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.

Based on document review and interview, the hospital failed to ensure for an effective quality assurance program to evaluate the quality and appropriateness of treatment by failing to ensure services affecting patient health and safety were evaluated in accordance with medical staff (MS) bylaws and Peer Review against 1 (one) of 3 (three) physicians (MD3) who failed to comply with the hospital policy for Patient Rights and was named in 3 of 12 hospital complaints/grievances.

Findings include:

1. Review of PolicyStat ID: 79, titled Patient Rights and Responsibilities, Last Revised 11/2019, indicated the following: Patients have the right to: Considerate and respectful care... Personal privacy...Receive care in a safe setting...Be free from all forms of abuse or harassment...

Review of Medical Staff Bylaws, approved (in whole) 11/27/19, indicated the following: 8.1 Routine Corrective Action 8.1(a) Criteria for Initiation: Whenever activities...or any professional conduct of a practitioner with clinical privileges are detrimental to patient safety, to the delivery of quality patient care, are disruptive, undermine a culture of safety or interfere with hospital operations, or violate the provisions of these Bylaws, the Medical Staff Rules and Regulations, or duly adopted policies and procedures; corrective action against such practitioner may be initiated...

Review of PolicyStat ID: 18, titled Peer Review, Last Revised 3/2020, indicated the following: It is the policy of (The Hospital) to conduct appropriate monitoring of the care delivered by its MS...and to promote safety and high quality health care for its patients... The following are circumstances requiring a Peer Review Assessment: Patient, Peer or Hospital Staff Complaint. The Medical Executive Committee (MEC) has designated a Peer Review Committee to oversee the Peer Review Process... The Director of Quality Management will be available to facilitate the flow of the necessary documents for review... Outcomes of Peer Review will be presented to the MEC for approval of review and recommendations...

2. Review of complaint/grievance logs between 1/1/21 and 3/16/21 indicated 12 complaint/grievances were documented; three of the twelve 3/12 were related to concerns related to care and physician behavior of MD3 as follows:
A. Date of event: 1/2/21 - Date of complaint 1/6/21. The spouse of patient P20 reported that MD3 treated the patient "horribly"... The complaint indicated the patient had experienced a fall and was in pain. The report indicated the physician asked the patient to move themselves to a CT (computed tomography) cart while in severe pain. The complaint further indicated the patient was told nothing was wrong with their back and the patient was discharged . The report indicated MD3 later phoned the patient to report that he/she did have "stuff" going on in his/her back. The report indicated the patient later went to their PCG (Primary Care Giver) and was told they had a fractured back. Response documented by the Chief of ED/MD1 indicated the following: Appears patient was discharged before official read. This is "ok" as long as we follow up with patient. No breech in standard of care. Could have gone more smoothly with staff. Forward copy to provider. A follow letter dated 1/11/21 was indicated as having been sent to the patient.
B. Date of event: 1/9/21 - Date of complaint 1/10/21. Phone call 1/10/21 per patient (P21). Went to ER and saw physician MD3 on 1/9/21 for rectal pain. Doctor did not look at rectum. Patient indicated they were upset due to physician only talked about having seen the patient a year ago related to an arm abscess and IV (intravenous) drug use. The report indicated the patient verbalized this as unprofessional conduct and indicated that he/she is now clean and did not feel that needed brought up... Response documented by MD1 indicated the following: Patient was tachy cardic. Rectal (at least visual) is documented. Follow up not clear...Appears to reflect standard of care... Will notify provider regarding the complaint. A follow letter dated 1/11/21 was indicated as having been sent to the patient.
C. Date of event: 1/11/21 - Date of complaint 1/12/21. Patient stated he/she went to the ED with complaint of an abdominal mass and that MD3 dismissed him/her as if he/she were one of the county's drug addicts. Patient stated he/she was upset at how he/she was being made to feel and left the leaving MD3 yelled "F...You" what is wrong with you people and claims MD3 started dancing and charging at him/her. The patient indicated he/she was afraid of the doctor and afraid to go to his/her local hospital. The patient voiced concerns of verbal assault...stated he/she is a recovering drug addict, gay and on Medicare and knows what "you people" he/she was referring to and that this was discriminating. Response documented by MD1 indicated the following: Patient complaint of (discussed with) provider, provider aware of "challenged" interaction. It appears that the standard of care was followed. Further documentation in the report indicated that the reviewer had spoken with the ER registration clerk on duty who indicated that he/she had heard the doctor yelling, but was not sure what he/she was saying... the clerk recalled as the patient was walking out he/she was heard saying the doctor is crazy. Additional documentation indicated that the reviewer had also spoken with a nurse on shift at the time of the event and that the nurse indicated that he/she did hear MD3 yelling at the patient things that should not be said to a patient. The nurse denied seeing him/her charge the patient or dance... Also stated that MD3 came to the nurse's station and stated "I shouldn't have lost my temper." Why did I let him/her get to me? The report indicated cameras were reviewed that showed the patient walking out of ER at normal pace with no visual signs of MD3 in hallway behind the patient. The report lacked documentation of camera review in the ER prior to the patient's exit. A follow letter dated 1/20/21 was indicated as having been sent to the patient.

The hospital lacked documentation of corrective action having been taken for any of the events or trend of events.

3. On 3/30/21, beginning at approximately 3:15 PM, A1, Director of Quality/Risk, indicated that no cases/issues had been presented for Peer Review since 1/1/21 in regard to complaints involving MD3. Beginning at approximately 4:30 PM, A1 indicated that the hospital did not have documentation of the MEC having reviewed patient complaints/grievances related to MD3. A1 indicated the MEC meets each month and verified meetings for 2021 included January and February MEC meetings without discussion of the concerns indicated in the grievance logs.

Based on document review and interview, the governing body (GB) failed to ensure protocol for COVID-19 testing was implemented for 1 of 10 patients (P3) who screened positive for symptoms of [DIAGNOSES REDACTED]

Findings include:

1. Review of hospital documents for COVID-19 protocol indicated the following:
A. Document titled "Coronavirus disease (COVID-19) SCREENING ALGORITHM", effective 1/6/21, listed 11 symptoms of [DIAGNOSES REDACTED]
B. Email documentation dated 2/1/21 indicated the following: The hospital now has the ability to perform the "Sophia [DIAGNOSES REDACTED] Antigen Covid Test." ... The testing supplies are limited and they are expensive so please consider the guideline below... -If the patient screens POSITIVE for 2 or more of the Covid signs/symptoms (s/s) and is currently experiencing symptoms... Please continue to order the PCR (polymerase chain reaction) for other patients...
C. Hand written note at the bottom of the above email dated 2/1/21 indicated the following from the Emergency Department (ED) Director: If patients test positive, the treatment is individualized based on presentations of s/s... we follow CDC (Centers for Disease Control and Prevention) guidelines.

2. Review of CDC guidelines for "Healthcare Workers" at, updated 3/17/21, indicated the following: Persons with signs or symptoms of [DIAGNOSES REDACTED]

3. The MR of patient P3 indicated the following: The patient (MDS) dated [DATE] and screened positive for 9 of 11 (fever or chills, cough, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea or vomiting and diarrhea) COVID-19 symptoms per the hospital's screening algorithm. ER Physician Documentation, by ER physician MD3 on 1/11/21 at 22:10 hours, indicated the following: Chief complaint: "lost smell sensation". Discharge: Home... Additional Instructions: "I suspect you have Covid 19". "Rapid tests are sometimes available at the...urgent care "fast paced urgent care"... Regular tests (4-5 days) are available at the local Armory." The MR lacked documentation of the patient having been tested for COVID-19.

4. The following was indicated in interview on 3/30/21:
Beginning at approximately 12:45 PM, A2, Registered Nurse, verified the MR of patient P3 indicated he/she screened positive of COVID-19 and the MR lacked documentation of the physician having ordered a COVID-19 test for the patient.
Beginning at approximately 2:30 PM, A4, Chief Nursing Officer, verified that in January of 2021 the hospital had available and was to be using a standard PCR (Polymerase Chain Reaction) test for COVID symptomatic patients.