HospitalInspections.org

Based on document review and interview it was determined that for 1 of 1 (MD #1) medical staff credentialing file reviewed, the governing body failed to ensure that the medical staff adherence to mandatory self-reporting as required by the medical staff bylaws.

Findings include:

1. On 12/14/2022, at 10:30 AM, the medical staff file for MD #1(anesthesiologist) was reviewed. MD #1 was hired on 09/09/2020 with the initial appointment date approved by the medical executive and governing council on 02/18/2021. MD #1's credentialing file included:

- Appointment letter dated 09/09/2020 signed by the President of Medical Staff, included, " ...Governing Council, at their September 9, 2020, meeting, approved your appointment, as Provisional Associate in the Department of Anesthesia, Section of Anesthesiology. You will be notified of your first reappointment cycle that will occur 03/31/2021 ..."

- MD #1's background check report dated 12/07/2022 included, "Report Summary: County Court Search - Complete, consider ...Filed Date: 03/13/2021; Charges: Misdemeanor; Original charge: Domestic Battery - Bodily harm, Disposition - pending ..."

2. On 12/14/2022 at approximately 11:00 AM, the Hospital's email letter dated 12/09/2022 was reviewed and included, documentation by MD#1 (Anesthesiologist) at 10:21 AM, addressed to E #1(Manager of Medical Staff Credentialing), MD #2 (Chairman of Anesthesiology), "Subject: Urgent Request: Attestation Needed ...Please find attached the requested documentation, as well as supplemental documentation - this is a very complex matter involving my former marriage ...[Attachment included] ...State of Illinois -IDPH [Illinois Department of Public Health] Health Care Professional Update Data Gathering Form ...signed and dated by MD #1 on 12/08/2022 ...Notification of changes ...Professional History: Confidential ...Criminal Actions: Have you been charged with or convicted of a crime ...criminal charges pending ...:Yes; ...Have you been subject of a ...criminal complaint ...domestic violence ...: Yes ...Form D - Criminal Actions: ...Date of Incident: 03/11/2021; Date of Complaint or Conviction: 03/11/2021; Date of Resolution: Set to be dismissed 03/09/2023; Type of Resolution: Not Guilty plea entered; Agreement for Deferred Prosecution entered; Dismissal and disposition of matter on 03/09/2023 ...Allegation: Domestic Battery ...Actions Taken Against You: None, Case Still pending ...Current status of situation: Case to be dismissed on 03/09/2023 pending mental health evaluation and domestic violence courses ...Medical Practice Privileges Affected As a Result of This situation: None ...signed and dated by (MD #1) on 12/08/2022."

3. On 12/14/2022 the Hospital's Medical Staff Bylaws dated 07/18/2022, was reviewed and included, " ...2.8.7 Mandatory Self-Disclosure: Each applicant and Medical Staff Member agrees to notify the Medical Staff President in writing promptly after they become aware (in no event later than the end of the next business day) of any of the following: ...(b) Any investigations, disciplinary action, adverse action, restriction, or change related to the ...(including but not limited to the applicant's ...health plans, and agencies ..."

4. On 12/14/2022 at 10:45 AM, the Manager of Medical Staff Credentialing (E #1) was interviewed. E #1 stated that the Chief of Anesthesiology (MD #2) received an email (dated 12/08/2022) from patient relations regarding an anonymous call referencing the anesthesiologist (MD #1). E #1 stated that she had not received any self-disclosure from MD #1 until 12/08/2022.

5. On 12/14/2022 at 11:45 AM, the Chief of Anesthesiology (MD #2) was interviewed. MD #2 stated that he does not remember the exact date and time, he received a phone call from the patient relations stating that they received an anonymous phone call referencing (MD #1) has criminal record for restraining order, person has videos about she (MD #1) is holding a knife, and that MD #1 is not safe to continue her practice at the hospital. MD #2 stated that it was a spoofed phone call with no telephone number or any person's name related to the phone call. MD #2 stated that he spoke (unsure of date, soon after being notified anonymous call) with (MD #1) and had conversation regarding the divorce paperwork that are still pending with her ex-husband. MD #2 stated that she did not report that she had a misdemeanor charge from the court.

6. On 12/14/2022 at 12:15 PM, the President of the Medical Staff (MD #3) was interviewed. MD #3 stated that she had very peripheral knowledge about the case. MD #3 stated that it was brought to her attention just lately on Monday, 12/12/2022. MD #3 stated that the medical staff (MD #1) should have self-reported when the criminal charges were filed on 03/11/2021.

7. On 12/14/2022 at 1:00 PM, the Chief Medical Officer (MD #4) was interviewed. MD #4 stated, "We became aware of this only on 12/09/2022." MD #4 stated that she (MD #1) made a mistake of not self-reporting to the medical staff office or to the chief of the anesthesiology (MD #2).