STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH, PETITIONER, v. CASE NO.: 2012-05878 AJAZ AFZAL, M.D., RESPONDENT. en | COMES NOW, Petitioner, Department of Health, by and through its undersigned counsel, and files this Administrative Complaint before the Board of Medicine against the Respondent, Ajaz Afzal, M.D., and in support thereof alleges: 1. 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. . 2 At all times material to this Complaint, Respondent was a licensed physician within the State of Florida, having been issued license number ME 95168. 3. Respondent’s address of record is 1030 Mann Street, Kissimmee, Florida 34741. 4. At all times material to this Complaint, Respondent was certified by the American Board of Internal Medicine and was registered as a dispensing practitioner. 5. On or about December 28, 2008, at around 7:45 p.m., Patient E.J., a 56 year-old female, was transported via ambulance to the emergency department of Osceola Regional Hospital in Kissimmee, Florida, _ in severe distress due to pain. 6. In the emergency department, Patient E.J.’s chief complaint was right flank and back pain starting and worsening over the last three days, a pain level of 10 on a scale of 1 to 10, and a history of chronic back pain but stating that this pain was different. 7. During the night of December 28, 2008, the ER physician noted Clinical indications of R/SPE and right flank pain, consulted with infectious disease and pain management specialists, ordered pain medications, ordered Rocephin and Zithromax (oral antibiotics), and ordered blood cultures and other laboratory and diagnostic tests. DOH v. AFZAL, P.A., Case Number 2012-05878 Page 2 of 14 8. Dr. S.S., an infectious disease consultant, noted that Patient E.J.'s blood cultures were pending and should be followed, her white blood count should be monitored, and her blood cultures should be repeated if her temperature spiked. 9. On or about December 29, 2008, at about 2:54 am., Respondent admitted Patient E.J. to the hospital with a diagnosis of back pain and atypical pneumonia. 10.. For the history and physical, Respondent noted that Patient E.J. had a history of “chronic back pain with spinal stenosis, but this pain is different” and noted “discomfort in the right flank area.” 11. Respondent failed to assess the type or location of Patient E.J.’s pain and failed to assess the visual presentation of the painful area. . 12. Respondent failed to assess whether Patient E.J.’s pain was localized at a specific vertebral body which could be suspicious for abnormal pathology. | . 13. Respondent failed to adequately assess Patient E.J.’s condition by failing to perform a complete physical examination of the thoracic spine, or failed to document such action. DOH v, AFZAL, P.A., Case Number 2012-05878 . Page 3 of 14 14. At around 4:00 a.m., Patient E.J.’s temperature was 99.3. At around 8:10 a.m., her temperature was 100.2. 15. Patient E.J. underwent a thoracic spine x-ray, a CT of the abdomen and pelvis, and a CTA of the chest. The tests were negative for any acute changes. ) 16. At around noon, due to Patient E.J.’s continuing severe back pain, she was transferred to the intensive care unit for pain management. 17. At about 12:30 p.m., Patient E.J.‘s temperature was 99.1. At about 12:40 p.m., it was 99.8. 18. Respondent failed to perform adequate diagnostic testing by failing to order an MRI of Patient E.J.’s thoracic spine, or failed to document such actions. 19. Respondent failed to obtain adequate consultation with specialists by failing to consult with a spine specialist or neurosurgeon, or failed to document such actions. 20. Notes ona lab sticker, dated December 30, 2008, indicate that Patient E.J.’s blood culture revealed an infection, specifically, “blood culture gram (+) cocci” (“Staphylococcus aureus”). \ DOH v. AFZAL, P.A., Case Number 2012-05878 : Page 4 of 14 21. The lab sticker indicates that Respondent was called at 7:34 a.m. regarding the lab results and that Respondent called back at 7:34 a.m. The lab sticker indicates that the “action” on the blood culture results was “no order received” from Respondent. 22. “Staphylococcus aureus” (referred to as “S. aureus” or “Staph aureus”) is a bacterium that is a facultative anaerobic Gram-positive coccal bacterium. Depending upon the type of infection present, an appropriate specimen is obtained and sent to the laboratory for definitive identification. A Gram stain is first performed and will show a typical Gram-positive . bacteria, cocci, in clusters. Second, the isolate is cultured on a selective medium that allows Staph aureus to grow. 23. After the presence of bacteria is identified in a blood culture, additional time is necessary to grow out and identify the bacterial species and even more time to determine the sensitivities of the bacterial species, Appropriate antibiotic therapy cannot be determined from the initial blood culture results. 24, On or about December 30, 2008, at around 11:00 a.m., Respondent advised Patient E.J.’s nurse that he would not discharge the DOH vy. AFZAL, P.A., Case Number 2012-05878 . Page 5 of 14 patient until after Dr. S.S. discharged her first from ICU; otherwise, the patient could sign out Against Medical Advice. 25. At around 2:00 p.m., Patient E.J.’s nurse advised Dr. S.S, that the patient wished to be discharged and that her temperature in the morning had been 100.6 but presently was 98.8. 26. Dr. S.S. advised Patient E.J.’s nurse that the patient could be discharged home if Respondent were available to provide an antibiotic prescription; otherwise, the patient would have to sign out Against Medical Advice. 27. At around 6:59 p.m.,. nursing notes indicate that Patient E.J, was discharged by Respondent and that: “vitals within normal. But temp is 99.4. Patient claims she will take Tylenol at home.” 28. Respondent noted on Patient E.J.’s discharge summary that the patient's final diagnoses were: 1. back pain from muscle spasm; 2. possible urinary tract infection; 3. Azelectasis with possible bilateral parenchymal - disease; and, 4. history of chronic back pain, spinal stenosis and other conditions. 29. The discharge summary contains no mention of Patient E.J.’s blood culture results. DOH v. AFZAL, P.A., Case Number 2012-05878 Page 6 of 14 30. The discharge instructions advise Patient E.J. to follow up with her primary care physician in 1-2 weeks. 31. Respondent discharged Patient E.J. with a prescription for Levaquin 500 mg po daily x7 days to treat her possible pneumonia. 32. Levofloxacin (called Levaquin in the U.S.) is a broad spectrum antibiotic. Numerous pathogens including Staphylococcus aureus now exhibit resistance worldwide. 33. The minimum standard of care for treatment of Staphylococcus aureus requires sensitivity and identification testing and the use of specialized and targeted antibiotics. 34. Respondent failed to adequately assess Patient E.J.’s condition by failing to obtain the results of the blood culture before discharging Patient E.J., or failed to document such action. 35. Respondent failed to adequately diagnose Patient E.J.’s condition before discharging Patient E.J., or failed to document such ~ action. 36. Respondent failed to develop an adequate treatment plan for Patient E.J.: . DOH v. AFZAL, P.A., Case Number 2012-05878 Page 7 of 14 (a) By failing to order appropriate antibiotic sensitivity and identification testing before discharging Patient E.J., or failing to document such action. (b) _ By failing to prescribe appropriate antibiotic medication to treat Patient E.J.’s Staph aureus infection, or failing to document such action. (c) _ By failing to advise Patient E.J. of the risks of leaving the hospital without knowing the results of her blood culture, or failing to document such advice. (d) By failing to advise Patient E.J. that she had a Staph aureus infection after learning of the results of her blood culture, or failing to document such action. 37. A reasonably prudent physician practicing within the prevailing standard of care and treating a patient with continuing fever and extreme back pain with negative CT results would have performed a complete - examination of the thoracic spine, would have ordered an MRI of the thoracic spine, and would have consulted with a spine specialist or neurosurgeon. DOH v. AFZAL, P.A., Case Number 2012-05878 Page 8 of 14 38. A reasonably prudent physician practicing within the prevailing standard of care and treating a patient with continuing fever and extreme back pain with negative CT results and pending blood culture tests, would have obtained the results of the blood culture before discharging the . Patient, would have adequately diagnosed the patient, would have obtained the results of the blood culture before discharging the patient; would have ordered appropriate antibiotic sensitivity testing before discharging the patient, and would have ordered appropriate treatment for the patient based on the blood culture results. 39. A reasonably prudent physician practicing within the prevailing standard of care and treating a patient with continuing fever and extreme back pain with negative CT results and pending blood culture tests, would have advised the patient of the risks of leaving the hospital without knowing the results of her blood culture and, after learning the results of the blood culture, would have advised the patient that she had a Staph aureus infection and needed immediate treatment. COUNT I 40. Petitioner re-alleges and incorporates Paragraphs One (1) through Thirty-Eight (38), as if fully set forth herein. OOH v, AFZAL, P.A., Case Number 2012-05878 Page 9 of 14 41. Section 458.331(1)(t), Florida Statutes (2008), subjects a physician to discipline for committing medical malpractice as defined in Section 456.50. “Medical malpractice” is defined by Section 456.50(1)(q), Florida Statutes (2008), 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.” 42. ‘Section 456.50(1)(e), Florida Statutes (2008), provides that the “level of care, skill, and treatment recognized in general law related to health care licensure" means the standard of care that is specified in Section 766.102, Florida Statutes, as follows: 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. 43. Respondent failed to meet the prevailing standard of care with regard to Patient E.J. in one or more of the following ways: a) _ By failing to adequately assess the patient; and/or ‘b) By failing to order adequate diagnostic testing; and/or c) By failing to obtain adequate consultation with specialists; and/or , DOH v. AFZAL, P.A., Case Number 2012-05878 Page 10 of 14 d) By failing to adequately diagnose the patient; and/or e) By failing to develop an adequate treatment plan. 44. Based on the foregoing, Respondent violated Section 458.331(1)(t), Florida Statutes (2008). COUNT It 45. Petitioner re-alleges and incorporates Paragraphs One (1) through Thirty-Eight (38), as if fully set forth herein. 46. Section 458.331(1)(m), Florida Statutes (2008), subjects a physician to discipline for 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. DOH v. AFZAL, P.A., Case Number 2012-05878 - Page 11 of 14 47. Respondent failed to maintain adequate medical records that justified the course of treatment for Patient E.J. in one or more of the following ways: a) By failing to document adequate assessment; and/or . b) By failing to document adequate diagnostic testing; and/or c) By failing to document consultation with appropriate specialists; and/or d) By failing to document an adequate diagnosis; and/or e) By failing to document development of an adequate treatment plan. 48. Based on the foregoing, Respondent violated Section 458.331(1)(m), Florida Statutes (2008). 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 Board deems appropriate. DOH v. AFZAL, P.A., Case Number 2012-05878 Page 12 of 14 SIGNED this 21st day of June, 2013. John H. Armstrong, MD, FACS, FCCP State Surgeon General & Secretary of Health, Sta “of Florida —_, Sy He — litur { taufa L. Glenh (S Assistant General Counsel Fla. Bar No. 0861413 FILED Florida Department of Health OF HEALTH Pp OEP ART TUTY CLERK Office of the General Counsel CLERK Angel Sanders 4052 Bald Cypress Way, Bin C-65 pate JUN 2.4 2013 Tallahassee, Florida 32399-3265 Telephone: (850) 245-4444, Ext. 8117 Facsimile: (850) 245-4684 Email: Laura_Glenn@doh.state.fl.us LLG © PCP Date: 6/21/2013 PCP Members: Dr. Avila, Dr. Averhoff, Mr. Dyches - GOH v. AFZAL, P.A., Case Number 2012-05878 Page 13 of 14 AJAZ AFZAL, M.D. CASE NO.: 2012-05878 NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 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 her 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 any other discipline imposed. DOH v. AFZAL, P.A., Case Number 2012-05878 Page 14 of 14

Docket for Case No: 13-003344PL