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YAKIMA REGIONAL MEDICAL AND CARDIAC CENTER 110 SOUTH NINTH AVE YAKIMA, WA 98902 April 4, 2012
VIOLATION: MEDICAL STAFF - BYLAWS AND RULES Tag No: A0048
Based on review of hospital approved policy and procedure and staff interview, the hospital failed to report a health care practitioner (anesthesiologist-MD #1) to the Department of Health following unprofessional conduct and resignation with the end of privileges at the hospital; and failed to ensure that Medical Staff Bylaws were in compliance with State and Federal regulations.

Failure to report health care practitioners to the Department of Health as required risked patient health and safety.

Findings:

1. Failure to Report
Administrative staff were interviewed on 4/3-4/2012 regarding complaint allegations that the hospital had knowingly allowed an impaired anesthesiologist (MD #1) to provide anesthesia to patients for a period of up to 2 years (2009-2011). Allegations included that supervisory staff ignored reports that the anesthesiologist had a strong odor of alcohol on his breath, and staff concerns regarding his ability to safely care for patients.

Staff interviews on 4/3-4/2012 identified that MD #1 had been monitored for documentation issues and carrying a bag of anesthesia drugs that were not hospital issue. They reported that MD #1 immediately complied with hospital policy related to those concerns. They stated there had never been a concern identified with his fitness for duty until August of 2011.

They stated that on approximately 8/25/2011, there was a staff report to administration that MD #1 came to work with alcohol on his breath. Immediately administrative staff confronted him and he resigned and entered the Washington Physician Health Program for MD's (a state physician substance abuse program). No direct patient care had occurred that day.

Review of the hospital policy/procedure, "Washington State Reporting of Health Care Practitioners Restriction of Privileges Based on Unprofessional Conduct " dated 4/14/2009, page 3 "Requirements, #1" read, "Reports to the Department of Health should happen within 15 days of conviction, or a determination or finding is made by the hospital that the health care practitioner has made an action of unprofessional conduct or the voluntary restriction or termination of the practice of a health care practitioner, including his or her voluntary resignation, while under investigation or the subject of proceedings regarding unprofessional conduct.
Requirement #2 read, "The Department of Health shall forward reports to the disciplining authority designated for the particular health care provider."

The hospital did not report MD #1 to the Department. Interview with administrative staff on 4/4/2012 revealed that the hospital was told by a representative of the physician substance abuse program that the program would notify the state of the change in MD #1's status. They believed their obligation to report was unnecessary based on the representative's statement, and did not implement their reporting procedure.

2. Failure to Ensure Medical Staff Bylaws were in Compliance with State and Federal Regulations.

The hospital policy: "Impairment" dated 4/21/2009 was reviewed. Under "Referral Process" it read, " ...Signs or symptoms of impairment may include the following ...strong odor or alcohol on breath." and;
"Per the Medical Staff Bylaws "...the impaired practitioner will be required to comply with one of two options: ...Removal of a practitioner from patient care due to impairment without evidence of patient harm shall be reported to the Washington Physician Health Program ..."
There was no requirement in this Medical Staff Bylaws policy and procedure for the hospital to report a practitioner to the Department of Health in the absence of patient harm.

Interview with administrative staff on 4/3-4/2012 verified that the hospital did not report MD #1 to the Department of Health.

Administrative staff interview revealed that the hospital understood and anticipated that the program representative would forward his information to the Washington State Department of Health and Medical Quality Assurance Commission. Per administrative staff interview on 4/4/2012, the hospital had already received a reference request for MD #1 from a hospital in Alaska.

The Revised Code of Washington (RCW) 70.41.210 applies in this case and reads as follows:
1) The chief administrator or executive officer of a hospital shall report to the department when the practice of a health care practitioner as defined in subsection (2) of this section is restricted, suspended, limited, or terminated based upon a conviction, determination, or finding by the hospital that the health care practitioner has committed an action defined as unprofessional conduct under RCW 18.130.180 <http://apps.leg.wa.gov/rcw/default.aspx?cite=18.130.180>. The chief administrator or executive officer shall also report any voluntary restriction or termination of the practice of a health care practitioner as defined in subsection (2) of this section while the practitioner is under investigation or the subject of a proceeding by the hospital regarding unprofessional conduct, or in return for the hospital not conducting such an investigation or proceeding or not taking action. The department will forward the report to the appropriate disciplining authority.(3) Reports made under subsection (1) of this section shall be made within fifteen days of the date: (a) A conviction, determination, or finding is made by the hospital that the health care practitioner has committed an action defined as unprofessional conduct under RCW 18.130.180 <http://apps.leg.wa.gov/rcw/default.aspx?cite=18.130.180>; or (b) the voluntary restriction or termination of the practice of a health care practitioner, including his or her voluntary resignation, while under investigation or the subject of proceedings regarding unprofessional conduct under RCW 18.130.180 <http://apps.leg.wa.gov/rcw/default.aspx?cite=18.130.180> is accepted by the hospital.
Cooperating with the Washington Physician Health Program for MDs did not absolve the hospital's responsibility to report MD #1 to the Department of Health/Medical Quality Assurance Commission.

Failure to report to the Department of Health and follow hospital approved policy and procedure and the intent of the law prevented public agencies with legal jurisdiction to provide needed practitioner oversight; prevented timely notification of other public agencies; prevented crucial tracking and monitoring of the healthcare practitioner; and placed the health and safety of future patients at risk.