Florida Board of Medicine: Disciplinary Action Case Studies Jason J. Rosenberg, M.D., FACS DATE

Statutes Chapter 456, Florida Statutes – General Provisions to all Health Care Practitioners Chapter 456, Florida Statutes – General Provisions to all Health Care Practitioners s (1), FS – Grounds for Disciplinary Action s (1), FS – Grounds for Disciplinary Action Chapter 458, Florida Statutes – Medical Practice Act Chapter 458, Florida Statutes – Medical Practice Act s (1)(, FS – Grounds for Disciplinary Action s (1)(, FS – Grounds for Disciplinary Action

Rules Rules 64B8, Florida Administrative Code Rules 64B8, Florida Administrative Code Rule 64B , FAC – Disciplinary Guidelines Rule 64B , FAC – Disciplinary Guidelines

Wrong Site, Procedure, Person Surgery Cases Violation: s (1)(bb), FS (2010) – Performing or attempting to perform health care services on the wrong patient, a wrong-site procedure, a wrong procedure, or an unauthorized procedure or a procedure that is medically unnecessary or otherwise unrelated to the patients diagnosis or medical condition. For the purposes of this paragraph, performing or attempting to perform health care services includes the preparation of the patient Violation: s (1)(bb), FS (2010) – Performing or attempting to perform health care services on the wrong patient, a wrong-site procedure, a wrong procedure, or an unauthorized procedure or a procedure that is medically unnecessary or otherwise unrelated to the patients diagnosis or medical condition. For the purposes of this paragraph, performing or attempting to perform health care services includes the preparation of the patient

1 st Case Study Summary: Performed vertebroplasty on wrong vertebrae Summary: Performed vertebroplasty on wrong vertebrae Hearing: Accepted Settlement Agreement Hearing: Accepted Settlement Agreement Penalty: letter of concern, $2,500 fine, costs, 5 hours CME in risk management, 1-hour lecture on wrong site surgery Penalty: letter of concern, $2,500 fine, costs, 5 hours CME in risk management, 1-hour lecture on wrong site surgery

2 nd Case Study Summary: performed surgery on the wrong finger; error was not discovered until the follow up visit at which time the patient was scheduled for the correct surgery Summary: performed surgery on the wrong finger; error was not discovered until the follow up visit at which time the patient was scheduled for the correct surgery Hearing: Settlement Agreement Hearing: Settlement Agreement Penalty: letter of concern, $5,000 fine, costs, 5 hours risk management CME, 1-hour lecture on wrong site surgery Penalty: letter of concern, $5,000 fine, costs, 5 hours risk management CME, 1-hour lecture on wrong site surgery

Prescribing Cases Violations: Violations: s (1)(t), FS ( ) – Notwithstanding s (2) but as specified in s (2): 1. Committing medical malpractice as defined in s The board shall give great weight to the provisions of s when enforcing this paragraph. Medical malpractice shall not be construed to require more than one instance, event, or act. 2. Committing gross medical malpractice. 3. Committing repeated medical malpractice as defined in s A person found by the board to have committed repeated medical malpractice based on s may not be licensed or continue to be licensed by this state to provide health care services as a medical doctor in this state. Nothing in this paragraph shall be construed to require that a physician be incompetent to practice medicine in order to be disciplined pursuant to this paragraph. A recommended order by an administrative law judge or a final order of the board finding a violation under this paragraph shall specify whether the licensee was found to have committed "gross medical malpractice," "repeated medical malpractice," or "medical malpractice," or any combination thereof, and any publication by the board must so specify. s (1)(t), FS ( ) – Notwithstanding s (2) but as specified in s (2): 1. Committing medical malpractice as defined in s The board shall give great weight to the provisions of s when enforcing this paragraph. Medical malpractice shall not be construed to require more than one instance, event, or act. 2. Committing gross medical malpractice. 3. Committing repeated medical malpractice as defined in s A person found by the board to have committed repeated medical malpractice based on s may not be licensed or continue to be licensed by this state to provide health care services as a medical doctor in this state. Nothing in this paragraph shall be construed to require that a physician be incompetent to practice medicine in order to be disciplined pursuant to this paragraph. A recommended order by an administrative law judge or a final order of the board finding a violation under this paragraph shall specify whether the licensee was found to have committed "gross medical malpractice," "repeated medical malpractice," or "medical malpractice," or any combination thereof, and any publication by the board must so specify. s (1)(m), FS ( ) – Failing to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or billing for each diagnostic or treatment procedure and that justify the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations s (1)(m), FS ( ) – Failing to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or billing for each diagnostic or treatment procedure and that justify the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations

1 st Case Study Summary: prescribed Ativan, Klonopin, Lortab and Ambien to patients, but failed to maintain medical records to justify the treatment Summary: prescribed Ativan, Klonopin, Lortab and Ambien to patients, but failed to maintain medical records to justify the treatment Hearing: Settlement Agreement Hearing: Settlement Agreement Penalty: reprimand, $20,000 fine, costs, UF drug course, FMA records course, QA assessment, PRN evaluation and compliance Penalty: reprimand, $20,000 fine, costs, UF drug course, FMA records course, QA assessment, PRN evaluation and compliance

Prescribing Cases Continued Violations: Violations: s (1)(t), FS (2009) – Notwithstanding s (2) but as specified in s (2): 1. Committing medical malpractice as defined in s The board shall give great weight to the provisions of s when enforcing this paragraph. Medical malpractice shall not be construed to require more than one instance, event, or act. 2. Committing gross medical malpractice. 3. Committing repeated medical malpractice as defined in s A person found by the board to have committed repeated medical malpractice based on s may not be licensed or continue to be licensed by this state to provide health care services as a medical doctor in this state. Nothing in this paragraph shall be construed to require that a physician be incompetent to practice medicine in order to be disciplined pursuant to this paragraph. A recommended order by an administrative law judge or a final order of the board finding a violation under this paragraph shall specify whether the licensee was found to have committed "gross medical malpractice," "repeated medical malpractice," or "medical malpractice," or any combination thereof, and any publication by the board must so specify. s (1)(t), FS (2009) – Notwithstanding s (2) but as specified in s (2): 1. Committing medical malpractice as defined in s The board shall give great weight to the provisions of s when enforcing this paragraph. Medical malpractice shall not be construed to require more than one instance, event, or act. 2. Committing gross medical malpractice. 3. Committing repeated medical malpractice as defined in s A person found by the board to have committed repeated medical malpractice based on s may not be licensed or continue to be licensed by this state to provide health care services as a medical doctor in this state. Nothing in this paragraph shall be construed to require that a physician be incompetent to practice medicine in order to be disciplined pursuant to this paragraph. A recommended order by an administrative law judge or a final order of the board finding a violation under this paragraph shall specify whether the licensee was found to have committed "gross medical malpractice," "repeated medical malpractice," or "medical malpractice," or any combination thereof, and any publication by the board must so specify.

Prescribing Cases Continued Violations Continued: Violations Continued: s (1)(q), FS (2009) – Prescribing, dispensing, administering, mixing, or otherwise preparing a legend drug, including any controlled substance, other than in the course of the physician's professional practice. For the purposes of this paragraph, it shall be legally presumed that prescribing, dispensing, administering, mixing, or otherwise preparing legend drugs, including all controlled substances, inappropriately or in excessive or inappropriate quantities is not in the best interest of the patient and is not in the course of the physician's professional practice, without regard to his or her intent s (1)(q), FS (2009) – Prescribing, dispensing, administering, mixing, or otherwise preparing a legend drug, including any controlled substance, other than in the course of the physician's professional practice. For the purposes of this paragraph, it shall be legally presumed that prescribing, dispensing, administering, mixing, or otherwise preparing legend drugs, including all controlled substances, inappropriately or in excessive or inappropriate quantities is not in the best interest of the patient and is not in the course of the physician's professional practice, without regard to his or her intent

Prescribing Cases Continued Violations Continued: Violations Continued: s (1)(nn), FS (2009) – Violating any provision of this chapter or chapter 456, or any rules adopted pursuant thereto s (1)(nn), FS (2009) – Violating any provision of this chapter or chapter 456, or any rules adopted pursuant thereto s (1)(m), FS (2009) – Failing to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or billing for each diagnostic or treatment procedure and that justify the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations s (1)(m), FS (2009) – Failing to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or billing for each diagnostic or treatment procedure and that justify the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations

2 nd Case Study Summary: dispensing physician in Pain-Management Clinic; excessive prescribing for multiple patients; failed to diagnose appropriately, maintain medical records to justify course of treatment, failed to complete History & Physicals, other tests, or refer the patient to specialists, failed to tell patient about alternative treatments available, refer the patient for addiction treatment, or follow up on positive drug screens Summary: dispensing physician in Pain-Management Clinic; excessive prescribing for multiple patients; failed to diagnose appropriately, maintain medical records to justify course of treatment, failed to complete History & Physicals, other tests, or refer the patient to specialists, failed to tell patient about alternative treatments available, refer the patient for addiction treatment, or follow up on positive drug screens Hearing: Was originally under an Emergency Suspension Order; Formal Hearing before the Division of Administrative Hearings Hearing: Was originally under an Emergency Suspension Order; Formal Hearing before the Division of Administrative Hearings Penalty: Revocation Penalty: Revocation

Out of State Discipline Cases Violations: Violations: s (1)(b), FS (2008) – Having a license or the authority to practice medicine revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of any jurisdiction, including its agencies or subdivisions s (1)(b), FS (2008) – Having a license or the authority to practice medicine revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of any jurisdiction, including its agencies or subdivisions s (1)(kk), FS (2008) – Failing to report to the board, in writing, within 30 days if action as defined in paragraph (b) has been taken against ones license to practice medicine in another state, territory, or country s (1)(kk), FS (2008) – Failing to report to the board, in writing, within 30 days if action as defined in paragraph (b) has been taken against ones license to practice medicine in another state, territory, or country

1 st Case Study Summary: failed to report action in NY for standard of care issues; probation for three years, prohibited from performing breast imaging studies; failed to report action in PA based on the NY action; probation in PA concurrent with NY probation Summary: failed to report action in NY for standard of care issues; probation for three years, prohibited from performing breast imaging studies; failed to report action in PA based on the NY action; probation in PA concurrent with NY probation Hearing: Hearing not Involving Disputed Issues of Material Fact Hearing: Hearing not Involving Disputed Issues of Material Fact Penalty: Revocation Penalty: Revocation

2 nd Case Study Summary: failed to report action in NC for physician/patient boundaries; reprimanded and required to attend CME Summary: failed to report action in NC for physician/patient boundaries; reprimanded and required to attend CME Hearing: Voluntary Relinquishment Hearing: Voluntary Relinquishment Penalty: License relinquished Penalty: License relinquished

Standard of Care Cases Violations: Violations: s (1)(m), FS (2006) – – Failing to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or billing for each diagnostic or treatment procedure and that justify the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations s (1)(m), FS (2006) – – Failing to keep legible, as defined by department rule in consultation with the board, medical records that identify the licensed physician or the physician extender and supervising physician by name and professional title who is or are responsible for rendering, ordering, supervising, or billing for each diagnostic or treatment procedure and that justify the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed, or administered; and reports of consultations and hospitalizations s (1)(t), FS (2006) – Notwithstanding s (2) but as specified in s (2): 1. Committing medical malpractice as defined in s The board shall give great weight to the provisions of s when enforcing this paragraph. Medical malpractice shall not be construed to require more than one instance, event, or act. 2. Committing gross medical malpractice. 3. Committing repeated medical malpractice as defined in s A person found by the board to have committed repeated medical malpractice based on s may not be licensed or continue to be licensed by this state to provide health care services as a medical doctor in this state. Nothing in this paragraph shall be construed to require that a physician be incompetent to practice medicine in order to be disciplined pursuant to this paragraph. A recommended order by an administrative law judge or a final order of the board finding a violation under this paragraph shall specify whether the licensee was found to have committed "gross medical malpractice," "repeated medical malpractice," or "medical malpractice," or any combination thereof, and any publication by the board must so specify. s (1)(t), FS (2006) – Notwithstanding s (2) but as specified in s (2): 1. Committing medical malpractice as defined in s The board shall give great weight to the provisions of s when enforcing this paragraph. Medical malpractice shall not be construed to require more than one instance, event, or act. 2. Committing gross medical malpractice. 3. Committing repeated medical malpractice as defined in s A person found by the board to have committed repeated medical malpractice based on s may not be licensed or continue to be licensed by this state to provide health care services as a medical doctor in this state. Nothing in this paragraph shall be construed to require that a physician be incompetent to practice medicine in order to be disciplined pursuant to this paragraph. A recommended order by an administrative law judge or a final order of the board finding a violation under this paragraph shall specify whether the licensee was found to have committed "gross medical malpractice," "repeated medical malpractice," or "medical malpractice," or any combination thereof, and any publication by the board must so specify.

1 st Case Study Summary: thrombectomy performed on patient; no post-op antibiotics provided; failed to respond to repeated requests from nurses that the patient was developing infection; no follow up or referral; patient had leg amputated as a result Summary: thrombectomy performed on patient; no post-op antibiotics provided; failed to respond to repeated requests from nurses that the patient was developing infection; no follow up or referral; patient had leg amputated as a result Hearing: Formal Hearing before the Division of Administrative Hearings Hearing: Formal Hearing before the Division of Administrative Hearings Penalty: $8,500 fine for count 1, $1,500 fine for count 2; probation for 6 months, 5 hours CME in risk management, indirect supervision with 25% review of charts with monthly visits from the monitor, first and last reports and appearances along with the standard terms applicable to probation Penalty: $8,500 fine for count 1, $1,500 fine for count 2; probation for 6 months, 5 hours CME in risk management, indirect supervision with 25% review of charts with monthly visits from the monitor, first and last reports and appearances along with the standard terms applicable to probation

2 nd Case Study Summary: failed to advise patient about cancerous mass Summary: failed to advise patient about cancerous mass Hearing: Settlement Agreement Hearing: Settlement Agreement Penalty: letter of concern, $5,000 fine, costs, 5 hours risk management CME Penalty: letter of concern, $5,000 fine, costs, 5 hours risk management CME

3 rd Case Study Summary: failed to follow up to ensure patient had adequate airway before discharging to rehab facility, failed to assess the gravity of the patients condition, failed to provide immediate treatment to the patient; patient ultimately died - suffered brain damage/death, acute respiratory failure and tachycardia Summary: failed to follow up to ensure patient had adequate airway before discharging to rehab facility, failed to assess the gravity of the patients condition, failed to provide immediate treatment to the patient; patient ultimately died - suffered brain damage/death, acute respiratory failure and tachycardia Hearing: Settlement Agreement Hearing: Settlement Agreement Penalty: Dismissed Penalty: Dismissed