When Loren J. Borud, MD, began his first case at about 8 a.m., an operating room nurse noticed he looked tired and wobbly. She was so concerned that she suggested Borud postpone his next patient. Borud said he had been up all night working on a book, but he kept operating, starting a second case, during which he briefly fell asleep, according to a report from Massachusetts investigators. These findings are part of a report in which state Department of Public Health investigators found that Boston-based Beth Israel Deaconess Medical Center provided poor care to Borud's second patient that day. They also faulted the hospital's response to Borud's apparent impairment.