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Based on document review and interview the facility failed to abide by the designated Medical Staff guideline and Governing Body over cite in one of one medical staff termination.

Refer to A 0535

Based on record review and interview the facility failed to abide by the established Medical Staff guidelines with Governing Body over cite in one of one medical staff termination.


On 3/17/2011 at 1:30 PM in the office of the Director of Nurses (DON) the medical staff guidelines were reviewed which indicate the following under Article VII Corrective Action.

Section 1. a. Whenever the activities or professional conduct of any practitioner with clinical privileges are considered to be lower than the standards or aims of the medical staff or they be disruptive to the operations of the hospital, corrective action against such practitioner may be requested by any member of the medical staff, by the president of the medical staff, by the Administrator, or by the Governing Body. All requests for corrective action shall be in writing, shall be made to the committee of the whole, and shall be supported by reference to the specific activities or conduct, which constitutes the grounds for the request.

Section 1. b. Whenever the corrective action could be a reduction or suspension of clinical privileges, the committee of the whole shall forward such request to the president of the medical staff wherein the practitioner has such privileges. Upon receipt of such request, the president of the medical staff shall
immediately appoint an ad hoc committee to investigate the matter.

On 3/17/2011 at 1:45 PM in the DON's office the DON confirmed that a conversation took place in a open hall way and was over heard by staff. The Medical Director was disruptive and insubordinate to the Administrator. The Administrator was explaining the termination of coworkers earlier in the day had been necessary for the stability of the facility. At which point the Medical Director and Administrator began shouting at each other. The Administrator terminated the Medical Director in the hearing of the staff. There was no due process.

A review of the Medical Director's progress note reads *Having been removed from medical staff by Administrator further orders will be from whom ever he designates effective immediately per administrator* The Medical Directors critical patient was not referred to another physician for care. The hospital functioned, with at least one critical patient, without physician coverage for inpatient care for 5 hours.

The facility did not follow the established medical staff guidelines for corrective action in the termination of the Medical Director. There was no written request for corrective action made to the committee of the whole. Although the Medical Directors conduct was witnessed by the staff there was no written reference to the disruptive conduct. which would constituted the grounds for request. The committee of the whole never met on this issue. An as hoc committee was never appointed and the event was never investigated. This is reflected in the medical staff meeting minutes. There was no emergency called meeting of the medical staff or governing body and the next regularly scheduled medical staff meeting simply reflects a new Medical Director.