptive behavior requires a discussion with the attending practitioner. The Chief Executive Officer and Chief of Staff shall initiate a meeting with the practitioner and emphasize that such conduct is inappropriate and violates hospital policy and the Medical Staff Bylaws.


These individuals shall discuss the matter informally with the practitioner, emphasize that if the conduct continues, more formal action will be taken to stop it. The identity of the individual who made the report of disruptive conduct WILL be disclosed at this time, unless the Chief Executive Officer and Chief of Staff agree in advance that it is inappropriate to do so. A basic sense of fairness would normally dictate that the physician must be aware of his accuser. The following guidelines shall be followed regarding the meeting:

1. The initial approach should be collegial and designed to be helpful to the physician. This might occur informally over a "cup of coffee."

2. The parties should emphasize that if the behavior continues, more formal action will be taken to stop it.

3. Informal meetings shall be documented with a written summary of the meeting. This documentation shall be maintained in the confidential peer review file of the practitioner.
4. A follow up letter to the physician shall state that the physician is required to behave professionally and cooperatively, along with a copy of this hospital policy of disruptive conduct.

5. Nothing herein shall be deemed to prohibit more formal corrective action as a result of a single incident. The Chief of Staff and Chief Executive Officer TOGETHER shall determine that the seriousness of the incident justifies such action. The matter will then go before the entire Medical Executive Committee.

If a second incident of disruptive conduct occurs, the Chief Executive Officer and Chief of Staff shall meet with and advise the physician that such conduct is intolerable and must stop. This meeting constitutes the physician's final warning. It shall be followed up with a letter reiterating the warning and summarizing the meeting. The practitioner may prepare a written response to the letter. The documentation and the physician's response, if any, shall be maintained in the practitioner's confidential peer review file. All meetings with the practitioner shall be documented.

After each meeting with the practitioner, a letter shall be sent to the practitioner confirming the hospital's and medical staff leadership's position. The practitioner will be required to behave professionally and cooperatively. This letter shall also include the potential consequences of continued noncompliance."


An interview with the CEO on 11/4/2014, at approximately 9:30 AM, confirmed the Medical Bylaws were not followed for a physician #15 disruptive behavior.


An interview with the Credentialing Coordinator (Staff #22) on 11/5/2014, at 9:00 AM, confirmed the hospital does not have a confidential peer review file of Physician #15. A review of Physician #15 file revealed no evidence about a meeting held with the CEO on 8/22/2014. Credentialing Coordinator was asked does the hospital even have confidential peer review files for practitioners. Staff #22 stated, "No, but maybe the Risk Management Director keeps a file."


An interview with the Risk Management Director (Staff #4) on 11/5/2014, at 9:30 AM, confirmed the Risk Management does not keep any peer review files for practitioners.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on record review and interview, the facility failed to inform patients of their rights prior to providing care to the patient for 1 (#4) of 8 patients.


A review of patient #4's record revealed no notice of patient's rights on the record. Patient had Cardiac Catheterization procedure on 9/17/2014.

An interview with Staff # 23 on 11/6/2014, at 10:00 AM, confirmed the medical record had no notice of patient's rights on the medical record.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records review and interviews, the facility failed to process a complaint in the Cardiac Cath-Lab Unit in a timely manner for 1 of 3 complaints that had been reported about the Cath-Lab unit. Further review of the complaint process revealed complaints had been received from follow-up phone calls on patients receiving care in the Cath-Lab, but the complaints had not been reported following the hospital process.


A review of the record titled, "Tracking Log" for the facility complaint log revealed complainant had filed a complaint to the facility on [DATE]. The log revealed a complainant's name, staff member responsible, date sent, but the final outcome and the follow-up date was left blank. A review of the complaint book where all complaint responses are kept and letters to the complainant with a resolution revealed no evidence for this complaint.


A phone interview with patient #9 on 11/18/2014, at approximately 5:00 PM, revealed the patient was never notified that the complaint had been investigated nor had the patient received any letter informing the complainant that the complaint had been investigated.


An interview with Staff #3 on 11/5/2014, at 2:00 PM, confirmed the complaint book did not have any documentation about the complaint filed on 8/13/2014.

An interview with the Staff #10 on 11/4/2014, at 4:00 PM, revealed patient complaints had been received from follow-up phone calls to the patient after receiving a procedure in the Cath-Lab. Staff #10 was asked were the complaints written and tracked for follow-up. Staff #10 stated, "I report them to the Medical Director (Physician #15) and that is as far as it goes." Staff #10 was asked do you report this in your quality improvement for the Cath-Lab. Staff #10 stated, "No."

An interview with Quality Director and Risk Management Director on 11/5/2014, at approximately 2:00 PM, revealed neither of them knew about the complaints that had been identified on follow-up phone calls from the patients receiving care in the Cath-Lab unit.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review and interview, the facility failed to inform patients of their rights prior to providing care to the patient for 1 (#4) of 8 patients.


A review of patient #4's record revealed the condition had been marked through and another procedure was written on the consent form for a "Left Heart Cath and Trans esophageal echocardiogram: coronary artery disease." This was written in the blank area of the condition that is to be filled out on the form and explained to the patient. The procedure blank area that explains to the patient what type of procedure will be performed read "Right and Left Heart Catheterization and Coronary Angiography with possible intervention." The changes to the consent form were not initialed by the patient or person making the changes to the consent. The consent was confusing due to the person completing the consent form had written procedures in two different areas of the consent.

A review of patient #7's record revealed the original condition had been marked through and "removal of loop recorder Dx: Palpations" was written in the condition blank area of the form to explain the condition to why the patient is having the procedure. The procedure blank area was marked through with no explanation of what type of procedure the patient was going to have. The consent form was dated 9/9/2014 at 5:39 PM, but the procedure was performed on 9/17/2014. The consent form was not signed by the physician or staff members working at the facility.

An interview with Staff # 23 on 11/6/2014, at 10:00 AM, confirmed the above findings on the consent of the medical record. Staff #23 confirmed that the witness signature on the consent form was not a hospital employee.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on record review and interview, the Medical Staff failed to ensure that the Medical Staff Bylaws were followed concerning practitioner's (physician #15) disruptive behavior and conduct with staff members working in the Cath-Lab Unit.


A review of physician #15's credentialing file revealed the practitioner had been reported to the National Practitioner Data Bank for disruptive and unprofessional behavior including abusive and/or demeaning statements to the hospital staff, and inappropriate conduct with female staff members in February 2011.


An interview with Staff #7 on 11/4/2014, at 3:15 PM, reported the following:

Staff #7 was asked if there were any issues in the Cath-Lab. Staff #7 stated, "I have heard Physician #15 uses the F ... word, stupid and moron toward the staff working in the Cath-Lab. Physician #15 is very direct when he speaks to me, but I am new to the scrub position." Staff #7 was asked if the foul language was used in front of patients and if patients were on the table waiting for the Physician #15. Staff #7 stated, "Yes."

An interview with Staff #8 on 11/5/2014, at approximately 12:15 PM, reported the following:

Staff #8 was asked if there were any issues in the Cath-Lab. Staff #8 stated, "Physician #15 is very demeaning, he calls me an F ...Up, idiot, and stupid in front of the Cath-Lab staff. I went to Human Resources couple of months ago trying to get a transfer out of the Cath-Lab to anywhere in the hospital. I wrote all of this on the hospital survey and I reported it to the Director of the Cath-Lab." The Director of the Cath-Lab told me that he had gone to administration, but that they wouldn't back him and he said, "It is what it is". Staff #8 was asked did the foul language get used in front of the patients and did the patients stay on the table for long periods. Staff #8 stated, "Yes."

An interview with Staff #10 on 11/4/2014, at 3:15 PM, reported the following:

Staff #10 was asked if there were any issues in the Cath-Lab. Staff #10 stated, "The hours are very long on Wednesdays, sometimes over 16 hours. Staff #10 was asked have you heard Physician #15 call the staff names. Staff #10 stated, "I heard him call the staff 'stupid and moron'." Staff #10 was asked did you report to anyone since you are the charge nurse in the Cath-Lab. Staff #10 stated, "I reported it to Director #9 and all he said was 'this is how it is and if you don't like it you can leave'. I have also reported this to Staff #1." Staff #10 was asked about the interview that Staff #9 (Cath-Lab Director) conducted. Staff #10 stated, "I was present during the interview with the staff and basically they all said the same thing that they were tired of being called names, and being belittled. Physician #15 has a way of demeaning the staff."

An interview with Staff #11 on 11/4/2014, at 2:30 PM, reported the following:

Staff #11 was asked if there were any issues in the Cath-Lab. Staff #11 stated, "I went to Human Resources (HR) about 2 weeks ago and talked with the Director. I was fearful for my job and fearful of Physician #15. Physician #15 was talking to the Cath-Lab staff about me using the computer at the hospital while at work and that I should be fired for that. I was taking a test on the hospital computer (I had been given permission from Human Resources as long as I was off the clock and I was.) I applied for another position in the hospital and was fearful if the Director of Cath-Lab #9 and the Medical Director #15 found out, they would fire me. So, that is why I went to HR for fear of retaliation. I have heard Physician #15 call Staff #8 'stupid' and he treats Staff #8 like a dog."

Staff #11 also had reported inconsistencies in patient care. Staff #11 stated, "I was taking care of a patient that Physician #15 had told the family the patient would have to be admitted after the procedure. Patient came down to post-op after the procedure. At 2:00 PM, patient and family were requesting to go to the floor, so I called the Physician #15 to see if patient could go to the floor and he said, 'I will be down to see him'. At 6:00 PM, Physician #15 had still not showed up. I called the physician again. Physician #15 called back at 7:00 PM, and said 'what patient'. He then gave me orders to admit the patient to the floor. "

An interview with Staff #12 on 11/4/2014, at 1:45 PM, reported the following:

Staff #12 was asked if there were issues in the Cath-Lab. Staff #12 stated, "There has been conflict in the Cath-Lab for the last 6 months. Physician #15 calls me 'useless and a moron'." Staff #12 was asked did you report this. Staff #12 stated, "I followed my chain of command, but the Director of the Cath -Lab told me to 'deal with it or find another job'. I liked my job, but I'm tired of being belittled and afraid of retaliation."

An interview with Staff #13 on 11/4/2014, at 2:00 PM, reported the following:

Staff #13 was asked if there were any issues in the Cath-Lab. Staff #13 stated, "About a month ago he got real loud with me, because I put a catheter plug in the wrong place. I have not had any issues with physician #15, except I have heard him belittle the other staff members and call them F ... ups. Sometimes it gets very uncomfortable. The scrub technicians get the worse of it from physician #15. Physician #15 is inappropriate with the scrubs and has got very uncomfortable in the Cath-Lab since the Director of the Cath-Lab has been gone." Staff #13 was asked does this type of behavior happen in front of the patient. Staff #13 stated, "Yes and the patients are lying on the table for an hour waiting on Physician #15. This hour wait is a regular occurrence. If the issues are not resolved I will not stay." Staff #13 was asked did you report this type of conduct. Staff #13 stated, "The Director of the Cath-lab has been there when it happens and nothing has been done."

An interview with Staff #14 on 11/4/2014, at 12:00 PM, reported the following:

Staff #14 was asked if she has heard Physician #15 call Cath -Lab staff names or belittle the staff. Staff #14 stated, "Yes Physician #15 calls the staff F ...Ups, stupid, idiots, and is this the first day you have ever worked here." Staff #14 reported the Director of the Cath-Lab had interviewed all Cath-Lab members last Thursday. I typed the report. Staff #14 was asked why you typed the report. Staff #14 stated, "I guess he didn ' t want it to be in his handwriting." Staff #14 was asked why the interviews were conducted. Staff #14 stated, "The working environment has been really bad the last 2 weeks. Physician #15 has threatened the staff that he is going to get us fired and he will black ball us." Staff #14 was asked what black ball means. Staff #14 stated, "He will not speak to you. The patient care is inconsistent at times. Some the patients are waiting for discharge for several hours. Like sometimes the patient can be up in 3 hours and sometimes it will be 6 hours before he lets the patient get up and it will the identical type of procedure. The Director of the Cath-Lab was supposed to go to administration with all the problems in the Cath-Lab, but he has not been back to work." Staff #14 was asked where the report was. Staff #14 stated, "I gave it to Staff #10 this morning."

During the interview process it was reported by Staff #14 that the Director of the Cath-Lab had conducted interviews with staff members #7, 8, 11, 12, 13, and 14 on October 30, 2014. A review of the interviews documented by the Director noted the same complaints voiced by staff members #7, 8, 11, 12, 13, and 14 when the complaint survey was conducted.


An interview with Staff #17 CEO (Chief Executive Officer) on 11/4/2014, at approximately 9:30 AM, reported there had been an occurrence with the Cath -Lab team about a year ago where Physician #15 had lashed out at the Cath-Lab team. Staff #17 was asked if anything was written up on the occurrence. Staff #17 stated, "No." Staff #17 stated, "The second occurrence took place in August (2014) and was reported to me by the Risk Management (Staff #4). There were two female employees working in Radiology that felt uncomfortable with the text messages they had received from Physician #15. There were several e-mails exchanged between Human Resource Director, Radiology, Risk Management, and myself concerning the occurrences. "Staff #17 reported he had a conversation with Physician #15 about the occurrence. Staff #17 was asked if the Chief of Staff or MEC (Medical Executive Committee had been informed of the disruptive behavior. Staff #17 stated, "No, but I think I will need to inform him of the occurrences."

An interview with the Chairman of the Credentialing Committee (Physician #16) on 11/4/2014, revealed he was not aware of physician #15 disruptive and unprofessional behavior with staff members. Furthermore he was not aware that the physician #15 had previous disruptive behavior prior to being granted privileges at the present facility.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on records review and interviews, the facility failed to ensure that staff working in the Cardiac Cath-Lab had completed a department orientation and skills check list for 5 (# 7, 8, 9, 10, and #12) of 8 staff members for performing assessments and procedures on patients. Also, the facility failed to complete annual evaluations for the staff members working in the Cath-Lab for 6 (#7, 8, 10, 11, 12, and #14) of 8.



A review of Staff #7's record titled, "Department Orientation and Skills Check List" was not completed. A review of the personnel file revealed no 90 day evaluation. Date of hire was 7/21/2014.


A review of Staff #8's record titled, "Department Orientation and Skills Check List" revealed no evidence of this document in the personnel file. A review of the personnel file revealed last evaluation was completed when the Staff #8 worked in the Critical Care Unit dated 1/9/2013.


A review of Staff #9's record titled, "Unit Based Competency" revealed the preceptor was Physician #15 and the check off date was 12/21/2011, and all competencies on the 13 page list were completed in the same day. Further review of the personnel file revealed no annual competency checklist for year 2012, 2013, and 2014.


A review of Staff #10's record titled, "Department Orientation and Skills Check List" revealed the competency was completed on 12/20/2011 and the preceptor was staff member #9 (Registered Cardiovascular Invasive Specialist 'RCIS') initialing nursing competencies for a registered nurse. Further review of the personnel file revealed no annual competency checklist for year 2012, 2013, and 2014. A further review of the personnel file revealed last evaluation was completed 2/15/2013.


A review of Staff #11's personnel file revealed the last evaluation was completed 1/2013.


A review of Staff #12's record titled, "Department Orientation and Skills Check List" revealed no evidence of this document in the personnel file. A further review of the personnel file revealed last evaluation was completed 2/15/2013.


A review of Staff #14's personnel file revealed the last evaluation was completed 1/23/2013.


An interview with Staff #3, #5, and #10 on 11/5/2014, at 5:00 PM, confirmed the above findings
VIOLATION: HISTORY AND PHYSICAL Tag No: A0952
Based on observations, records review, and interviews, the facility failed to ensure History and Physicals were updated by the physician prior to Cardiac Catheterization procedures on 2 (#1 and 2) of 8 patients.


Observed during a tour of the pre-op area on 11/5/2014, at 11:30 AM, two forms titled, "Assessment & Update" forms were signed by Physician #15 dated 11/5/2014, at 10:20 AM. Patient #1's form assessing the respiratory, cardiovascular, neuro/musculoskeletal, hepato/gastrointestinal, and renal /endocrine systems was completed. Patient #2's form assessing all the systems was left blank, but had been signed by physician #15 dated 11/5/2014, at 10:20 AM. Staff #14 was asked who is filling out the updated assessment for the history and physical on patients prior to the procedures. Staff #14 stated, "I do." Surveyor asked staff #14 again, you are filling out the updated history and physical for the patient. Staff #14 stated, "Yes." Staff #14 was asked is the physician pre-signing the History & Physical form without seeing the patient. Staff #14 stated, "Yes."