STATE OF FLORIDA DEPARTMENT OF HEALTH
DEPARTMENT OF HEALTH,
Petitioner,
v. DOH CASE NO.: 2009-13016
ALFRED 0. BONATI, M.D.,
Respondent.
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Petitioner, Department of Health, by and through its undersigned counsel, files. this Administrative Complaint before the Board of Medicine against Respondent, Alfred O. Bonati, M.D., and in support thereof alleges:
Petitioner is the state department charged with regulating the
practice of medicine pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 458, Florida Statutes.
At all times material to this Complaint, Respondent was a licensed physician within the State of Florida, having been issued license number ME 38324.
At all times material to this Complaint Respondent's address of record was Gulf Coast Orthopedic Center, 7315 Hudson Avenue, Hudson, Florida 34667-1158.
Filed December 26, 2012 12:25 PM Division of Administrative Hearings
In 2003, Patient SM, a 39 year-old female, had previously undergone a posterior lumbar interbody fusion performed at the L4-5 level.
Subsequently, SM sought treatment at the Gulf Coast Orthopedic Center {Gulf Coast) In Hudson, Florida for her complaints of back, hip, and bilateral hip and left leg pain.
On or about November 6, 2006, SM first presented to Gulf
- - - - C""g" -ast-foi:-an-inn:Jal- .evaluation-wllich was ...cond uctecl _b y Respoode.n..t.....'.s...,,
advanced nurse practitioner.
SM was initially diagnosed with lumbar spine pain with symptoms of radiculopathy, rule out lumbar disc disease, spinal stenosis and post lamlnectomy syndrome of lumbar spine; SM was then referred to Respondent for_ further evaluation.
The Initial November 6, 2006 evaluation noted the SM had
complaints of low back, bilateral hip pain, and left leg pain which radiated into the left lateral thigh, this was consistent with primarily an L3 nerve root irritation and possibly L4.
The preoperative MRI of November 6, 2006, performed at Gulf Coast, shows no evidence of any irritation of either of those nerves other than for possible postoperative scarring.
· The preoperative MRI of November 6, 2006 indicates that patient SM had a posterior lumbar interbody fusion performed at the L4-5 level, but the ·MRI was of poor quality; it did not show an abnormality which would be oorrectible through surgical means, it also failed to delineate a specific cause of pain, and without more was an inadequate
and an insufficient basis upon which to base surgical decisions.
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surgeries detailed in th fs· Administrative Complaint.
SM was not appropriately evaluated with a high-quality MRI and CT scan to determine if there was objective evidence of Inappropriate screw placement causing nerve root impingement. ·
The preoperative MRI studies of November 6, 2006 do not indicate inappropriate screw placement or neurologic Impingement.
The medical records fail to show that Respondent considered
an alternative to surgical intervention such as referring SM to a pain management specialist for the treatment of her pain.
On November 9, 2006, Respondent performed a re-exploration of spinal fusion at L/3 L/4 left with removal of hardware (screw) L4 vertebra.
On November 14, 2006, Respondent performed a re exploration of lumbar laminotomy L/4 L/5 left, with re-exploration of spinal fusion and removal of hardware (screw) LS vertebra.
On November 20, 2006, Respondent performed a re exploratlon of lumbar laminotomy L4 L/5 right, with removal of hardware (screw) 5th vertebra.
19. On February 20, 2007, Respondent performed a re-exploration of lumbar lamlnotomy L4 l/5 left: with decompression of nerve root, dural leak repair and removal of bone spur.
20 On March 5, 2007, Respondent performed a re-exploration of lumbar lamlnotomy L3 L/4 left with dural leak repair and epidural blood patch.
On March 7, 2007, Respondent performed a re-exploration L3 L/4 left with re-exploratlon/eminectomy and with dural leak repair and epidural blood patch.
On April 6, 2007, Respondent performed a re-exploration with irrigation and debridement L3 L/4 left, with dural leak repair and e.pidural blood patch.
On April 11, 2007, Respondent performed a re-exploration with
irrigation and debrldement L3 L/4 left, with dur.al leak repair and epidural blood patch.
- - - - - - 2-4.---.On-APf-U-13, 2007, Respondent performed a re-explorati irrigation and debridement L3 L/4 left, with dural leak repair and epidural
blood patch.
25. On April 24, 2007, Respondent performed a re-exploration with Irrigation and debrldement L3 L/4 left:, with dural leak repair.
26 on May 3, 2007, Respondent pelformed a re-exploration and evacuation of cerebral spinal fluid from cyst L3 l/4 left.
On May 23, 2007, Respondent performed a re-exploration with inclsio"n and drainage of a meningocele and platelet gel patch insertion L3 L/4 left:.
Despite nine (9) attempts to do so, Respondent was unable to
repair the dural leak at L3/L4 left that he first attempted to repair on February 20 2007.
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Despite the foregoing, Respondent failed to refer SM to a neurosurgeon after failing on the second or third attempt to repair the dural leak.
Despite the .foregoing, Respondent failed to refer SM to a hospital for appropriate follow up and care.
Respondent's initial surgical plan induded two separate·
,sur.gedes-f or:-tbe- piecemeal removal of---1:De hardware and repea_ _ _foraminotomies, induding one at L4-5 on SM's right, despite the fact that according to the initial evaluation this was not where SM symptomatic.
Respondent's medical records and diagnosis were contraindicated by the MRI performed at Respondent's clinic in ·that It did· not show a medical condition capable of being remedied by surgery.
The subsequent surgeries Involving re-exploration of L/3 L/4 indicated Iatrogenic instability at that level of the lumbar spine (an adverse physical condition caused by the effects of Respondent's prior surgical treatment), but Respondent failed to note the cause of these iatrogenic changes In SM's medical record.
Ultimately, SM consulted with an independent orthopedic surgeon and underwent two (2) additional cervical and lumbar spine surgeries to address her continuing pain and the repair of her dural leak.
COUNT ONE
Paragraphs 1 through 34 are adopted and realleged as though fully set forth herein.
Section 458.331(1)(t), Florida Statutes (2006, 2007), provides that .committing medical malpractice constit es grounds for disciplinary action by the Board of Medicine.
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Statutes (2006, 2007)! as the failure to practice medicine in accordance with the level of care, skill, and treatment recognized in general law related to health care licensure. For purposes of Section 458.331(1)(t), Ronda Statutes (2006, 2007), the Board shall give great weight to the provisions of Section 766.102, Florida Statutes (2006, 2007), which provide that the
prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers.
Respondent failed to practice medicine with the level of care, skill, and treatment which, In light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably p udent similar health care providers in one or more of the following ways:
By misdiagnosing the cause of SM's lumbar pain;
By failing to accurately Interpret the MRI scan of SM's lumbar spine;
By erroneously conduding that SM had a clinical condition
that could reasonably be resolved by the treatment plan involving surgical removal of the hardware at L3/L4 and
I' LS·I·
By failing to have a surgical plan that would resolve SM's lumbar pain in a reasonable manner and which would benefit SM without causing further injury to her or aggravate any pre-existing condition;
By falling to consider the possibility of Iatrogenic injury
and by failing to prevent iatrogenic injury by performing thirteen (13) surgeries between November 9, 2006
through May 3, 2007;
By inadequate surgical technique in the performance of the surgeries referred to herein between November 9, 2006 through May 3, 2007;
By failing to plan an efficient and reasonable means of resolving SM's pain;
By failing to refer SM to a neurosurgeon after his second or third unsuccessful attempt at dural leak repair;
By failing to refer her to a hospital to undergo an open approach in the surgical repair of the dural leak;
By persisting in performing eight (8) additional unsuccessful surgeries in an attempt to repair a dural leak
- - - - - - - - - ------ itheut the skiWaining or ability to do so;
Based on the foregoing, Respondent has violated Section 458.331{1)(t), Florida Statutes {2004-2007).
COUNTTWO
Paragraphs 1 through 34 are adopted and realleged as though fully set forth here.
·41. section 458.331{1)(m), Florida Statutes (2006, 2007), provides
that failing to keep legible, as defined by department rule In consultation with the board, medical records that, among other things, 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, is grounds for discipline by the Board of Medicine.
Respondent failed to keep legible medical records that justify the course of treatment of the patient in one or more of the following
ways;
By falling to adequately document reasoning or· justification for perfonning the surgical procedures on SM
between November 9, 2006 and May 3, 2007;
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February 20, 2007 when Respondent first punctured SM's dura;
c) By failing to record the basis for proceeding with eight (8) more attempts at dural leak repair using the same approach and technique.
Based on the foregoing, Respondent has violated Section 458 331(1)(m), Florida Statutes (2006, 2007), by failing to keep legible, as defined by department rule in consultation with the board, medical records that, among other things, 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.
WHEREFORE, the Petitioner respectfully requests that the Board of Medicine enter an order imposing one or more of the following penalties: permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the
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SIGNED this L day of _ ..""-=, - .-...P""'--A.&(' ..-.. , 2012.
John H. Armstrong, MD State S...r- ....n General and
of Health
-o bert • ilne
Assistant General Counsel Florida Bar # 622338
DOH Prosecution Services Unit 4052 Bald Cypress Way-Bin C-65 Tallahassee, Florida 32399-3265
(850) 245-4640 Office
(850) 245-4681 Facsimile
w:
PCP Date: C\ I c l lz. · ,
PCP Members: "'c.-hes+ , -r},.-twls.
NOTJCE OF RI GHTS·
Respo dent has the right to request a hearing to be
. conducted in accorda ce with Section .1 "20 .5 69 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or his behalf if a hearing·is requested.
NOTICE REGARDING ASSESSMENT OF COSTS
Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of
this matter. Pursuant to Section 456.072{4), Florida statutes, the Board shall assess costs related to. the investigation and prosecution of a disciplinary matter, which
may include attorney hours and costs, on the Respondent in addition to any other discipline imposed. ·
