~ct?cw - the patient safety league4patientsafety.org/documents/delashaw, johnny bill 2019...1...
TRANSCRIPT
BEFORE THE . MEDICAL BOARD OF CALIFORNIA
DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA
In the Matter of the First Amended Accusation Against:·
) ) ) )
JOHNNY BILL DELASHAW, JR., M.D. ) Case No. 800..:2017-032648
Physician's and Surgeon's Certificate No. G89104
Respondent
) ) ) ) ) _________ ___,_ _____ )
DECISION
The attached Stipulated Settlement and Disciplinary Order is hereby adopted as the Decision and Order of the Medical Board of California, Department of Consumer Affairs, State of California.
This Decision shall become effective at 5:00 p.m. on February 15, 2019.
IT IS SO ORDERED: January 16, 2019.
MEDICAL BOARD OF CALIFORNIA
~ct?cw Ronald H. Lewis, M.D., Chair Panel A
1 XAVIER BECERRA Attorney General of California
2 MARY CAIN-SIMON Supervising Deputy Attorney General
3 ALICE W. WONG Deputy Attorney General
4 State Bar No. 160141 455 Golden Gate Avenue, Suite 11000
5 San Francisco, CA 94102-7004 Telephone: (415) 510-3873
6 Facsimile: (415) 703-5480 Attorneys for Complainant
BEFORE THE
7
8
9
10
11
MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS
S'J;'ATE OF CALIFORNIA
In the Matter of the First Amended Accusation Case No. 800-2017-032648 12 Against:
13
14
15
16
17
18
19
20.
21
22
23
24
25
26
27
28
JOHNNY BILL DELASHAW, JR., M.D. 'OAH No. 2017090832
20 Garnet Hill Drive Sedona, AZ 8~336-3795
Physici~n's and Surgeon's Certificate No. G 89104
Respondent.
STIPULATED SETTLEMENT AND DISCIPLINARY ORDER
,IT IS HEREBY STIPULATED AND AGREED by and between the parties to the above-
entitled proceedings that the following matters are true:
PARTIES
1. Kimberly Kirchmeyer (Complainant) is the Executive Director of the Medical Board
of California (Board). She brought this action solely in her official capacity and is represented in
this matter by Xavier Becerra, Attorney General of the State of California, by Alice W: Wong,
Deputy Attorney General.
2. Respondent Johnny Bill Delashaw, Jr., M.D. (Respondent) is represented in this
proceeding by attorney Peter R. Osinoff, whose address is: 355 South Grand Avenue, Suite 1750
Los Angeles, California 90071.
1
STIPULATED SETTLEMENT (800-2017-032648)
1 3. On or about January 27, 2012, the Board issued Physician's and Surgeon's Certificate
2 No. G 89104 to Johnny Bill Delashaw, Jr., M.D. (Respondent). The Physician's and Surgeon's
3 Certificate was in full force and effect at all times relevant to the charges brought in Accusation
4 No. 800-2017-032648, and will expire on August 31, 2019, unless renewed.
5 JURISDICTION
6 4. · Accusation No. 800-2017-032648 was filed before the Board, and is currently
7 pending against Respondent. The Accusation and all other statutorily required documents were
8 properly served on Respondent on August 14, 2017. Respondent timely filed his Notice of
9 Defense contesting the Accusation. A First Amended Accusation was served on Respondent on
10 October 23, 2018.
11 5. A copy of First Amended Accusation No. 800-20.17-032648 is attached as exhibit A
.12 and incorporated herein by reference.
13 ADVISEMENT AND WAIVERS
14 6. Respondent has carefully read, fully discussed .with counsel, and understands the
15 charges and allegations in First Amended Accusation No. 800-2017-032648. Respondent has
16 also carefully read, fully discussed with counsel, and understands the effects of this Stipulated
17 Settlement and Disciplinary Order.
18 7. Respondent is fully aware of his legal rights in this matter, including the right to a
19 hearing on the charges and allegations in the Accusation; .the right to confront and cross-examine
20 the_ witness~s against him; the right to present evidence and to testify on his own behalf; the right
21 to the issuance of subpoenas to compel the attendance of witnesses and the production of
22 documents; the right to reconsideration and court review of an adverse decision; and all other
23 rights accorded by the California Administrative Procedure Act and other applicable laws.
24 8. Respondent voluntarily, knowingly, and intelligently waives and gives up each and
25 every right set forth above.
26 CULP ABILITY
27 9. Respondent agrees that, at an .administrative hearing, Complainant could establish a
28 prima facie case with respect to the charges and allegations contained in First Amended
2
STIPULATED SETTLEMENT (800-2017-032648)
1 Accusation No. 800-2017-032648 and that he has thereby subjected his Physician's and Surgeon's
2 Certificate to dif)cipline as forth in the Disciplinary Order below.
3 CONTINGENCY
4 10. This stipulation shall be subject to approval by the Medical Board of California ..
5 Respondent understands and agrees that counsel for Complainant and the staff of the Medical
6 Board· of California may communicate directly with the Board regarding this stipulation and
7 settlement, without notice to or participation by Respondent or his counsel. By signing the
8 stipulation, Respondent understands and agrees that he may not withdraw his agreement or seek
9 to rescind the stipulation prior to the time the Board considers and acts upon it. If the Board fails
1 o to adopt this stipulation as its Decision and Order, the Stipulated Settlement and Disciplinary
11 Order shall be of no force or effect, except for this paragraph, it shall be inadmissible in any legal
12 action between the parties, and the Board shall not be disqualified from further action by having
13 considered this matter. ,, r'
14 11. The parties understand and agree that Portable Document Format (PDF) and facsimile
15 copies of this Stipulated Settlement and Disciplinary Order, including PDF and facsimile
16 signatures thereto, shall have the same force and effect as the originals.
17 12. In consideration of the foregoing admissions and stipuiations, the parties agree that
18 the Board may, without further notice or formal proceeding, issue and ehter the following
19 Disciplinary Order:
20 DISCIPLINARY ORDER
21 IT IS HEREBY ORDERED that Physician's and Surgeon's Certificate No. G 89104 issued·
22 to Respondent Johnny Bill Delashaw, Jr., M.D. is revoked. However, the revocation is stayed
23 and Respondent is placed on probation for three (3) years on the following terms and conditions.
24 1. PROFESSIONALISM PROGRAM CETHICS COURSE). Within 60 calendar days of
. 25 the effective date of this Decision, Respondent shall enr~ll in a professionalism program, that
26 meets the requirements of Title 16, California Code of Regulations (CCR) section 1358.1.
27 Respondent shall participate in and successfully complete that program. Respondent shall
28 provide anyinformation and documents that the program may deem pertinent. Respondent shall
3
S~IPULATED SETTLEMENT (800-2017-032648)
1 successfully complete the classroom component of the program not later than six (6) months after
2 Respondent's initial enrollment, and the longitudinal component of the program not later than the
3 t.ime specified by the program, but no lat~r than one (1) year after attending the classroom . .
4 component. The professionalism program shall be at Respondent's expense and shall be in
5 addition to the Continuing Medical Education (CME) requirements for renewal oflicensure.
6 A professionalism program taken after the acts that gave rise to the charges in the First
7 Amended Accusation, but prior to the effective date of the Decision may, in the sole discretion of
8 the Board or its designee, be accepted towards the fulfillment ofthis condition if the program
9 would have been approved by the Board or its designee had the program been taken after the
1 O effective date cif this Decision.
11 Respondent shall submit a certification of successful completion to the Board or its ·
12 designee not later than 15 calendar days after successfully completing the program or not later
13 than 15 calendar days after the effective date of the Decision, whichever is later.
14 2. PSYCHIATRIC EVALUATION. Within 30 calendar days of the effective date of
15 this Decision, and on whatever periodic basis thereafter may be required by the Board or its
16 designee, ~espondent shall undergo and complete a psychiatiic evaluation (and psychological
17 testing, if deemed necessary) by a Board-appointed board certified· psychiatrist, who shall
18 consider any information provided by the Board or designee and any other information the
19 psychiatrist deems relevant, and shall furnish awritteri evaluation report to the Board or its
20 designee. Evaluations for disruptive physician behavior conducted after the acts that gave rise to
21 the charges in the Accusation, but prior to the effective date of the Decision may, in the sole
22 discretion of the Board or its designee, be accepted towards the fulfillment of this condition ifthe
23 program would have been approved by the Board or its designee had the program been taken after
24 the effective date of this Decision. The cost of the psychiatric evaluation, including any and all·.
25 testing deemed necessary by the examiner, the Board or its designee, shall be borne by the
26 licensee.
27 Respondent shall comply with all restrictions or conditions recommended by the evaluating
28 psychiatrist within 15 calendar days after being notified by the Board or jts designee.
4
STIPULATED SETTLEMENT (800-2017-032648)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Respondent shall not engage ~n the practice of medicine until notified by the Board or its
designee that Respondent is mentally fit to practice medicine safely. The period of time that
Respondent is not practicing medicine shall not be counted toward completion of the term of
probation.
· 3. PSYCHOTHERAPY. Within 60 calendar days of the effective date of this Decision,
Respondent shall submit to the Board or its designee for prior approval the name and
qualifications of a California-licensed board certified psychiatrist or a licensed psychologist who
has a doctoral degree in' psychology and at least five years of postgraduate experience in the
diagnosis and treatment of emotiona,l and mental disorders. Upon approval, Respondent shall
undergo and continue psychotherapy treatment, including any modifications to the frequency of
psychotherapy, until the Board or its designee deems that no further psychotherapy is necessary.
The psychotherapist shall consider any information provided by the Board or its designee ·
and any other information the psychotherapist deems relevant and shall furnish a written
evaluation report to the Board or its designee. Respondent shall cooperate in providing the
psychotherapist with any information and documents that the psychotherapist may deem
pertinent.
Respondent shall have the treating psychotherapist submit quarterly status reports to the
Board or its designee. The Board or its designee may require Respondent to undergo psychiatric
evaluations by a Board-appointed board certified psychiatrist. If, prior to the completion of
probation, Respondent is found to be mentally unfit to resume the practice of medicine with9ut
restrictions, the Board shall retain continuing jurisdiction over Respondent's license and the
period of probation shall be extended until the Board determines that Respondent is mentally fit
to resume the practice of medicine without restrictions.
Respondent shall pay the cost of all psychotherapy and psychiatric evaluations.
4. SOLO PRACTICE PROHIBITION. Respondent is prohibited from engaging in the
solo practice of medicine. Prohibited solo practice includes, but is not limited to, a practice
where: 1) Respondent merely shares office space with another physician but is not affiliated for
purposes of providing patient care, or 2) Respondent is the sole physician practitioner at that
5
STIPULATED SETTLEMENT (800-2017-032648)
1 location.
2 IfResp~ndent fails to establish a practice with another physician. or secure· employment in
3 · an appropriate practice setting within 60 calendar days of the effective date ofthis Decision,
4 Respondent shall receive a notification from the Board or its designee to cease the practice of
5 medicine within three (3) calendar days after being so notified. The Respondent shall not resume
6 practice until an appropriate practice setting i.s established,
7 If, duringthe course of the probation, the Respondent's practice setting changes and th.e
8 Respondent is no longer practicing in a setting in compliance with this Decision, the Respondent
9 shall notify the Board or its designee within five (5) calendar days of the practice setting change.
10 If Respondent fails to establish a practice with another physician or secure employment in an
11 appropriate practice setting within 60 calendar days of the practice setting change, Respondent
12 shall receive a notification from the Board or its designee to cease the practice of medicine within
13 three (3) calendar days after being so notified.' The Respondent shall not resume practice until an
14 appropriate practice setting is established.
15 5. NOTIFICATION. Within seven (7) days of the effective date ofthis Decision, the
16 Respondent shall provide a true copy of this Decision and Accusation to the Chief of Staff or the
17 Chief Executive Officer at every hospital where privileges or membership are extended to
18 Respondent, at any other facility where Respondent engages in the practice of medicine,
19 including all physician and locum tenens registries or other similar agencies, and to the Chief
20 Executive Officer at every insurance carrier which extends malpractice insurance coverage to !
21 Respondent. Respondent shall submit proof of compliance to the Board or its designee within 15
22 , calendar days.
23 This condition shall apply to any change(s) in hospitals, other facilities or insurance carrier.
6. SUPERVISION OF PHYSICIAN ASSISTANTS AND ADVANCED PRACTICE
25 NURSES. During probation, Respondent is prohibited from supervising physician assistants and
26 advanced practice nurses.
27 7. OBEY ALLLA WS. Respondent shall obey all federal, state and local laws, all rules
28 governing the practice of medicine in California and remain in full compliance with any court
6
STIPULATED SETTLEMENT (800-2017-032648)
1
2
3
4
5
6
·7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
ordered criminal probation, payments, and other orders.
8. QUARTERLY DECLARATIONS. Respondent shall submit quarterly declarations
under penalty of perjury on forms provided by the Board, stating whether there has been
~ompliance with all the conditions of probati?n.
Respondent shall submit quarterly declarations not later than 10 calendar days after the end
of the preceding quarter.
9. GENERAL PROBATION REQUIREMENTS.
Compliance with Probation Unit
Respondent shall comply with the Board's probation unit.
Address Changes
Respondent shall, at all times, keep the Board informed of Respondent's business and
residence addresses, email address (if available), and telephone number. Changes of such
addresses shall be immediately communicated in writing to the Board or its designee. Under no
circumstances shall a post office box serve as an address of record, except as allowed by Business
and Professions Code section 2021 (b ).
Place of Practice
Respondent shall not engage in the practice of medicine in Respondent's or patient's place
of residence, unless the patient resides in a skilled nursing facility or other similar licensed
facility ..
License Renewal
Respondent shall maintain a current and renewed California physician's and surgeon's
license.
Travel or Residence Outside California
Respondent shall immediately inform the Board or its designee, in writing, of travel to any
areas outside the jurisdiction of California which lasts, or is contemplated to last, more than thirty
(30) calendar days.
In the event Respondent should leave the State of California to reside or to practice,
Respondent shall notify the Board or its designee in writing 30 calendar days prior to the dates of
7
STIPULATED SETTLEMENT (800-2017~032648)
1 departure and return.
2 10. INTERVIEW WITH THE BOARD OR ITS DESIGNEE. Resp~:mdent shall be
3 · available in person upon request for interviews either at Respondent's.place of business or at the
4 probation unit office, with or without prior notice throughout-the term of probation.
5 11. NON-PRACTICE WHILE ON PROBATION. Respondent shall notify the Board or
6 its designee in writing within 15 calendar days of any periods of non-practice lasting more than
7 30 calendar days and within,15 calendar days of Respondent's return to practice. Non-practice is
8 defined as any period of time Respondent is not practicing medicine as defined in Business and
9 Professions Code sections 2051 and 2052 for at least 40 hours in a calendar month in direct
1 O patient care, clinical. activity or teaching, or other activity as approved by the Board. If
11 Respondent resides in California and is consid~red to be in non,-practice, Respondent shall
12 comply with all terms and conditions of probation. All time spent in an intensive training
13 program which has been approved by the Board or its designee shall not be considered non-
14 practice and does not relieve Respondent from complying with all the terms and conditions of
15 probation. Practicing medicine in another state of the United States or Federal jurisdiction while
16 on probation with the medical licensing authority of that state or jurisdiction shall not be
17 considered non-practice: A Board-ordered suspension of practice shall not be considered as a i
18 period of non-practice.
19 In the event Respondent's period of non-practice while on probation exceeds 18 calendar
20 months, Respondent shall successfully complete the Federation of State Medical Boards' Special
21 Purpose Examination, or, at the Board's discretion, a clinical competence assessment program.
22 that meets the criteria of Condition 18 of the current version of the Board'·s "Manual of Model
23 Disciplinary Orders and Dis~iplinary Guidelines" prior to resuming the practice of medicine.
24 Respondent's period of non-practice while on probation shall not exceed two (2) years.
25 Periods of non-practice will not apply to the reduction of the probationary term.
26 Periods of non-practice for a Respondent residing outside of California will relieve
27 Respondent of the responsibility to comply with the probationary terms and conditions with the
28 exception of this condition and the following terms and conditions of probation: Obey All Laws;
8
STIPULATED SETTLEMENT (800-2017-032648) ·
1 General Probation Requirements; Quarterly Declarations; Abstain from the Use of Alcohol and/or
2 Controlled Substances; and Biological Fluid Testing ..
3 12. COMPLETION OF PROBATION. Respondent shall comply with all financial
4 obligations (e.g., restitution, probation costs) not later than 120 calendar days prior to the
5 completion of probation. Upon successful completion of probation, Respondent's certificate shall
6 be fully restored.
7 13.. VIOLATION OF PROBATION. Failure to fully comply with any term or condition
8 of probation is a violation of probation. If Respondent violates probation in any respect, the
9 Board, after giving Respondent notice and the opportunity to be heard, may revoke probation and
1 O carry out the disciplinary order that was stayed. If an Accusation, or Petition to Revoke Probation,
11 or an Interim Suspension Order is filed against Respondent during probation, the Board shall have
12 continuing jurisdiction until the matter is final, and the period of probation shall be extended until
13 the matter is final.
14 14. LICENSE SURRENDER. Following the effective date of this Decision, if
15 Respondent ceases practicing due to retirement or heal~ reasons or is otherwise unable to satisfy
16 the terms and conditions· of probation, Respondent may request to surrender his or her license. .
17 The Board reserves the right to evaluate Respondent's request and to exercise its discretion in
18 determining whether or not to grant the request, or to take any other action deemed appropriate
19 and reasonable under the circumstances. Upon formal acceptance of the surrender, Respondent
20 shall within 15 calendar days deliver Respondent's wallet and wall certificate to the Board or its
21 designee and Respondent shall no longer p:actice medipine. Respondent will no longer be subject
22 to the terms and conditions of probation. If Respondent re-applies for a medical license, the
23 application shall be treated as a petition for reinstatement of a revoked certificate.
24 15. PROBATION MONITORING COSTS. Respondent shall pay the costs associated
25 with probation monitoring each and every year of probation, as designated by the Board, which
26 may be adjusted on an annual basis. Such costs shall be payable to the Medical Board of
27 California and delivered to the Board or its designee no later than January 31 of each calendar
28 year.
9
STIPULATED SETTLEMENT (800-2017-032648)
l i
8CCEPTAN~ , I
2 I have carefu~y read the above Stipulate.dfSettkment and Disciplinary Order: and have f1.1Hy ~, ·: f
3 ~S<:ussed it with my attom.ey, Peter R. Osinoff: ! I understand the stipulation and the eftect it will
4
5
6
8
9
: . f
Jt.~ve on my Physic~ao-'s and Surgeon'; Certificate· I enter into this Stipulated Settlement and
l~isdplinary Order :Voluntarily~ kno\vingly, and~ntelligently, and agree to be bound by the
t:i~::dD;J?i'~;;OMdof~ifotif, _ M__ i ', ' JOl . "BILL DELASH W, J ·~ M.D.
, R , ndei1t
l _ I have read ~1d fully discussed with Resdonctent Johnny Bill Delashaw, Jr., Y..tD. the terms
10 -- dud conditions andiother matters contained in tie above Stipulated Settlement and Disciplinary
~ } j 11
12
13
14
15
16
17
IS
19
20
21
Order. I ~1pprove its fonn and content ! , ' ' - I
DATED:
! ~ .,
i
A ttor1*y for Resp<mdent f ~
ENt?Jl~SEMENI j
_ The foregoing Stipulated Settlement andfDisciplinary Order is hereby respectfully i i - ' l -~bmitted fur con~ideration by tl1e N~edical Bojlrd of Calif omia I Dated: \ - I Respectfully submined,
i
' ~ , XAV)ER BEC..'ERRA Attorney General of California MARY CA.JN-SIMON Supc:..-rvising Deputy Attorney General
22
23 l AUCB W. \VONG
24 ! ~
25
26 fsr-2011203154
27
28
,-----·~---·------.... ---·---------·-·--· IO
Deputy Attorney General Attorneys for Complainant
STTPlJLATED StTll.EMENT(800·20l i-03264$)
..._ ______ ,,_. ________________ ._,_, _________________ ----
Exhibit A
Accusation No. 800-2017-032648
1
2
3
4
5
6
7
8
9
10
XAVIER BECERRA Attorney General of California JANE ZACK SIMON Supervising Deputy Attomey General ALICEW. WONG . Deputy Attorney General State Bar No. 160141
45 5 Golden Gate A venue, Suite 11000 San Francisco, CA 94102-7004
. Telephone: (415) 703-5597 Facsimile: (415) 703-5480
. Attprneys for Complainant
-BEFORE THE l\'IEDICAL BOARD OF CALIFORNIA
DEPART1\1ENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA
In the Matter of the First Amended Accusation Case No. 800-2017-032648 11 Against:
12
13
14
15
16
17
Johnny Bill Dela:shaw, Jr., M.D. 20 Garnet Hill Drive Sedona, AZ 86336-3795
. ;physician's and Surgeon's Certificate No. G89104,
Respondent.
18 Complainant alleges:
FIRST AMENDED ACCUSATION
19 PARTIES
20 1. Kimberly Kirchmeyer (Complainant) brings this First Amended Accusation solely in
21 her official capacity as the Executive Director of the Medical Board of California, Department of
22 Consumer Affairs (Board).
23 2. On or about January 27, 2012, the Medical Board issued Physician's and Surgeon's
24 Certificate Number 089104 to Johnny Bill Delashaw, Jr., 1vLD. (Respondent). The Physician's
25 and Surgeon's Certificate was in full force and effect at all times relevant to the charges brought
26 herein and will expire on August 31, 2019, m1less renewed.
27
28
1
(JOHNNY BILL DELASHAW, JR., M.D.) First Amended Accusation No. 800-2017-03264
1
2 3.
JURISDICTION
This First Amended Accusation is brought before the Board, under the authority of
3 the following laws. All section references are to the Business and Professions Code (Code)
4 unless otherwise indicated.
5 4. Section 2227 of the Code provides that a licensee who is found guilty under.the
6 Medical Practice Act may have his or her license revoked, suspended for a period not to exceed
7 one year, placed on probation and required to pay the costs of probation monitoring, or such other
8 action taken in relation to discipline as the Board deems proper. \
9 5. Section 2305 of the.Code states:
1 O "The revocation, suspension, or other discipline, restriction or limitation imposed by
11 another state upon a license or certificate to practice medicine issued by that state, or the
12 revocation, suspension, or restriction otthe authority to practice medicin,e by any agency of the
13 federal government, that would have been groi:tnds for d\scipline in California of a licensee under
14 this chapter shall constitute grounds for disciplinary action for unprofessional conduct against the
15 licensee in this state."
16 6. Section 141 of the Code states:
17 "(a) For any licensee holding a license issued by a board under the jurisdiction of the
18 department, a disciplinary action taken by another state, by any agency of the federal government,
19 or by another country for any act substantially related to the practfoe regulated by the California
20 license, may be a ground for disciplinary action by the respective state licensing board. A
21 certified copy of the record of the disciplinary action taken against the licensee by another state,
22 an agency of the federal government, or another country shall be conclusive evidence of the
23 events related therein.
24 "(b) Nothing in this section shall preclude a board from applying a specific statutory
25 provision in the licensing act administered by that board tj.1at provides for discipline based upon a
26 disciplinary action taken against the licensee by another state, ari agency of the federal
27 government, or another country."
28
2
(JOHNNY BILL DELASHAW, JR., M.D.) First Amen4ed Accusation No. 800-2017-03264
1
2
3 7.
CAUSE FOR DISCIPLINE
(Discipline, Restrictions, or Limitation Imposed by Another State)
On or about May 5, 2017, the Washington Medical Quality Assurance Commission
4 (Commission) issued an Ex Parte Order of Summary Suspension, suspending Respondent's
5 license to practice medicine in Washington pending further disciplinary proceedings. Th~ Ex
6 Parte Order of Summary Suspension was based on findings that Respondent posed an immediate
7 threat to the public health and safety if Respondent has an unrestricted license. The ExParte
8 Order of Summary Suspension stemmed from allegations filed against Respondent in Statement
9 of Charges No. M2016-1084: (1) Respondent engaged in a pattern of psychological and physical
1 O intimidation.of co-workers and staff at the hospital he was employed, placing the public at risk of
11 care; (2) Respondent discouraged staff from reporting errors, placing patients at unnecessary risk;
12 and (3) Respondent discouraged staff from asking questions, resulting in a chilling effect on
13 nurses and staff and putting patients at risk of medical error.
14 A copy of the Ex Parte Order ofSurrimary Suspension and Statement of Charges No.
15 )\12016-1084 are attached as Exhibit A.
16 8. Following a nine-day hearing on the allegations of_unprofessional conduct on or
17 about April and May 2018, the Commission found Respondent committed unprofessional conduct
18 and issued Findings of Fact, Conclusions-of Law, and its Final Order. Respondent was placed on
19 three years of oversight, with terms and conditions including: (1) within three (3) months of the
20 effective date of the Order, Respondent will obtain a comprehensive, multi-day evaluation for -
21 disruptive physician behavior and will fully comply with ~y recommendations made by the
22 evaluators, (2) employment restrictions,{3) personal appearance within three (3) months and
23 thereafter, semi-annually, before the Commission for compliance oversight, and (4) Respondent
24 ordered to pay a fine of $10,000.00. On August 31, 2018, the Cormnission issued an Amended
25 Corrected Findings of Fact, Conclusions of Law, and Final Order (Amended Final Order)1 The
26 Amended Final Order clarified the employment restriction condition, which specifically preclude
27
28 _ 1 Respondent sought clarification of the previous Order regarding empleyment restriction.
3
(JOHNNY BILL DELASHAW, JR., M.D.) First Amended Accusation No. 800-2017-03264
1 Respondent from any employment positions that require Respondent to supeivise other
2 physicians.
3 A copy of the Amended Final Ord.er is attached as Exhibit B.
4 9. Respondent's conduct and the action of the Washington Medical Quality Assurance
5 C01mnission as set forth above, constitute cause for discipline pursuant to sections 2305 and/or
6 141 of the Code.
7 PRAYER
8 \VHEREFORE, Complainant requests that a heaiing be held on the matters herein alleged,
9 and that following the hearing, the Medical Board of California issue a decision:
1 O 1. ·Revoking or suspending Physician's and Surgeon's Certificate Number G89104,
11 issued to Respondent.;
12 2. Revoking, suspending or denying approval of Respondent's authority to supervise
13 physiciai1 assistai1ts and advanced practice nurses;
14 3. Ordering Respondent, if placed on probation, to pay the Board the costs of probation
15 monitoring; and
16
17
18
19
20
21
22
23
24
25
26
27
28
4. Taking such other and fmiher action as deemed necessary and proper.
DATED: ~~O=ct=o~b~e=r~23=---·~2~0~1~8~~
SF2017203754
Executive ff ector Medical Board of California Department of Consumer Affairs State of California · Complainant
4
(JOHNNY BILL DELASHAW, JR., M.D.) First Amended Accusation No. 800-2017-03264
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Exhibit A
First Amended Accusation No. 800-2017-032648
(JOHNNY BILL DELASHAW, JR., M.D.) First Amended Accusation No. 800-2017-03264
STATE OF WASHINGTON . . DEPARTMENT OF HEALTH MEDICAL QUALITY ASSURANCE COMMISSJON
In the Matter of the License to .Practice · as a Physician and Surgeon of: Master Case No. M2016-1084
JOHNNY 8. DELASHAW, JR., MD EX PARTE ORDER OF. SUMMARY License No. MD00023061 SUSPENSION
Res ondent.
COMMISSION PANEL: Warren Howe, M.D., Chair Robert Small, M.D. Miml Winslow, J.D., Public Member
PRESIDING OFFICER: Matthew R; Herington, Health L.aw Judge
This matter came before the Medical Quality Assurance Commission (Commisson)
· on May 5, 2017, on an Ex Parte Motion for Summary Action (Motion) brought by the Office
of the Attorney ·General. The Commission issued ~ Statement of Charges alleging
Respond.ent violated RCW 18.130.180 (4). After reviewing the Statement of Charges,
Motion, and supporting evidence; the Commission grants the motion. Respondent's
iicense to practice as a physidan and surgeon is SUSPENDED pending further action.
I. FINDINGS OF FACT
1.1 ·Johnny B. Delashaw, Jr. (Respondent), is a physician and surgeon
licensed by the state of Washington at all times applicable to' this matter.,
1.2 The Commission issued a Statement of Charges alleging Respondent
violated RCW 18.130.180 (4). The Statement of Charges was accompanied by all other
documents requir.ed by WAC 246-11-250.'
EX PARTE ORDER OF SUMMARY SUSPENSION Master Case No. M2016-1084
PAGE 1OF4
1.3 As set' forth in the allegations in the Statement of Charges. as well as the . . .
Motion, Respondenfs behavior towards hospital staff in and out of the operating room
was extremely dis~uptive and below the standard o~ care. This disruptive behavior
incl~des · yefling. swearing. shaking and pointing his finger at others. and making
threatening .movements towards staff. Respondent stifled the ·vital free flow of thoughts.
c9mments. and observations by the surgical team in the operating room in regards to
patients and their care. Respondent's yelling. threatening, and sarcastic comments in·
response to the operating team's. statements before,· during. and after surger)I .
suppressed oversight and caused the operating team to keep their thoughts and
observations to themselves. thereby creating an increased risk of patient harm.
1.4 . As set forth in the allegations in th~ State.me_nt o~ Charges. as well as the
_Motfo n, · Re$pQ nderit further. im p_acted_p_a1Le11tsafet~hY--_disc0-uraging-sta:ffJrn m.-r:eporting
mistakes. oversights·. and· non-pr~cedural events to· the hospital administration. By
discouraging these reports. Respondent was ensuring that mistakes and oversights
were not tracked and that no corrective or remedial action could ?e taken to support
patient care. Due 'to the disruptive. and toxic atmosphere surroundipg Respondent, . . .
many staff members resigned or transferred from the hosp.ital, including a number of
longwterm, highly experienced nurses. This loss of experienced personnel put patients
at risk as there were newer. inexperienced staff on duty without experienced· staff on
hand to help train them.
1.5 The above allegations, supported by the Declaration of Health Care·
Investigator in Support of Motion for Summary Action together with the attached exhibit, ·
justify the determination of immediate danger in this.case and a decision to immediately
suspend the credential until a hearing on the matter is held.
EX PARTE ORDER OF SUMMARY. SUSPENSION . _Master Case No. M2016-1084 ·
PAGE 2 OF 4 ..
fl. CONCLUSIONS OF LAW
. 2. t The Commission has jurisdiction over Respondent's credential to practice
as a physician and a surgeon. RCW 18.130.040.
2.2 · ·The Commission has .authority to take emergency adjudicative action to
address an immediate threat to the public health and safety. RCW 18.130.050(8) and
18, 130.135.
2.3 The Findings of Fact establish th.e existence of i:in immediate threat to the
public health and safety if Re~pondent has an unrestricted credential. The Findings of
Fact establish that . the requested summary action is necessary and adequately
addresses the threat to public health and safety.
UL ORDER
. _3_.i __ .-8ased __ on_the_Eindings_oL .. Eact-ar:id~the-Cof-ldusior:is-0f--Law~- it - is
ORDERED that Respondent's license to practice as a· physician and -surgeon is
SUMMARILY SUSPENDED · pending further disciplinary proc~edings - by the
Commission.
3.2 It is HEREBY ORDERED that a protective order in this. case is GRANTED.
RCW 34 .. 05.446(1) and WAC 246-11-400(2) and (5). This. Protec1ive Order prohibits the
release of health care information outside of these proceedings. Unless required by
!awl anyone . ihvolved in these proceedings must keep confrdentia1 and not· disclose
. health care information obtained through these proceedings. · Health care information
includ~s information in a.ny form "that identifies or can readily be associated with the .
EX PARTE ORDER OF SUMMARY SUSPENSION Master Case No. M2016-1084
I .
PAGE,3 ~F 4
identity of a patient and directly relates to the patient's health care."
RCW 70.02.010(16). The parties may share the information with their attorney: if any.
ay of May, 2017.
7.>.. For more information. visit our W~b site al htf°p:.'i1~·ww.J;>h.\\'O~~ov/h~;Lri11g<;.
. ~
. ·.
I declare that !his is a lrul! and accurate ~opy of the originii on fie with the Washington State Department of HeaKh
MedicaJQuftyAss~ce Commission ' IJ\M ,., ~~ Mlchae11Kramer
Date
·-: ~
EX PARTE OROER OF SUMMARY SUSPENSlON Master Case No. M2016-1084
,,,,un11ur1111 ,,,,,,, f WAsl.!'',,, .. ,,~~ 0 ~·r"'"'••, .. 1"/A:'' .. , . ~..tV ,~• • FIC '•• r~ ....
-1~.··-~·.~ l ~·.,.-~ · ~ L'ff'..- oi. ~;\ ;,.\o~ ~ ~.:. . " . : . :,.t/lf · I °!. z·= •:.i&o • VI • .. •
:1:..:ft"• ":'- . ··-i~\ ·, '. .. · i ···~ ~ •. .,,., .'~:: ~ \.~ .. . . .... ·A...~i '- - • .~ill ···~~ '-',.'.:. •• •• ~~~ •• ~· 'x.~ ~ 41.:·.~·· ··;.:.i: '-~
ii' .. ,, \If' ~'' . ,,,, ; .. • ' ,,,..,~
''''"' inl•'''
PAGE4 OF 4
~.
STATE OF WASHINGTON MEDICAL QUALITY ASSURANCE COMMISSION
In the Matter of the License to Practice as. a Physician and Surgeon of:
JOHNNY B. DELASHAW, JR., MD License No. MD00023061
Res ondent.
No. M2016-1084
STATEMENT OF CHARGES
The . Executi~e Director of the Medical Qu.ality Assurance Commission
(Commission) is authorized to ma_ke the allegations below, w~ich are supported by the
evidence contained in file numqer.2016-3527.
1. ALLEGED FACTS
1.1 On July 25, 1985, the state of Was~ington issued Resp.ondent a license to
. _ practice as a physician and surgeon. Respondent's license is currently active.
··········------,··· _J.2_ .. :_Resp.ondenLbegao__w_o_rking __ at.an_arnaJJ.osp.itaUrLO.c.tober:_-2.0-1-3.-During ... _ ---
the time that he worked there he created an environment within th.e hospital in which he
endangered patient$ by the way he treated staff: . threatening, yelling, and interfering
with them and affecting their ability to do their jobs effectively. Respondent's disruptive .
behavior to staff created immediate danger to the public health and safety.
Engaged in Pattern of Intimidation with Staff
. . 1.3 R!3spondent directly intimidated co-wo~kers who were subordinate to _him
in the work environment. The intimidation- was not just psychological but, in many
instances, physical ::;is well. Respondent's intimidation of co-workers and staff disrupted
the work flow of personnel directly responsible for patient care. These acti6ns put the
public at risk of care that is below the accepted standard of care. Examples of this
behavior include, but are not limited to, the following:
1.3.1 In. December of 2015, Respondent became enraged about t~e
availability of operating rooms and confronted the charge. nurse. Respondent
stuck his head through the office window, became red in the face, shook his
STATEMENT OF CHARGES NO. M2016-1084 ORIGINAL
PAGE 1OF5 SOC- REV. 2-07
.. ,
finger' at the nurse and yelled at her. The charge nurse was i_ntimidated by
Respond·e0t's actions and behavior and felt threatened enough to back away
from Respondent.
1.3.2 Another nurse reported that Respondent mistakenly thought she. . .
had reported . him ~o the hospital's administration for· a procedural violation.
R~spondent. barged into a small conference room when the nurse and her
super-visor were meetrng and commenced yelling, screaming, and pointin_g his
finger at the nurse. The nurse stated that she became concerned for her. physical
safety as Respondent leaned into her.personal space during his outburst. . .
1.3.3 On another occasion,· Respondent yelled at a circulating nurse in
the operating room in front of the rest of the surgical team, when she pointed out
to. Respondent that he had not given- sufficient warning of his intent to take x
rays .. Respondent became r~d in the face, approached the nurse, and shook his
·finger in ·her face ...
-1.3A· During Respondent's time at-the hospital; a nurse sent an email to
· ····· --- ·· ·· ··.:.Respondent· reminding-him-to-be-more-car-eft1l-after--a-miss+ng-stirgicai-sponge
turned up in his discaroed surgical gloves. Respondent contacted the executive
di.rector of nursing to complain about the email.
1.3.5 Respondent has been· witnessed repeatedly yelli_rig at staff in the
hallway, at nursing stations, and on his cellphone. On one occasion, a nurse
paged ~espondent concerning patient safety in an upcoming surgery for that
day. Respondent screamed at the nurse for bothering him during his rounds.
Discouraged Staff from Reporting_ Errors
. .
1.4 Several members of the hospital staff reacted to Respondent's behavior
by filing reports to their supervisors and/or the hosprtal administration. These. reports . -
·were. filed for information purposes-when staff observed some action or lack of action
that they thought violated hospital policy or put a patient at unnecessary risk. Some of
the examples of this are outlir:ied above, but others include the following:
1.4.1 During a meeting with the nu·rsing administrator at the hospital
regarding a staff report concerning Respondenfs practice of scheduling multiple·
.STATEMENT OF CHARGES NO. M2016~1084
PAGE 2 OF5 SOC - REV. 2--07
surg\3ries at once, Respon~ent became upset and demanded the reporting nurse .
be disciplined for reporting the matter.
1.4.2 Another nurse stated that she .. w~s asked by Respondent not to fill
out error or p~oblem reports on Respondent, his Fellows, or his patients.
Discouraged Staff from Asking Questions
1.5 Several nurses reported that Respondent would provide mumbled or
incomplete instructions to staff involving patient care. Jf.. staff asked for clarification,
.Respondent would engage in yelling, shouting, swearing, threatening, or sarcastic
behavior toward. the questioner. This had a. chilling effect on nurses and staff members
asking. questions or trying ·to cle.ar up confusion. and put patients at risk of medical err<:n.
Examples of this behavior inc!udeJ but are not limited to, the following: \ . . . .
1 .. 5.1 A nurse reported that during a surgery R.espondent would take .a
tissue sample from a patient and har:id. the sample t9 an operatil'lg 'room (OR)
... --·----·-·---~~!f m.embe.r_._~_ut mumbl_e. his instructions· on where the sample came from_, __ _
where it was supposed. to go, what was to be tested, etc. When the staff'
member asked for clarification, Respondent would. respond in a hostile, ''
demeaning, or sarcastic manner, either belittling the staff member who asked the ·
question, yelli~g at the individual, or spelling .the instructions out as !f the staff
member were a child. As a result, staff in the OR did not want to ask for
. clarification or point out concerns. This left no one advocating· for the patient.
This type of disruptive behavior in the OR wa·s seen by multiple staff members.
1.5.2 Because of· Respondent's behavior, staff members became
dnwilling to engage Respondent to ask que·stions or get clarifications from him .
that were needed to properly care for patients. ·This leads to an· increased
ch.ance that mistakes could happen, such as tissue samples being potentially .
mislabeled, procedures done incorrectly, and mistakes missed. This reluctance
of staff to engage Respo~dent imparted an enormous amount of risk onto the
patients and puts them at great risk.
JI
II
STATEMENT OF CHARGES NO. M2016·1084
PAGE 3 OF 5 SOC- REV. 2-07
Contributed to Loss· of Expetienced Personnel
1.6 Respondent's disruptive and·. ho"stile behavior· made for a very stressful
working environment for those around him. As a result, many nurses, some of them
fong term employees with many years of experience, transferred to a different company
facility, hospital, or quit altogether. These health care professionals directly ·cite
Respond·ent's disruptive behavior and the chaos ·it caused . in the hospital as their
primary reason for leaving. Some expressed concern for the continued m\=lintenance of
adequate p~tient care due to the loss of experienced staff .... Patients and the public are ·
put at. increased risk due fo this loss of experience at the. hospital, with too few . .
experienced hands left to pass on their experience and knowledge to newer staff.
1. 7 . Respondents behavior during his tenure at the hospit?I constituted a
pattern of "disruptive physician behavior." Respondent's disruptive and abusive ·
behavior compromised team effectiveness and cre_ated an unreasonable risk of patient
harm that was below the accepted stang_ar~ of C?re.
·--:----------· ----·-···-·2-;-AttcGEO-VlOCATTONS ·-·---·--2.1 B'ased on the Alleged Facts, Respondent has committed unprofessional
:conduct in violation of RCW 18.130.180 (4), which provide:
RCW 18.130.180 Unprofessional conduct. The following conduct, acts, ·or conditions constitute unprofessional conduct for any license holder under the jurisdiction of this chapter:
(4) Incompetence, negligence, or malpractice which results in injury to a patient or which creates. ain unreasonable risk that a patient may be harmed. The use of a nontraditional treatment by itself shall not constitute unprofessional contjuct, provided that it does not result in injury to a patient or create an unreas9nab!e risk that a patient· may be harmed;
2.2 The above violations provide grounds for imposing sanctions under
RCW 18.130.160 .
./!
II
II
II
STATEMENT OF CHARGES . NO. M2016-1084
PAGE 4 OF 5 SOC - REV. 2-07
3. NOTICE TO RESPONDENT
The charges in th.is document affect the public health, safety and welfare. The
Executive Director of the Commission directs that a notice be issued and served on
Respondent as provided by law, giving Respondent the opportunity to defend against
these charges. If Respondent fails to defend agains~ these charges, Respondent shall be
· subject to discipline and the imposition of sanctions under Chapter 18.130 R,CW.
DATED: __ -L..(1-~~· ~,._,,o_..__. --~-' 2017,
.... ----··----'----
ROBERT W. FERGUSON ATIORNEY GENERAL
WSBA#22950 ORNEY GENERAL
I declil'e that this Is a true and accurate copy of the original on file wtth the Washington Slate Department of HeaHh,
Medlc=N~r~sslon Micha J. Kramer
.5°'10 -11 Dale
STATEMENT OF CHARGES NO. M2016~1084
STATE OF WASHINGTON MEDICAL .QUALITY ASSURANCE COMMISSION
~dt_~ MELANIE DE LEON EXECUTIVE DIRECTOR
''''""""''''' . I ,,,,re. ..... A c_.. ,,,~ . "''' 11" ... "' ,,, .... , .. ' 0~ ......... !.[f14;! .. ~ ..
.... 'h_ "~ftc~ .. ~~ . ~~~··· '"""· .. ~-~~ ~- .. ·O~'('•"'-=-. ..:i·L, .... .' -..._ • .o.•. ::.-: . \ z,-;. . = UJ: . I . ·' =··: · .. ~ -. :j ..• /i·.
:: ~~ ·, . ·~ .... , . . :. . ·. I ·~1 \ ... ..~ .• ·~ ~§ \ .. ~· .. ~ .... ~1'\.:)~:· .~: .
,, ·········~ ~'if· . ,,, r&:::t,..,; 01..- ,,, ~,,, --~ , , .. . ,,,,
''''""J.iu.o•'"
PAGE 5 OF 5 SOC-REV. 2-07
1
2
3
4
5
6
7
8·
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
ExhibitB
First Amended Accusation No; 800-2017-032648
(JOHNNY BILL DELASHAW, JR., M.D.) First Amended Accusation No. 800-2017-03264
STATE OF WASHl_NGTON DEPARTMENT OF HEAL TH
MEDICAL QUALITY ASSURANCE COMMISSION
In the Matter of:
JOHNNY B. DELASHAW, JR.,. License No. MD.MD.0002.3061,
Respondent.
APPEARANCES: . .
Master Case No. M2016-1084 .
AMENDED CORRECTED FINDfNGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER
. ···.
Johnny B. Delashaw, Jr., the Respondent, by Bennett Bigelow & Leedom, P.S. per Amy Magnano. and Carol Sue Janes, Attorneys at Law
Department of'Heafth Medical Program (Program), by Office of the Attorney General, per ·
... Alan Anders_on.Tracy.B~ihm, and Christina ffiuger,_Assistant Attorneys General
--PANeb;--Glaire-Treseott-.M;D;;-Patlel--Ghair------------John Rooks, M.D. Mimi Winslow, J.D., Public Member.
PRESIDING OFFICER: Matthew R. Herington, Health Law Judge
RECONSIDERATION
The Respondent seeks clarification of paragraph 3.3 of the Corrected Final
Order . Specifically, the Respondent reque~ts clarification of whether: (1) the .. -~::r~: ·'-~ '
"Commission intended to limit the scope of its restrictio_ns solefy to employmen~ wi~hin
the state of Washington; and (2) whe~her it int~rn;ls ~o. allow him to hold an academic
position that involves supervision of other physicians. The· Program did not file an
objection to a c!ariflcation.
AMENDED 'CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 1 of 30
Master Case No. M2016-1084
·. ,' .
Purauarit to In re Gregory L. Jantz, OPS No. 90-07-31-065 MA, Order on ·.·
Request for Extension of Time (Department of Health Significant Decision 1993), the
Commis~ion all'}ends Paragraph 3.3 ·of the Corrected Final Order. Amendments are in
bold below. . .
A nine-day hearing regarding allegations of unprofessional ·conduct was held in . . . -
this matter from April 23-26 and April. 30--May 4, 2018. OVERSIGHT.
ISSUES
Did _ the Respondent commit unprofessional conduct as. defined by RCW 18.130.180(4)?
. If the Program proves unpro.fessional conduct, what are the appropriate. sanctions under RCW 18.130.160?
__ ~UMMARY_QfJ~_ROC_EEOIN_GS
·.
-----Gn--May-5,-2-01-7,---the-R-espondent~s-credential-was~ommaTify suspentl-OO-bytlte ______ ---
Medical Quality Assurance. Commission via an Ex P~rte Ord.er of Summary Suspension.
. Pursuant to tne Respongent's request,. a show cause hearing was· held on June 13,
2017. Subsequently, the Commission issued an Order on Show Cause Hearing on
June 19, 2017, upholding the Ex Parte Order of Summary Suspension pending a futl
adjudication of the aflegations. · ·
A full evidentia,.Y hearing was consequently held on Aprit.:?3-2~ .. anq A"f?ri.I· 3o-May ' . ..~ . .
.: .. _4, 2018. At the hearing, the Program presented the 'testimony .. of: Trish Flett, RN;
Deborah DesJardin-Rowland" RN; Mary Fearon, RN; Caroline Dufault, RN; Bemedette I
Ha~kins, RN; En~dina Norton, RN; Ra!pli -i:>ascualy, M.D:; Peggy Hutchiso·n, M.D.;
i
Christie -Morrison Thomp·son; Elizabeth Hendershott, RN; Arthur Lam, M.D.;
. ,• . - ----.._
AMENDED CORRECTED "FINDINGS OF FACT, CONCLUSIONS. OF LAW,
, ________ -
AND FINAL ORDER Page 2 of 30 -
Master Case No. M2016-1084
· ...
.... ·~ ~
Diane·Sanders, RN; Rose M. Raney, RN; Niki Ellington, RN; Meredith Gould, D . .N.P.;
Frances Broyles, M.D.; Marc May~~rg, M.D.; Kent Neff, M.D.; Eric Vallieres, M.D.; and
Charles Coqbs, · M~P.· . . -· ... · .
. . · The Respondent testified on his OV\t'.IJ. beh.alf. ln addition, the Responaent
.,: ...... >·presented the ·testimony of: Emilie Daniels, Seymur Gahramanov, M.D.; Cameron . ~ .
McDougall, M.D.; Russell Vandenbelt, M.D.; Lauree.n Driscoll; Marc Moisi, M:D .. ; Daniel
Dilorenzo, M.D.; Parthasarathi · Chamiraju, M.D;; Daniel Klinger, M.D.; Christian
Bowers, M.D.; Adrie~nne Oden; Margaret Danc_an; Lester Manuel; Ian _Wright, M.D.;.
Zachary Litvak, M.D.; Kevin Yuen, M.D.; and ~eviriReinard, M.D .
. Prior to and dur!ng the hearing, the Presiding Officer admitted "the _following
exhibits: ···--·-----·· .·
P-roaram's.Exl:libits-----~--·- ~--'--"--'''---------------···------·--- ·- ..
Exhibit D-1 : . ! __
. Exhibit D-2:
Exhibit P-3:
Exhibit D-4:
Exhibit D-6: -
Exhibit D-'8:
Exhibit D-1 O:
Exhibit D-13:
Respond_e.nt's crede~tial v_iew screen;
Curriculum Vi~ae of _Kent Neff,_M.D.;
· Declarat_ion of. Kent Neff, M.D.; .
Anonymous complaint, received at DOH March· 29, 2016;
Dech:~ration of Deborah Desj~rdin-R.0w!and, dated June 8, 2017;
Emails regardi11g Respondent and sponge count from September 2015;·
,.-. .. . . ... ·. Declaratio~ of_ Ma~ Fearon, dated June 7, 2017;
Declaration of Niki Eilington, dat~d June 8, 2017;
. AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page ~ of 30
Master Case No. M2016-10S4
E~hibit D-15:
·Exhibit D-17:
Exhibit D-18:
Exhibit D-19:
. Exhibit D-20:
Exhibit D:-22:
Exhibit D-23: . : ...
Declaration of Bernedette . Ha-skins, dated June 8, · 2017; .
Emails of Respondent" regarding f!uoroscopy, August 2015; .
Email from Betsy Vo to Betina Ponnoosamy, dated -August 14, 2015, regarding Respondent's certification for "SHS.: Radiation Safety" August 14, 2015;
Case _Review for event August 15, 2015;
C-Arm ana~radiation machine rules and regulations for Swedish· Medical Center; _ ·
Declaration of C~roline Dl,lfau!t, dated June i, 2017;
· Attachment A to Caroline Dufault's declaration, dated June. 7, 2017; · · ·
Exhibit D-48: · . . Letter. ffQm .. Charle.s .,Cpbbs to_Teres~ Bigelo·w. - ._ . Charr>·B6arcl;~~of-tffu"~1e·es;· swedisfi.::.MEicllc~W' · .
---··--·---··-----·-·--- · -~-· · :._·-Gente~eat~fi.'.cf:'e~fti~TJ11:S; :201-r,: :·t··-:· ... ,:: -:r-,7·' =-~~·-',...,.=---· :.,__. --···-- ·--·- ·
Exhibit D-30:
Exhibit D-31;
Exhibit D-32:
Exhibit D-41:
.. Exhibit D-45:
Exhibit D-46:
Exhibit D-47:
Letter _Drafts of October 31, and November 1, 2016, and Letter to. Anthony Armada from Charle~ Cobbs_. dated November 4, 2016;
Email from ·Charle~ Cobbs, dated November 4, 2016;. ·
Email· from Charles Cobbs to Respondent, dated February 15, 2017; · ·
Letter from Dr. Pascualy, dated November 8, 2016; . . .
Email between John Vassall, M.D., and Respondent, August 2015;
Email communication between Peggy Hutchison and Re_spondent, dated August 13, 201.s;
Email between Peggy Hutchison and Respondent,· dated August 13, 2015;
AMENDED CORRECTED FINDINGS . OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page,.4 of 30
Master Case No. M2016-1084
"'".•.· ..
Exhibit D-51-:-
Exhibit D-52~
Exhibit D-53:
Exhibit D-54:
Exnibit D-55:
.Exhibit D-56: . . .·. ;._.-.
. Exhibit D-57: ..... ~.t ·.: ~: ::,. -·-··
. ... , ·.~· ' .... . . . .
Email chain ·between John Va~sall and Peggy _ Hutchison, dated July 10, 2015;
Email between Clark Coler to Peggy Hutchison, dated July 3, 2015; · ·
Email from Clark Coler to Peggy Hutchison, dated July 4, 2015; · .
Email from Caroline Dufault to Peggy Hutchison, · dated July 6; 2016, and notes regarding Swedish resignations; Peggy HutchispnJist of "incidents of'problenis"; · .
Peggy Hutchisoi-,.; discussion by· phone, June · 29~ 2016;
Peggy Hutchison· list of people spqker:1 ··t6 _2o 1.-$_ "20-1: ~ : _.· -:~ (page 1 of 3 onry);
--- Exhibit D-63: - Letter ·to. Respondent from ,ooH Investigator -------·--- --···---· --·-·-- --------·· --Ste~heFt-Gerrea,-dateehlttne-zr.-zeta:~, ------
Exhibit D-64:·
Exhibit D-69:
. Exhibit.D-70:
Exhibit D-72: .··•·"·i..:..• ...
Exhibit 0-7 4:
Exhibit D-75:
. -
Letter· from Amy· Magnano, attorney for Respondent, to Investigator Correa, dated August ,3, 2016;
.. ~ .. -........ Email from Blain~ B51rtletl, Life ·coach, to Respondent, dated January 31, 2016; · ·
Emails to/fro_m · Respondent's .. · Life Coaches, Nov_ember 2016;
. Documents regarding. Respondel)t'_~ r~signation froll! Swedish Medical Center; · ·
./
Swedish Hospilal Code of Conduct· ·and Di$ruptive · Behaviors Powerpoint presentation;
MQAC Poncy M.D.2012-01 "Practitioners; Exhibiting Disruptive Beha~ior," effe·cuve February 1~, .. 20;1-2,;"~, .... Re~ffirmed May 13, 2016; ·
. AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 5 of 30
Master Ca?e No. M2016-1084
:.- .
..... · ...
Exhibit D-76:
Exhibit D.;.77:
Exhibit D-78:
Swedish Medical Center/Cherry Hill, Summary Statement of Deficienc'ies, survey completed June 8, 2017;
CMS cover letter and Swedish Medical Center/Cherry Hill Summary Statement of Deficiencies, cover letter,
. dated August 7, ·2011; ·
Swedish-Cherry Hill Investigative. Report investigation, between April 2017-July 2017;
Exhibit D-79: · Emails between Ryder Gwinn; M.D.,. Charles
. . •-: ...
Cobbs, M.D., Rod Oskouian, M.D., Stephen ._ ... Monteith, M.D.,. and Akshal Patel, M.D., and
.Jens Chapman, dated October 31, 2016; · .
. -· Exhihft D-80: Emails betWeen Dr. Gwinn, Dr. Cobbs, Dr. Oskouian and Jens Chapman, M.D., dated October 31 to November 1·, 2016; and
Exhibit D-81: Email frorn Dr. _G_v~inri to Dr._ Chapman, et al,; dated November 1, 2016; ·
Respondent's Exhibits
Exhibit R-1:
Exhibit R-10:
Exhibit R-14:
Exhibit R-17:
Exhibit R-19: ... ·· .....
Exhibit R-24;
Exhibit R-26:
Exhibit R-27:
Exhibit R-33:
Declaration of June Altaras;
Statem~nt of Parthasarathi Chamiraju;
Declaration of Johnny Delashaw, M.D.; - . ··:· ............. ~ ... '"':: ....... ::- .
Declaration of Laureen Driscoll, M.D.; . . .
Declaration of Seyrnt.ir Gahramanov, M.D.;
Statement of Frank Hsu; .
Declaration of Patrida HLdson;
Supplemental Declaration of Patricia Hudson;
· Declaration of Daniel Klinger;
AMENDED CORRECTE.D FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 6 of 30
Master Case No. M2016-1084
Exhibit R-35:
Exhibit R-39:
Exhfbit R-40:
Exhibit R-43:
Exhibit R-44:
Exhibit R.,48:
....... . . Exhibit R-66:
Exhibit R-67:
Decla·~atibn ·of Zachary Litvack, M.D._;
Decla~ati~n of Marc Moisi, M.D.;
Declaration of Adrienne Oden;
Dec!aration of Kevin Reinard, M.D.;
Supplemental Declaration of Kevin Reinard, M.D.; ·
Declaratiori. of Barbara Shaw;
Email from Cfaig Roos~ndaal to Johnny. Delashaw, dated August 12, 2015; ·
Letter from Kevin ReinarQ regarding radia~ion event, dated August 12, 2015; . . · · : · ·
· brawing by Kevin Reinard ·of SNI Surgical Suite from· !Jec~111_ber.2-_1,_20JS;_ ..
______ · _.:.E:.xhfbit--R-6g-: --GeAfrdeAtia1-lnvestigative-Report-Pre:pa1ed-fontTe~-. ----- - _. __ _
Exhibit R-70:
Exhibit R-71: -· =~ ~-- ·: ·• :
Exhibit R-77:
. . .. Exhibit R-78:
Exhibit R-SO:
Medical Quality Assurance Commission; ·
Letter issued by Dr. Delashaw;s 'counsel to the_ Commission's investigafor, dated· Au-gust 3, 2016, accompan~ed by: · (1) the Declaration of Patricia· Hudson (2) the Declaration of Kevin Reinard, M.D., and (3) Dedaration of Daniel Klinger, M:D.;
. -Letter from Stephen Correa to Johnny. Delashaw,_ Jr., M.D., dated June 27, 2016; . ·
Medical Quality A~st.iranc~ · .. Commission. Medical lnvestiga.tions,·Addition.al Investigation; ·
Forwarded Email from Gordon Wright to Stephen Correa, Denise Gruchafla, and Alden Roberts, dated March 17, 2017; ·.·· ··
Me.gical Quality Assurance Com.mission Additional · · Investigation #2, dated.March 27, 2017;
AMEN.OED CORRECTED FlNDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL bRDER Page 7 of 30
Master Case No. M2016-1084
Exhibit R-81: Task Activity Report by Stephen Correa, dated March 27,2017; -
Exhibit R-82: Email from Candace Vervair to Niki Ellington, dated June 7, 2017;
Exhibit R-83: Email from Candace Vervair to Niki Ellingion, dated June s,- 2917; ·
.· , Exhibit R~84: · . Email from Candace Vervair to Mary Fearon, ·dated June 6, 2011;
Exhibit R-85: Em~ll from' Canda~.e· Vervair to, Trish Fie~, dated · August 1, 2017;· .
Exhibit R-86: E_mail from Trish Flett to Candace Vervai~, _ dated __ August-1, 2017;
Exhibit R-87: Email from Trish Flett· to Candace Vervair, dated _______ /:\lJgysU, 2017; __ _ _ _ _ ___ _
gxhitlit-R-SB-: ---gmait-fr-0m-Ga-m;Jaee-VeFVat-F-te-:-BemeE!ett-e-Has-k:iA-s~. -dated June 6, 2017;
Exhibit R-89:
Exhibit R-90:
Exhibit R-91;
Exhibit R-9;2:
Exhibit R.:93:
Exhibit R'."94:
- -Email from Candace Vervair to Bemedette Haskins, with attachment; dated June 6, 2016; .· :···. -:?o:·
Email exchange between _ Candace - Verva[r and· : Elizabeth H~ndershott, from June 2016;
Ernail from Candace Vervair to -Rose Raney, dated Junrf 6, 2017,; · ·
Email froni Candace Vervair to Rose Raney; with \ attachment, dated June 6, 2017;
· · Eniail ·fro~: ··e=~~d·~i::e Vervair to Deborah . Rowland, dated Jurie ·1:2011;
· Email from Candace _ Vervair to Deborah Rowland, with attach~ent; dated J_une 6, 2017;
AMENDED 'CORRECTED FINDINGS OF FACT, GONCLUSIONS OF LAW,· AND FINAL ORDER . Page 8 of 30
Master Case No. M2016.:.1"084
Exhibit R-95:
Exhibit R-96:
Exhibit R-97:
Exhibit R-1 DO:
Exhibit R-101:
Exhibit R-112:
Email from Deborah Rowland to Candace Vervair, dated June 7, 2017;
Email from Deborah ,DesJardin-Rowlanp ~o Meredith Gould, dated December 29, 2015; -
. Email from D.eborah DesJardin-Rowland to Candace Vervair, with attachment, ·dated June a; 2017;
Contract. between Medical" Quality Assurance Commission arid Kent Neff, signed February 9, 2017;
Swedi.sh Cherry Hill Neurosurgery Institute - 2/21/17 (with redactions);
Facilities Report, investigation date 7/20-21; 2016 (DELASHAW ~FP 2 & 7, pages 986-987);
Exhibit R-116: Focused. Cas~ Review ·far Patient Safety Events, · Event type: Radiation Expo.sure· in the OR, Event
___ .. _.Qate: .August 1_5, 201~;: .. ·-~·. --- - --
-----'" ____ .£xl:tibit-.RA-'.l-7~--E-maif-from-Rpd-es·koniarr-ro-i-.ta""U ...... re""e..,.n,-1D"'\or~1s=co"'l'l, -;id-;;iath;;;e-;:r-d--'--·-·~----
.·~·-:/ .. :· _.:. : .. ~~t~~~~~:$;··
;;;;.:i_::::::.; .. ;:..:~:~·;~~~·7 ... :
Exhibit R-118:
Exhibit R-119:
Exhibit R-120:
Exhibit R-121:
Exhibit R-122:
· Exhibit R-123:
Exhibit R-124:
.. , ·:-·g~-h.ibit R-125:
September 15 (DELASHAW· 1063);
Email from Merecfoh · Gould to Rod Oskouian. (DELASHAW 1070)~
Curriculum Vitae of Robert F. Spetz1er, M.D.;
Curriculum Vitae of Rus~~ll"vahdenoelf;:·~.Q.;·
Curriculum Vitae of Dr. John.ny B. D.elashaw, Jr.;
Floor Plan.of Swedish Cherry Hill ORs; , .
Surgical scheduf~ fro.m 12/21 /15;
Li~t of p~o~le who joined Swedish Neuroscience Institute ·sub.sequent to Dr. Del_ashaw's chairmanship;
Letter from Tracy Bahm to Dr. Neff, dated February· 22, 2017 (Neff Exhibit 42, pages 1-2);
AMENDED· CORRECTED FINDINGS OF FACT, CONCLUSIONS O~ LAW; AND FINAL ORDER Page 9 of 30
Master Case No: Jv12016-1084.
Exhibit R-126:
Exhibit R-130:
Exhibit R-133:
Excerpt from the American Psychiatric Association, The Principles of. Medical Ethics, 2013 Edition (Neff Exhibit 54 ); . .
. . . Declaration of Ramon Frias; . . . ~
Declaration of Frances· Broyles, M.D.;
Exhibit R-1'34: · tieclaratinn of Marc Mayb~rg, M.D.;
Exhibit R-135; Declaration of Ralph Pascualy, ,M.O.;
Exhibit R-137: Declaration-of En~ Vallieres, M.D.;
·Exhibit R-139: September 15/16,. 2015 email. communic~tion amongst ·· Meredith Go·uld, Dr. Oskouian, Laureen Driscoll, and Dr. Delashaw regarding sponge in gown; · ·
_ ExhibitR-:140: .. . __ March 23, 2015 .emaiL--communicatidri ·~amongst June Altaras, Dr. Delashaw; Mary Fearon, and
---------------EHzabetlrFl-ettregard!mftmrow-up meeting;
Exhibit R-142:
Exhibit R-143:
Exhibit R-145:
September 15, 2015 email from Elizabeth Hendershott to . Dr. Delashaw re_garding_ ·discarded Raytec; ·
Septe'.mber 3, 2015 emails amongst Dr. Delashaw, Laureen Driscoll, and Sarah Hopkins;
September · 15/16, · 2015 . email communication amongst Dr. Oskouian, . .Dr. · Dela~haw, Laureen Driscoll, · and Elizabeth · · H~ndershott regarding discarded sp"onge; - ·
Januaiy 24, 2014 email from Dr. Mayberg_ to Dr. Delashaw, et al.;
Exhibit R-146: May 23, ·2014 email· from Dr. Marc Mayberg to . ·Voltaire Tiotuico, et al. regarding April ·: 2014 ·
, ._ . :··. ~omp£?nsatron Report; . : ... : . . :.. . .. ~"'·
AMENDED CORRECTED FINDINGS OF FACT,- CONCLUSIONS OF LAW, AND FINAL. ORDER Pag"e 1 a pf 30
Master Case No. M2016~1084
Exhibit R·148:
Exhibit R-152:
Exhibit R-153:
....... : ' ............ :- ..
Exhibit R-154:
Exhibit R·155:
Exhibit R-157:
Exhibit R-158:
- ·-··
July 15, 2016 email from Cameron McDougall to Charles Cobbs;
November 1, 2016 Charles Cobbs email · to Rod . c5skouian, et al.;
November 1, 2016 Charles Cobbs email to Ryder Gwinn, et aL;
November 1, 2016 Charles Cobbs em·ail; . I
November 3, 2016 Charles Cobbs email;
Novemoer 3, 2016 Ryder .Gwinn email to Charles Cobbs; . · .. • .....
November~. 2016 Charles Cobbs ~mail;
November 4, 2016 Charles Cobbs email to Rod Oskouian; ·
" .. _____ ------------· Exhibit R-159: November 6, 2016 Charles Cobbs email to
---------------Ryder-Gwinn;
Exhibit R-160:
Exhibit R-161:
Exhibit R-162:
E:xhibit R-164:
Confidential SNI ~ame Plan;
· November 6, 2016 Ryder Gwinn · email to Charles Cobbs;
November 6, 2016 Charles Cobbs email to Ryder Gwinn;
November 8, 2016 Tony Arma.da email to Charles Cobbs;
Exhibit R-187: . ~· .. July 24, 2017, Charles Cobbs ernaili
Exhibit R-188: Chair position description;
Exhibit R-189: c;;har[~.s Cobbs'.email to Dayid Newell;
Exhibit R~190: . Charles Cobbs' email fo D~vid Newell;
AMENDED CORRECTED FINDlNGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER . . Page 11 of 30
Master C~se No. M2016-1084
Exhibit R~191:
~xhibit R~1$2:
Exhibit R~195:
Exhibit R·197:
Exhibit R~211:
Exhibit R-212:
Exhiblt RJ213:
Exhibit RJ215: ·
Exhibit R·216: ·- .
Charles Cobbs' notes;
Letter from Andy Costentin_o tQ. Charles Cobbs;
Tammy Williams email to Doug Backous, et al., dated January 29, 2016, with attached spreadsheet;
July 12, 2013 letter to Or. Marcel Loh; . . ..... ~ .. ,. ....... "\; ..
August 16, 2015 John Vassall email to Johnny Delashaw;
January 30, 2018 Dayid Norman email to John· Somerville; · · ·
MQAC Assignment Memo; ', ,"':' --~ ... -;L:•'• .,:.1:. .. \ ,.•'
I
Text Messages between Charies .C~bti;.··arici: ~ira'Ft .. Fouke; and
~ ____ Text ME::J~~~g~s_between_Charles Cobbs and Johnny Delashaw.
After the Panel determined during its deliberations that the Respondent had
?Ommitted a violation of_ 18.130.180(~).· the Presiding Qfficer provided the Panel
members with the Respondenf s sanctions brief, along with attached declarations from
Sandra-Giicher-Kimmel and Richard A. Kirkpatrick, M.D.1
. . . .· -- . t FINDINGS OF FACT
1.1 After gr.aduating from medical school at t_he University· of Washington in
1983, the Respondent sups,equently completed a residency ih neurosurgery. The
Respondent has a lifetime board certification in neurosurgery.
1.2 The Respondent was granted a license to practice as a physician and_
1 The Program did not provide a sanctions brief.
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL OROER Page 12 of 30
Master Case No. M2016-1084
surgeon in the state of Washington on July 25, 1985. As of the time of the hearing-, the . .
Respondent's li~ense: was suspended pursuant tO a summary suspension.
1.3 Pr~vi~enc_e H~alth .-Sy~t.~ms (Providence) is· ~ffil~ated with Swedish
Neuroscience Institute_ In 2013, the R~spond.ent was hired by Pfoyidence ·to potentially
work at both Swedish Neuros~ience Institute (SNI) in· Seattle, Washington, as well as a· ·
planned similar institute in the state of California. In October_2013, the Respondent
~egan wo~king at SNl.2 ~rior to that time, the Respondent had ~orked in academia ·
essentially his· entire career. ·
1.4 As part of his work at SN!; the Respondent serled in a leader~hf p role
· from the ~eginning _of his time there, and was respon·sible f9r performing neurosurgery.
-·-------~t Sweidish~Ch~rry .HiH _Hospital_ _fri_S_e_attle, __ Washington._ - The .Respondent also
.. ---reestaelis-l'leEJ-a-eli-nie-ir;-his-former-hometowrrof-L-ongvie~ast1i11gtor1: l~pril""2015,..._, _________ ..
the Respondent was selected to be the .chair of SNI. . .
1.5 Patient volume and complexity of cases increased sjgnificaritly while the
· Respondent was _at SNI. Howe·ver, ten.sion~· also· developed betw~en the Respondent . '
·anef hospital st~ff ..
1 __ 6 During the time that the R~spondent worked at SNI, the Resporident
engaged- in a pattern of intim.idation with staff, discouraged ~taff from reporting errors, • ...~ih .·. :_ : .. ··~ .: .:·;·~ · . •. :'-:" ·· .. -i' • • • •
· · '· · discouraged staff. from asking questions, and contributed to. the loss. of experienced . . . .
personneL These actions jeopardized Swedish-Cherry Hill Hospital's culture of safety
2 The planned institute in California never n:aterialized.
AMENDED.CORRECTED FINDINGS OF.FACT; CONCLUSIONS OF LAW, AND FINAL ORDER · P9ge 13 of 30
Master Case No. M2016-1084
and normalized unacceptable and unsafe practices, creating an atmosphere of
riqrrnalized deviance. As a result, patients were put at an incr:eased risk of harm.· . '
Pattern of Intimidation wlth Staff
1. 7 · · The· Respondeht engaged in .multiple acts of intimidation of hospf~al staff,
forming a disturbing pattern of behavior. As a result of this pattern ofiritimi9ation, the·
Respondent created an environment in which the ability of staff to provide safe patient . . . . :,,
care was put at jeopardy. S.ev~ral ~xamples o( this intimidation ·are listed below.
Example 1 .
1.8 On December 21, 2015, the· Respondent :wq.s perf6rmfng neurosurgery·at
Swedish-Cherry Hill. Mospital in the_ operati~g room (OR). Late .that afte_moon: the
_________ Respondent wanted _ _t~_beg_in _an.add'.'.on. surgical case.3 . When-.the .. f{espondent was·
---fiinfei<mee-ey-T-Fish-F-lett-,RN-;--that-he-eofjld-not-begin-an-ar.kl=on--su r gi ca I-case- a~ere ..
was another add-on case in li~e _ahead of him- he became. quite angry and upset. The . . .
. Respondent_ subsequently went·to make a phone call and either threw the phone or
sJa~med the phone ~own in ange:r. as the phone w~nt sliding across the floor. The . . .
Respondent subsequently stormed out of the OR, telling Ms. Flett that she "should start
· looking for another job." . .
1.9. At that time, Deborah ·oesJardin-Rowland, RN, was workin~ as a charge
nurse· seated at a .desk foc$ted approximately a one-minute· w~lk. · a'!"aY from the OR.
The Respondent angrily came up to. the desk, red in the face, and pointed· his finger at
s Deborah DesJardin-Rowland testmed that an "add-on case" was Ma.case that [waJs schedul~d the day of · · and not previously scheduled ... .". (Testim~ny of Deborah DesJardin-Rowland) ·
AMENDED CORRECTED FINDINGS . OF FACT, CONCLUSIONS OF LAW,
AND FINAL' ORDER Page 14 of 30
Master Case No. M2016-1084
Ms. DesJardin-Rowiand. Tf')e Respondent yeiled at Ms: DesJardiri-Rowrar:id, telling her .. "'. ~~.:..... . .
.. ·~ . ~' .... ~ .... :.. . . .
that "Pep.pie ."are going to die if I can't get my ca~es. done. I'm going to go .upstairs, find
, more cases and you will be workjng all night!" While yelling at Ms: Des~~rp.in~Rowland,
the Respondent was standing close eno.ugh· to her that she couid ·feel the Respondent's .. . \. . .
. spit on her :arms. . Ms. DesJardin-Ro~land b'ecaine alarmed enougti about. the
Respondenfs behavior that. she stood up from her :ch.air in surprise. Emilie Daniels,
who was wo~klng as a health. unit coordinator for. the OR. at the. tim~. was. also present .
with 'Ms. DesJardin-Rowland and perc~ived th~ Responqent's behavior to be .
intimidating.
· .1.10 . On. December 29, 2015, Ms .. DesJardin~Rowland sent an e-mail to
_________ !!lanage~E:JDt~t~ff f~~yi_0g .w.ha1_b~~d happened. See ExhibjtJ~~6·---·
-----E*amsle-2
.1.1 ~ . In March of 2015, Elizabeth Hendershott, RN, was working as a circulating • ·'= • .. !1: ... , i•·l ' - • • . • .
· nurse at Swedish:..Cherr:y Hill Hospital. While acting as ·a preceptor f9r anot~er nurse,
Ms. Hencjershot became· aware of -a possible misunderstanding over who may be
performing a certain surgery (i~e., whether or ·.not ·neurosurgrcal fell~ws would be
-;•,·.performing particular s~rgeries rather than the Respondent). As a ~e-sult of the dispute,
- " .. ,Ms,. H~f.!dershott became concerned and subsequently informed the fellows that 'she .. ' .... ·"' .. . . . . . . .
. might file a Quality Variance Report {QVR) to .r;lpcument the situation.4
4 A Quaiity Variance Report (QVR) was a mechanism at Swedish-Cherry Hill Hospital whereby staff~ere able to electronically document unexpected outcomes or ·changes in procedure, inciu9ing ,professional misconduct. · : ·
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 15 of 30
Master Case No. M2016-1084
1.12 After the surgeries were completed, Ms. Hendershott participated in a . .
meeting with Mary.P..e.?ron, RN, and the Respondent to discuss the incident. During the
meeting, the ~espondent was yelling and pointing, and. behaving in a very aggressive
manner. The Respondent also told Ms: Hendershott that' she was the reason. for
problems occurring in the OR. However, after Ms. Hendershott to~d. th:3 Respondent
that she did not in fact file a QVR. the Respondent stopped yelling and calmed down,
The Respondent then said that he would have the fe_Hows apologize to her and buy her . .
a coffee.
Example 3 . ·,: ~ .
1.13 On August 5, 2015, a patient .was undergoing a two-part surgical
. -~ocedure C3tth~:_sw~c:li$_h-Cherry_l:fUIJ:f.o_spitaLOJL_As-the:.fir.st-.part: of.the ii:6cedure · ·---···--···-- -· . , .
--WSS-fiRishiiig,--tfie-R-esfieflEleAt-r-eEj·tfesied-ttlat-fltJOro'SCOpy-!Je-do11e to ensure tllat me--. -.-.. --.
har~ware used in the surgery was appropriately positioned.5 Because a radiologic
technologist was not immediately available, the Respondent decided to take the i~ages·
himself.6 ·
1.14 Altlidugh th~ Respondent made at least some sort of announcement pria·r
to taking the images, not everyone in the operating room heard the announcement. In
particular, at least tvvo nurses- including Bernedette Haskins, RN~ did not hear the . .
announceni~nt. As a result, those nurses were not wearing the ~ppropriate protec_tive
covering at the time the images were taken.
s A fluoroscope uses x-rays to ~xamine structures within the body.
s There is no dispute that the Respondent had the skill and training to operate the fluoroscopic machine;
AMENDED CORRECTED FINDINGS OF FACT, CON°CLUSIONS OF LAW, AND FINAL ORDER · . Page 16 of 30
Master Case No. M2016-1084
1.15 After the Respondent 'finished taking the images, Ms. Haskins told the
.. Respondent that not everyboqy yvas ready fQrthe flupro~copy shots at the time that he
took them. The Respondent replied angrily to Ms. Ha~kins, yelling at her, p~inting his
finger at her, and sarcastically asking her if he should "throw something" at h~r next
tim.e to g~t her attention.
· 1.16 Shortly after the confrontation with the R_espondent, Ms. Haskins went to
speak with Caroline .Dufault, RN, in Ms. Dufault's office. At tha~ time, Ms. Dufault
obsel"Ved that Ms. Haskins was· visibly upset and seemed physically sh.aken.· In
addition, Ms. Haskins' voice was QL!i_v~ring an<;! she seemed. to be taking deep br~aths
in an attempt to settle herself .
.. Examgle4 .....
----~-:l-7-0R---Septemb~-5.-2~-5"1wni-le-eempleti-n§~rgfea·l-case-wittrihe
Respondent, Ms. Haskins determined that the post-surgical .sponge count was not
corrE?ct. . After conducting an investigation, Ms. Haskins discovered that the missing
sponge was in one of the Respondent's gloves _in the garbage.
1.18 Not long after the missing sponge had been found, Ms. Haskins sent
an e-mail to the Respondent notifying him that a sponge had been found, and reminding -.
the Respondent "to be· mindful to prevent a .QVR and ~n_necessary -~~dj?~ion."
See -Exhibit 0-8.
1.19 Rather than use the incident as a f earning opportunity, the Respondent
consequently co_mplained to the ch~ef nursing. o'fficer at Swedish-Cherry Hill H~~pital,
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND flNAL ORDER Page 17 of 30
Master· case' No. M2016-1084
Meredith Gould, D.N.P: The Respondent i:vas very upset .that Ms. Haskins would
"call him out" over this incident.
Examp'.e 5 . . . , _::::«:~:-:·~~t~';:~::~)t:~JJ~t!::::.:~~:: . , - 1.20 In addition to the yelling incidents discussed above, there were-a'lsq'='-5ther·
occa~ions when the .Respondent inappropriately ·yelled at Swedish-Cherry Hill H~spital
staff.
1.21 On_ one occasion: Niki E!Jington, Rf':J,. became aware of a potential rssue
.. with the mai"ntenance of sterile'.tec~nique. This incident involved the Respondent's . .
fellows, so Ms. Ellington paged the Respondent to discuss the issue. The Respondent . .
subsequently called her back and shoute~ at ~er. The Respondent told Ms. Ellington
that he knows what he is doing-and that she §.hQ.Yld.DQtqy_e.stio_n_hfrn...__·· _ -------- - .. ·- -····-·----··-· - ··-·-·-····------··-·- -----··------- ·-. . . . . .
------r1_..::.2-2~-r-i--aR0tt:ier-GGsa~ieA,-Oef0r-e-a-[3laflfled-me-eting-o~~"E?Tir 19 -cur 11mtttee ·
was -to begin, the Respondent took a phone call af th_e table while seated with the other
participants. The Respondent yelled at the person. on the othe·r end of the phone lirie· I " 'I - '
1 •• ,'.._,,' ~
0 : •
for severai minutes.7 ·
Dis·couraged Staff fro~ Reporting Errors
· 1.23 Some of the staff memb~rs· -reacted to the Respontjent's disruptive
behavior by filing QVRs· or by making reports· to supervisors, in order to document
issues that may put" patients at risk. However,. the Respondent contributed to an ·
environment where reporting s.uch 1 inc1dent$ was discouraged. As examples, the
1 Somewhat ironically, the purpose of the steering committee meetings was to 'address the deterioration ot the culture of safety in the OR, including how to improve ~ommunication.
AMENDED CORRECTED FINDINGS OF FACT, .CONCLUSIONS OF LAW, ANO. FINAL ORDER Page 18 of 30
Master Case No. M2016--1984 ...... ~~~ ..
incidents outfined in examples 2, 3, 4, and 5, supra, all discouraged staff from reporting
errors.
· 1.24· The · Prog~am also alleged that during a .meeting with a nursing
adminis_trator ·at iti-S ·has<!.'pltal regardin~ .. a staff r~port concerning "th.e Respondent,.s
practic~ of. scheduling ~~-ltlple ~urgerie~f ~t· o~ce, the Respondent became upset and . .
demanded the reporting nurse· be.reported for reporting the matter. There is not enough
evidence. to demonstrate that this incident occurred. (See Alleged Fact 1.4.1) ·
Discouraged Staff from Asking Questions
1.25 The R~sponde~t's ·beh~vior also discouraged staff from ·asking questions
a"nd, consequently, put patients at risk of medical error.
····-··---· ...... 1.26 During .surgeries, .. the Responde·nt would· sometimes--t-akE! tissue samples·
----1--,t-lat-woolt:f-tfieA-be-pFeviefed_-t-o-a-pathologist-WI 1e1 1 1 tul ses would asK-fo r clanf1cation or·
verification of.the name of a partlcular tissue specimen, the Respondent would at' times
respond in a sc:ircastic or demeaning mannei:. This included the Respondent ro\ling his
eyes, sighing, · or·· sarcastically over-enunciating his words. Hospital staff were
discouraged from 'pointing out possible concerns with identification of tissue specimens.
1.27 · As a result cif this behavior, as well as the behavior described in examples
.1, 2, 3, 4, and 5, -supra, hospital staff w~re dJscouraged from asking questions. Thi~ .
increased the chances that a mistake could occur; ·it also diminished staff members' . .
ability to advocate for~ patfentS. As a result, there was a. significantly increased -risk to
patients:·
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 19 of 30
Master Case No. M2016-1084
. ·.-;- .......
...... . . · .. -"·.-.--~~ .. -. • ... • : •• :ro.i.~ ....... ~.... --
.:.• ,--,_ .. ,--::~.t~•}he R~spondent's Actions Contri~uted to Loss of Experienced Personnel
. 1.28 As a result of the Respondent's disruptive behavior, multiple nurses left . . . . . .
their positior:is at SWedish-Cherry Hill Hospital: c·onsequently,. Lis.age of traveling nurses
· increased and new nurses had to be hired·.
1.29 Alt"ho.ugh it is ·true that part of the· reason that Swedish-Cherry Hill' Hospital . . .
. began to use inc~~ased numbers ·of traveling nurses was d~~-t~ increased surgical
v.orume, a significant-reason for the increased usage was that nurses had left due to the
negative environment that the. Respondent had helped to create.·
1.30 Some of the nurses Who left their johs at Swedish-Cherry Hill had
__ __:_ ___ §ignificant.wcpectenc~w9rf<.t11g in.neu.rq~urgery. Newly-_bire_d_staff. Were thus U.nable to· ..
__ ...._.abso.i:f?.-tile-k.r:iowled.gs-tl:iat-tf::ley-wotild-l:iave-rf?eeiveEf-f-r-em-ex~e,rie'f!eed-staff:-A-s-a
result,.patients and th~ public were put at increased risk.
Expert Witness Credibility and Persuasiveness
1.31 The Commis~ion finds the testimony of Kent Neff, M.D., to be persuasive
and convincing for several reasons. First of all, Dr. Neff~ vasf experience working on
the_ issue of disruptive providers demonstrated· specialized knowledge and expertise that
was ~elpful to the C<?mmission. . Dr. Neff. has. written a book chapter on disruptive
providers and is cited in the Commission's policy statement. In addition, Dr. Neff has
evaluated many . disruptive providers ·and consulted with hospitals on this issue.
Furthermore, Dr: Neff s. testimony was logical; p·roviding a convincing outline of how the
·Respondent's behavior fit into a pattern, and how that pattern. led to a .. disruption of the
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 20 of 30
Master Case No. M2016-1084
culture of safety at the Swedish-Cherry Hill . Hospi~al. Although Dr. Neff did not
personally meet with the Respondent, Dr. Neffs te.stimony.wa~· credible because he
w;es a~le to.· asses~ the irnp'\'ct ~f the REispondent;~ -~~~Y~~~R'~li~\ttof __ an. . .· . . . - . . . - .:·· -... ~!.~~::::~.~~:::·:··~~ -:
organizational setting in which the Respondent had caused considerable dam~ge . . .
1.32 In contrast, the--:Commi,ssion qoes not find the testimony ·of Russell
Vandenbelt, M.D., to be as persuasive. Although Dr. Vanden~elt has significant
experience in psychiatry, his experience in dealing with disruptive. provider behaviors is
· ·mu~h less extensive than Dr. Neff. Additionally, it was apparent from Dr. Vandenbelfs·
. ' . testimony that he had disagreements with the Commission's written policy on disr~ptive
physicians. Dr. Vandenbelf "did testify that the Respondent ~ad engaged ·in .disruptive
.. ---- __ behavior. Neverthefess, Dr .. Vandenbelfs_opinior.Lwas-tbat the Respondent was not a ·
--d·i-sru~+v~rnvider=;--T-l"le-Gemmission~otesihaMtrer;e-ts-clear arid convincing evidence
that the Respondenf s behavior was not isolated. Thus, the· Commission finds
Dr. Vqndenbelt to not be crE?gible. • o • ' I ' o ~ ... :• o' ~-~"' ofo:•",,'; • •"•
Fact Witness Credibility
1.33 Credibility findings: The panel finds the testimony of D~borah Desjardin- ·
Rowland, Elizabeth Hendershott, Bernedette Haskins, Caroline Dufault; Enedina .
Norton, and Niki Eliington"to be credible. The testimony of these nurses was consiStent
wi.th each other, even thou.gh witnesses were excluded from hearing the other
witnesses' testimony. It was also ap.parent that many of these witnesses did not
necessarily want to come to·testify at the _hearing, as the_y did not have anything to gain
from testifying. For the most part, the testimony was also consistent with the
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDE~ Page 21of30
Master Case No. M2016-1084
declarations that had been provided. The nurses provided convincing testimony that . .
the Respondent engaged in disruptive behavior. ·
1.34 Credibility Finding: The panE?_IJinds the testimony of Peggy Hutchison to
be credible. Although o"r. Hutchison di~ not work directly with the Respondent, many
people complained "to her about the Respondenfs disruptive behavior. In addition, .
Dr. Hutc(lison had nothing to gain. by indicating that she had been inform~d of .the -
Respondent's behayror.
1.35 Credibility Finding: The panel finds the testimony of the former fellows and
physicians who testified on behalf of the Respondent to not be persuasive:
Seymur Gahramanov, M.D.; Cameron McDougall, M.D.; Marc Moisi, M.D.; Daniel
____ --~_[JiLorenzo, _ ¥.D.; Pc:trtha_~aEat~} Charniraj~J- _M_.D._i __ p_ai:t_if31 .Kfioger, M.D:; ___ .Qhristian
--B.ow.e.r:s,-M .. ~-laJLWJ:igbt,_M.D.~-Zachacy_LJ_btak.-M.D~.e-v~r-i--¥-Uef-l.-MD~-@Rd-K~v~f-1--·-· - --·---·-
Reinard, M.D. These ind_ivid1,.1a!s testified that they· did not observe the Respondent
engaging !n what they perceived to be disruptive behavior. However,· as physicians,
these witnesses were not in the same positi.6n as the nursing staff: The fact that these
witnesses did not see t.he behavior does. not mean the behavior. did not occur"' it simply
means that the behavior was not seen by these witnesses. In addition, the .very real
power differential between physicians and nurses means that these witnesses would
simply not be as vul_nerable. to the impact of 'disruptive behaviors exhibited by the
Respondent. Consequently, the testimony is given little weight.
1.36· Credibility Finding: With regard· to the issue of whether or not the
Respondent was engaged in disruptive conduqt quring his time at SNI, the panel finds .
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER . Page 22 of 30
Master Case No. M2016-1084
. ·:
the .Re5pbndent to not be credible. Althou~h the Respondent did .not dispute. that th~
incidents testifled to at ~-~.ar\ng took· place generally, his recoHection was very different
than described by· the test.ifying nurses.· On the whole, the. Respondent's testimony was
self-serving, and he blamed the problems at ·sNr and Swedish-~herry Hill Hospital· o"n
others. The Respondent was ev~.~ive w~en asked if he would be concerned about the· ...... --
beh~vior described by the nurses in· the Safety Takes ·Teamwork document
(Exhibit D-2~). ·con~.~fl~§~tli.-, tbe. panel gi.ves more weight to the·-testimony of the
nurses 'l'.Vho te~t~fied. than.to the .Respondent. • !~~ .b,";.•, ..
1.3_7 The Respondent's behavior while working for Swedish Neuroscience
Institute constituted disruptive physician behavior. Furthermore, the Respondent should . . .
---~have been aware that his __ behav'ior was__disr.upti¥e,--as disruptive-behavkir--was both
---Glef-i·AeG-iff-Swedis~:s-Gese-ef-Gefidttet--and--tmr-eo-m-mtssioll'rPoli~t~ement
· (Se.e Exhibits D-74 ~nd D-75). The Res.pondent's behavior negatively affected the
cult~re c:if safety, ultimately replacing it with a culture of fear. This led to a compron:iise
of team effectiveness and, as a result, an unreasonable risk of patient harm ... ·
1,38 Any· inter~af disputes that the Respondent f)1ay have had with other
phys.icians at SN! .reg~rding. ~.alarie~:,or admini~trative control of SNI. or any workload . :" .· ...... .
disputes that.the nurs.es at Swedis~-Cheny Hifl had with .physicians a.n.d managem~nt
st~ff, are not relevant to the fact. that the Respondent committed disruptive physician
behavior.
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 23 o~ 30
Master case No. M2016-1084
II. CONCLUSIONS OF LAW
2.1 The Medical Quality Assuranc~ Co.mmission.(Cor:nm[f?.~ion),h~s j4risdiction . . . : • ..... :~ .. ~~·.;.:,=~;:.-:~~~;;~~~;,:-*:-::··~~14 ... ~:
over the Res.pendent and subject of this proceeding. RCW: 18.13o.o4q~-~:~'.;~.~r-~t·~,.~:,.\~-¥<,,· . .. ·... . . .- ..
2.2. . The.: Washfngton. s·upreme Court has· held the standard of proof in
disciplinary proceedings against physicians is proof by cl~ar--and convincing evidence.
Nguyen v.-DeP_artment of Health, 144 Wn.2d ?16, 534 (200.1), cert. denied, 535 U.S ..
904 (2002).
2.3 The Commission used its experience, · competency, and specialized . ... .
knowledge to evaluate the evidence. RCW 34.05.461 (5). -
2.4 · The Program proved by_ ·clear and convincing evidence that the
.... _Respondent committ~d unprofessional---coliduct-as-- defrn.ed_:_in--RGW-18~1_30A 80(4),
-~-~wt1iet-l-staf·A-S!:---------.....:....-,;-------~----------------,-
Incompetence, negligenc~. or ITT?lpractice which ~esults in injury to. a. patient. or Which creates_. ~n unreasonable risk that. a patient may. be._ harm~d. ·The use of a nontraditional treatment by itself shaHnof constitute· unprofessional conduct, provided that it does not result in injury to a patient 'or create an unreasonable risk that a patient may be harmed; ·
2.5 The Program requeste.d that the Commission issue an order.requiring: (1)
the. Respondent to· obtain a Commission-approved eval~atlon by" a group th~t is
. experienced in evaluating disruptive-behavior, that those evaluators be given full access . .
to this 'lnformation in this case, and that the Respond~nt be required to sign_a ~l~~se ·
enabling the evaluators to communicate freely and ·fully ·with the Commission; (2) a
_consequent appearance befo~e the Commission with th~ recommendation_s from the
evaluators to have furth~r conditions imposed before he resumes practice; and (3) the .· . ...:.:-.:-··.·
. )
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS ·aF LAW, ANQ FINAL. ORDER · . Page 24 of 30
. . Master Case No. M2016-1084
...... f~·· ..
Responde!'lt to be put on probation. The Program also requests that the Respondent be
required to pay a fine. · The Respondent requests the ·allegations against him be
dismissed.
2.6 In determining the appropriate sanctions, public safety must be . .. . ........ ..
considered before the rehabilitation of the Respondent. RCW 18.130.160. · The ,• . . .· --- .
Respondent's conduct falls in Tier B of the.Pra'ctice below standard.of care schedul~~ . . .
WAC 246-.16-810. The panel considered the following aggravating factors when
· determining the sanction in. this matter: .the incidents qf the Respondent's disruptive . . . . . .
conduct were not isolated; the Respondent'~ disl\..lptive conduct formed a pattern. of
behavior; the Respondent's behavior contributed to the normalization of devia!lce at his ..
... __ .. __ .workplace; and the· Respondent .did not show remorse for~l:iis behavior;- . The panel
-~-'I· 'CGAS-iclereEl-t.f:le-feHewi·fl§-mitigat-irrg--f-aetors-wherrdetermining tile sanctmninthIS matter:
. no -.prior· miscqnduct; and the Respo~dent has a long history· of providing needed .
services _to his community.
Ill. 'ORDER
3.1 The Respondent's license to practice as a phys,ician and surgeon in the·
state of Washington is REINSTATED and placed on OVERSIGHT for ·a period of at.
least three years.
3.2 · Evaluation of Disruptive Behavior. Within three (3) months of the . .
effective date of this Order, the Respondent will obtain a comprehensive, multi-day - .
evaluation from a ·group of evaluators that is experienced · iii .. evaluatlng disruptive
physician _behavior. The group must be approved in· advance by the Commission. The ·
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS.OF LAW, AND FINAL ORDER Page 2S of 30
Master Case No. M2016-1084
•'
Respondent yvill provide.the· evaluator with a copy of this Order prior to th.e evaluation.
The Respondent w!ll sign ·any waivers or rele8:ses necessary to allow the evaluators to
communicate with the Commission, and will cause the evaluator to submit a written
report· directly to the Com.mission. The Respondent will fully corriply with any
recommendations made by the e.valuators.
3.3 Employment Restrictions. During the period of oversight, the Respondent . : - .
shall be employed as a physician in the state of Washington only upon compfi~nce with
the following terms ,and cond!tions:
A. The Respondent may not hotd a medical leadership position .O.e.~ fa1 . . . ... o : I t' o ... '._~ •_•': :.\ ' ... ;.':°:;.~.::~ ':._ ::•, • o ·.:, >:~~-.. &:~·~~",\~
position that requires the Respondent to supervise other. p~ysicians)i · · ";: :.::~~:,':.'r-.-:.·.i.::::<:·:'<.~ .. ~-~~:\
B. Jhe above. re$trJction.~.o~~SJJot probibiLtbe .. Hespondentfrom holding an -
.-~,academie-p6s.itJon-. -As.:-non-e.x.cf-~sive-e-x-amples,-lee-t-uri-ng-oM-neur-oanatomy 0.1
conducting ·neuroscience research would be permissible academic positions.
HoYJ"ever, r~gardless of the work setting, the Respondent may not hold a position
that re·quires that he· supervise other physicians.
3.4 Personal Appearances. Within 'three (3) months of the disruptive
physician evaluation, or as soon thereafter as the Commission's schedule permits. the
Respondent must personally appear at a date and location determined by the
Commission. At his personal appearance, the Respondent shall be prepared to disc.uss
the evaluation that he attended, struggles and successes he has faced with his . .
disruptive behavior, how he, is complying with the recommendations m~de by the
evaruators, and how he intends to modify his behavior in the future: Thereafter, the . . .
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 26 of 30
Master Case No. M2016-1084
Respondent must m~k:~:·d~~~b:A~kappearances before the Commission semiannually. • i • • -· .. .·.··: ' ... •••• • .
Respondent must participate in a · brief telephone call with the Commission's .
Compliance Unit ·prior to any appearance. The purpos~ of appearance is to provide
meaningful" oversight over the Respondent'~ compliancf3, with .the reqt,1irements of this
Order a_nd to ensu_re that the Respondent is c_omplying_ with recommendations made by
the evaluators. The Commission will provide reasonable notice of all. scheduled
•, ..
3.5 Fine. The Respondent shall pay fine to the Commission in the amount of
ten-thousand d.oilars ($1 o,ocio.oo); which must be received by the Commission within · . . .
six (6) months of the ~ffective date of this·Order. The fine shall be pald by certified or
.. · · ·:·, ·.·· ___ cashier's chec_~ o~ mop~y or~-~~. made..,p9ya_~l13tg__th~.PeP.i:lrt11l_eotof _Healtll '30..Q mailed
_ _.....tCL..tti.e_o.ep.arun.enL.of_He.altb.,_M.e.dlcaJ_c.o.rnm1ssior:1,-P-O-Sox.-:1-~9,-0l¥m.Pia,--WA-----
9s507 .1099, Credit or debit cards can also be used for payment at the front counter of
th~ Department of Health building at 111 Israel Road SE, Tumwater, WA 98501, during
regular business hours.
3.6 Modification. The Respondent may not seek modification of this order for
. a. period of three (3) years from the date.of this. Ol9er ...
- 3.7 Change of Addr~ss: The Respondent shall inform the program manager·
and the Adj~dicatiVe "':.s·~~ice Unit, in writin.g, of changes in his residential and/or
business address within 30 day:; of ~u.ch change.
3.8 Assume Compliance Costs. The R.esP,~mdent shall assume .au costs of
complying with all requirements, terms, :9nd conditions of this o~er.
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 27 of 30
Master Case No. M2016-1084
/
3:9 P·rotective Order.. The presiding officer may issue a protective order at
his or her discretion to preserve ·c_:onfidentiallty related to heal~h care records or
provider-:-client it:iformation and to. comp'ly . with applicable . slate or federal law: . . . ..
WAC 246-tt-400. Pursuant to WAC 246-11-560(5.): "Final orders may contain ·orders
that ·sp~cified portions of the agency record shall n9t be disclosed as publ!c r~cords if . .
. necessary to protect privacy interests; the public welfare, or vital governmental
.fu.ny1;JQ.O.~;'.;_~-~~..y9h order~ shall !nclude but are not limited to protective orders issued ........ : . . . . . . ·· .. : .... _. \.·-:-.... ·,,,,·-·.:.:~::--" . during the p·roceeding or pursuant to WAC 246M11.-400." Pursuant to the agreement of
the parties, E(Chibits D-19, R-116, R;-146, and R-197 are SEALED. ·Iii addition, the
hearing was briefly close~ to ·t~e public for discussion and testi~ohy regarding Exhibit
_ ~----· ___ D-19. The Adjudicative ClE?rKs Offl_ce __ ~halLpJace. Exhibits_n~ 19,. B~116,J~~-14.6, and R-- .
• -- ·'---~-9.7-fa-a-Sealed-e.rweJo.pe-witf:l-a-GGfJ-Y-ef-tAi-s-Gr-Ger--att-ae-Recl-t-e-tfie-eat-stde-eH-h-e-seafed-----
env:e!ope ..
. In addition, Exhibit 47 th~t was attached to the Respondent's Motion to Vacate
Ex Parte Order of Summary and Fo.r Dismissal was SEALED pursu~nt to -Prehearing
Order No. 19. 8
3.10 Failure to Comply. Prot~cting the· public requires practice under the terms
and conditions imposed in ~his order'. Failure to comply with the terms and ton~itions of
this order may res~lt in suspension and/or revocation of the Respondent's license after
a show cause hearing. If the Respo.ndent falls to comply with ·the terms- and conditions . .
of this order, the Commission m~y hold a hearing. At that hearing, 1he Respohderi~-. . .-.~~- · . . . ::.. =--.:. - - : ··~:.,.· ~ .
AMENDED CORRECTED FlNDiNGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 28 of 30
Master Ca_se No. M2016-1084
. . .
. ..
. I
··.
must show eause why his license should not ~e susp"ended. Alternatively, the
C6inmi~~i6n_. may bring ad_ditio11al. ch~rges;·. of : u~professional . conduct u~der ~
.. RCW 18.130.180(9). In either·.~se,)he):~,~.~P,9nd~nt .\.\'.ill be.given .notice· a.nd .. an • • I • • '. • • ~ ': :.:.: r : •"• • • ' o ' • • '
opportunity for a hearing on the i~sue of non-cqi:t:ipli?nce: .- . . . r. . . . .
Dat~g.ih_rs3/~9,~Y.9f .~.~Q.IJS~1,JQJ8 .. ' ..
URANCE CQMM(~$10N.
CLAIRE ES"COTT,·M.D. PC!riel C"haif · · ·
ci.eR.K·s ·siJMMARY ......... ···.
·-------------'"--,-j. ~ar-ge ction RCW 18.130.180(4} . VlO~tED.
NOTICE TO PARTIES" . . ' .. . ..... 'I.~··'}~.: .. • .
: · This ·oi-der is subject to the reporting. requirements of . RCW 18.130. f10, Section 1128E of the Social Sec~r.ity Act,:~nc(ary q"#1.¢_r appl.~~*~te".i0te.rs~.~~ ~r:n~~!or:i~I . reporting requlrem.ents. If discipline i!) ·t~~em, ·~ :tnust-_be ·rep-Ortea tO th·e tj~af1b:~re
. l.ntegrlty ProtectiQn Data ~ank. · . · · .. . · · . · · . . ·.· ... · · ·. · ·· .
-·
... . . . . . ",.
. . ·.:; ., . '• · ........ . .... .
,.,
·. ' :.: .... . · . . . ·. . .... ~_;~': . :. ':.,
. . . ; . .... .. ~ ........ " ..
. ·.- . . . . .... · ·'/.:
... . . ~' . ·"': l ~
. .· ... ~ '
.. . '· ·- -· · .. ,,
- . ·. -: .... :.;, ·. . - ·. ·~~:.:• .:: .. ~.--=· _ _...:.. _______ ..,-----'-------''----.:....-~-_,;..-------- • .. · .
08 This document was attached to Prehe~rlng Ord~r Nb: 19 i11 a sealed envetope. · .. ·.·,:·>\:·
• • • - • • •• ~ • •• • • • •• of' ; - • • 1.'; :::· ..
· AMENDEO CORRECTED FINDINGS OF FACT, CONCLUSIONS"OF LAW, AND FINAL ORDER . page 2~ .. of ~o
Master Case No:M2Q16-1084" .
-·- .. ·---------·--·---·--· ..... ,, ____ .. ,_ ..................... ,_ .. : .. ------·· ... -·-··~-.
. .. . . ..
~ . . . . .... . •• ' ..... ,.1,
.. A"';~\ ::\ · -j:r1~.
-- ·-·---·-·-">-'~--
".
Either party may file a petftion for reconsideration. RCW 34.05.461(3); · - 34.05.470: T:he petiti_on must be filed within 10 days of service of this order with: .
AdjL,Jdicative Service Unit P.O. Box 47879'
Olympia~· WA 98504-7879
and a copy must be sent to:
Department cit Health Medical Program · . . P.O. BoK47866
·Olympia, WA 985.04-7866.
The petition niust state the specific grounds for reconsideration anci what relief is · requested, WA01 246-11 ~580. ~he petition is denied if the. Commission does not respond in writing within .20 days of the filing of th.e petition.
A petition. for judicial .. review must be .filed .and se~ed withiry 30 d_ay$. after service of· this order.. RCW 34.05.542. The'- procedures are identified in chapter 34.05 RCW, Part v,· Judicial Review and Civil Enforcement. A petition for reconsideration is not requireq · before seeking judicJ~l __ _J§_yie\l\f~ .. If_ a· petition fpr
·--:-· -,-- reco·nsideration iS filea, the aoove 30-day period does not start until the petition is resolved. RCW 34.05.470(3 . · · ·
The order is in effect while a petition for reconsideration or ·review is filed. "F1Hng" means actual rec?iPt of the document by the Adjudicative : SerV\ce µnit. . RCW 34.05.010(6} .. This order is "served" the day it is deposited In the United States mail. RCW 34.05.010(19).
For more infonnatio~ visit our website at: http://www.doh.wa.gov/hearings
-.~. . : .: .=· • - . • . :· .• -t·-.
i
AMENDED CORRECTED FINDINGS OF FACT, CONCLUSIONS OF LAW, AND FINAL ORDER Page 30 of 30
Master Case No. M2016-1084