Nurses allege doctor botched procedure, told them to falsify report, cover it up

A complaint before the Guam Board of Nurse Examiners – GBNE-CO-21-005 – alleges a doctor at Guam Regional Medical City inserted the wrong sized catheter in a patient, then told the nurses who assisted him to falsify the medical records so no one would get in trouble.

GBNE member Gia Ramos during the board’s November 18, 2021 meeting, made the following report:

“My case is involving a falsification of records and alteration of documents. So I interviewed GRMC, Ms. Jennifer Cruz, and what happened here is apparently they were doing a, um, a catheterization. These nurses were assisting the doctor in inserting a, a um, a catheter in the cath lab. So, the doctor ordered a certain size to hand to him during the surgery and the nurses heard him saying, um, a different size. Um, the doctor claims he ordered size 13, the nurses heard size 12. They did the proper procedures, how, they hand the size 12 and another person double checks the size. I think there’s two more people that double checks the size. So based from the nurses’s standpoint, they heard a size 12. So, the size 12 was handed to the doctor and it was inserted. To find out later on it was the wrong size; that he really wanted the 13. So what ended up happening, the doctor was so upset at them, um, I guess he went berserk and was, um, yelling at them, and got really upset and told them that, to alter the documents; to put on the notes that they gave 13, the size 13. The nurses did not give size 13, they gave size 12; but because of the doctor really upset and saying how, I guess one of the nurses, the main nurse, his argument is that he wanted to protect the nurse. That she’s gonna get reported to the board, that she’s gonna lose her license, so therefore, ‘we need to help her by changing the size in their documentation from a 13 to a 12.’ The nurses did not want to do it, but they were so, um, I guess afraid of the doctor that they went ahead and changed the documentation.”

GRMC has been a defendant in medical malpractice cases, which are nearly impossible to bring against bad medical providers on Guam because of the Medical Malpractice Mandatory Arbitration Act. The MMMA Act requires arbitration, the cost of which must be borne by the person alleging malpractice, before any claim can be made in a court of law. Lawyers and those who previously have tried to sue doctors for alleged malpractice have said the starting cost for arbitration is around $60,000.

Several medical providers – including Guam Memorial Hospital, Seventh Day Adventist Clinic, Dr. John Garrido, FHP’s Dr. Dennis Sarmiento, among others – have been named in complaints and lawsuits involving alleged medical malpractice.

In one case involving the death of five-year-old Asher Dean Lubofsky at GMH on October 31, 2018, GMH settled its liability with Asher’s father and mother, paying the Lubofskys the maximum amount allowable under Guam law.

Speaker Therese Terlaje has tried to change the law, introducing Bill No. 112-36, which would give poor and middle class Guamanians access to due process, when legitimate claims of medical malpractice arise. Most doctors, including doctors who practice at both GMH and GRMC, have opposed the legislation.

Asher’s father, David Lubofsky, provided the video above.


  • I’ve always had horrible experiences at GRMC. The most recent time I was there was in October. I was 25 weeks pregnant, and I was in so much pain. I was unaware that they didn’t have an OBGYN at the time or apparently at all. I sat in the lobby for 4 hours crying in pain while multiple nurses walked passed me not even caring to assist me. I asked when I would be seen how many times!!! I was told they have more important patients to assist and they needed the rooms for them. After hours of waiting, the doctor finally came out and brought me into a room, then told me to wait for the nurse. I waited another 30 minutes. The doctor came back and started asking what was wrong, so I explained my situation, and he seemed so dumbfounded. The doctor and the nurse didn’t seem to know what to do. They did a bunch of test and I waited another 3 hours. They came back saying I had an infection but they didn’t know how or where it was coming from, so they had to do more test which took another 2 hours. In the meantime, he said he would give me a shot that would stop the pain from the “infection”. 45 minutes later, the doctor came back saying that they sent my test results off and they would call me in a few hours to let me know what it was. While being discharged, I told the nurse I was still in so much pain, but she didn’t seem to care. That same day, I called for my results because they never called me. I was told they didn’t have It yet. A few days later, I called and was told they couldn’t find my results. Mind you, this wasn’t the first time they lost my results. I asked to speak with the doctor who assisted me, but they said they couldn’t do that. They couldn’t assist me in any way, so I asked to speak to an OBGYN, and the lady said,” Uhhh, we don’t have any Obstetrician here… have to go to GMH for that”. Instead of telling me this when I was there so I can be properly assisted, they made me sit in pain for hours KNOWING they didn’t know what the hell to do. I was so pissed because anything could’ve happened to my baby. Till this day, I still never got my results. Thank God I was helped over at GMH and my baby is fine. I’m never going to GRMC again. SHAME ON THEM!!!!

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