Jun 18 2008 15:51 Jun 18 2008 14:49 P.03 ‘gee’ an fon S STATE OF FLORIDA DEPARTMENT OF HEALTH | DEPARTMENT OF HEALTH, PETITIONER, 3 v. CASE NO.: 2007-28124 ‘DONALD J. MOYER, M.D., RESPONDENT. / - -ADMINISTRATIVE COMPLAINT Petitioner, Department of Health, by and through its undersigned counsel, files this} Administrative Complaint before the Board of Medicine against Respondent, Donald J. Moyer, M.D., and in support thereof alleges; 1. | Petitioner is the state department charged with regulating the practice df medicine pursuant to Section 20.43, Florida Statutes, ‘and Chapters 456 and 458, Florida Statutes, 2. | At all times material to this Complaint, Respondent was a licensed 3. | Respondent’s address of record is 12700 Creekside Lane, Suite 101, Fort Myers, Florida 33919, 8002 TO AW Jun 18 2008 15:51 Jun 18 2008 14:49 P. O04 ae 7 At all times material hereto, Respondent practiced medicine at Cape 5. | Respondent is certified by the American Board of Neurological Surgery 6. | Patient S.G. was seventy years old when her MRI results showed evidence of a left L4-5 disc herniation, A disc herniation is a medical condition affecting the spine in which a tear in the outer, fibrous ring of a dis allows the soft, centrbl portion to extrude out, Arrangements were made for Patient $.G. to be admitted into the Cape Cora| Hospital, in Cape Coral, Florida, on June 25, 2007, fora left-sided 14- 2 microerldoscopic diskectomy, Microendoscopic diskectomy is a surgical procedure |which directly deals with the offending extruded disc fragment and decompresses the nerve root. | Patient S.G. was admitted into the Cape Coral Hospital on June 25, 2007, whefe she signed a consent form authorizing Respondent to perform a “Left L4-5 Micro Endoscopic Discectomy.” | 9. [Upon admission, $.G. had a history and physical examination DOH v, Donald J. Mdyer, M.D. 2 Case Number 2007-P8124 : 3:\PSU\Medical\MargGXx\Cases\Moyer, Donald 2007-28124\AC,doc Jun 18 2008 15:51 Jun 18 2008 14:50 P.O5 ‘aw! ae! was to have a “Left sided L4-5 microendoscopic diskectomy” to be performed by Respondgnt on June 25, 2007. | 10.) The admission/pre-procedure history and physical report recorded the indication as “L [circled] Lower extenuatory pain posteriorly to calf,” and the planned procedure as “Left microendoscopic discectomy L4L5.” | i1.] The neurosurgical pre-procedure order indicated a diagnosis of “Disc Herniation L [circled] L4-5,” and that the patient had consented to the procedure “L [circled] L4-5 MED,” , 12.]| The operative nurse’s notes indicate a pre-op diagnosis of “left L4-5 a“ herniated Idisc. 13. | Prior to start of the procedure a “time out” was Performed and all personneltin-the-operating-room-agreedthat-the surgical-procedure-about to be performed was scheduled for the left side of the patient. A “time out” is a final check to make sure that the correct patient is about to undergo the correct procedure] on the correct site. | ~ao.o4.. -hen-Respondent:started the-procedyre he stood at the right side of . and performed surgery on her right side. | Patient S. DOH v. Donald J. Case Number 2007-28124 . 3:\PSU\Medical\MafrGXx\Cases\Moyer, Donald 2007-28124\AC. doc Jun 18 2008 15:51 Jun 18 2008 14:50 P. O06 ‘ww ‘ew! 15.) Respondent’s operative report indicates that he performed a “Bilateral |L4-5 Microendoscopic Hemilaminectomies and Extensive Foraminotomy and Left 4-5 Microdiskectomy.” : 16.| No where in the medical records is there any evidence that Patient 5,G. consented to surgery on her right side. | 17.| No where in the medical records is there any evidence that Patient 5.G. was} diagnosed pre-operatively with any condition | that would warrant surgery oh her right side. 18.| No where in the medical records is there any explanation of why Respondent performed a surgical procedure other than the one consented to by Patient S.f. : 19. -Ne-where-in-the medical records-is-there-any-documentation-of any examinatipn or test results which formed the basis for performing surgery on the right side jof Patient S.G. 20. | No where in the medical records is there any explanation of why -Respondeht=performed:a-surgical procedure other than the one indicated to be DOH v. Donald J. Moyer, M.D. 4 Case Number 2047-28124 : 1:\PSU\Medical\MerrGX\Cases\Moyer, Donald 2007-28124\AC.doc Jun 18 2008 15:52 Jun 18 2008 14:50 P.O? ger! ‘oe COUNT ONE 21,| Petitioner realleges and incorporates paragraphs one (1) through twenty (2D), above, as if fully set forth herein. ! 22.| Section 456.072(1)(bb), Florida Statutes (2006), subjects a licensee to discipline for 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 patient's diagnosis or medical condition. 23. | Respondent performed a wrong-site procedure, a wrong procedure, or an unauthorized procedure or a procedure that is medically unnecessary or otherwise |unrelated to the patient's diagnosis or medical condition on Patient -—-§.G;-i9-on¢-ormore-of-the-fallewing-ways:——- en ee | a. By performing a procedure on the wrong site; : b. By performing a procedure without the patient's written authorization; and, : -—-By-performing:a-procedure-unrelated.to the patient’s-diagnosis of Left L 445 Disc Herniation, DOH v. Donald J. Case Number 2004-28124 J:\PSU\Medical\MaprGx\Cases\Moyer, Donald 2007-281 24\AC.doc Jun 18 2008 15:52 Jun 18 2008 14:50 P. 08 Nee’ ‘uel? 24.| Based on the foregoing, Respondent violated Section 456.072(1)(bb), Florida Statutes (2006), by performing or attempting to: perform health care services qn the wrong patient, a wrong-site procedure, a wrong procedure, or an unauthorized procedure or a procedure that is medically urfnecessary or otherwis4 unrelated to the patient's diagnosis or medical condition. | COUNT TWO 25.| Petitioner realleges and incorporates paragraphs one (1) through twenty (20), above, as if fully set forth herein. | 26.| Section 458.331(1)(m), Florida Statutes (2006), subjects a licensee 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 nder-and-supervising-physieian-by-name-and-professionai-title who responsible for rendering, ordering, supervising, or billing for each consultations and hospitalizations. DOH v. Donald J] Mayer, M.D. / 6 Case Number 2407-28124 J:\PSU\Medical\MarrGx\Cases\Moyer, Donald 2007-28124\AC.doc Jun 18 2008 15:52 Jun 18 2008 14:51 P.09 Nowe! : “ee! 27, Respondent failed to maintain adequate medical records in one or more of tne following ways: : a. By failing to maintain medical records that contain an adequate documentation of the examination and test results which formed the basis of the surgical procedure performed on the Right 14-5 segment of Patient S.G/s lumbar spine; : b. By failing to maintain medical records that contain an adequate doctmentation or explanation of why a surgical procedure performed on Patient S.G. was inconsistent with the consent which had been obtained from her; and, , | c. By failing to maintain medical records that contain an adequate ———decumentation-orexplanation-of why a surgical procedure performed on | Patient $.G. was inconsistent with her documented diagnosis. 28.| Based. on. -the foregoing, - Respondent has violated Section 458.331(1)(m), Florida Statutes (2006), by failing to keep legible, as defined by department ruletin-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, DOH v. Donald J. Moyer, M.D. Case Number 2007-28124 J:\PSU\Medical\NarrGXx\Cases\Moyer, Donald 2007-28124\AC.doc Jun 18 2008 15:52 Jun 18 2008 14:51 P.10 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. WHEREFORE, Petitioner respectfully requests that the Board of Medicine enter an|Order imposing one or more of the following penatties: 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 bled or collected, remedial education ener any other relief that the Board deems appropriate SIGNED this-25 day of April, 2008. Ana-M-Viamonte-Ros;M.D-- MPH, ~ State Surgeon General | j , whee ti Tian GregS. Marr : Assistant General Counsel . DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 a — Fallahassees-Fl-32399-3268=-: Florida Bar No.: 131369 (850) 245-4640 Ext. 8145 © (850) 245-4681 Facsimile _ DOH v. Donald J] Moyer, M.D. 8 Case Number 2007-28124 3:\PSU\Medical\arrGX\Cases\Moyer, Donald 2007-28124\AC.doc Jun 18 2008 15:53 Jun 18 2008 14:51 P.11 ‘ewe’ al | e: Donald 3. Moyer, M.D. Case No. 2007-28124 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 poena and subpoena duces tecum issued ¢ on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF costs *R pondent 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. | oo pen i ara —- | DOH v, Donald. Moyer, M.D. 9 Casé Number 2007-28124 J:\PSU\Mediea\MarrGX\Cases\Moyer, Donald 2007+28124\AC.doc

Docket for Case No: 09-000992PL