STATE OF FLORIDA DEPARTMENT OF HEALTH
DEPARTMENT OF HEALTH,
Petitioner,
V. DOH CAS-E NO.: 2008-12432
ALFRED 0. BONATI, M.D.,
Respondent.
ADMINISTRATIVE COMPLAINT
Petitioner, Department of Health, by and through undersigned counsel files this Administrative Complaint before the Board of Medicine against Respondent, Alfred 0. Bonati, M.D., and in support thereof alleges:
Petitioner is the state agency 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 not board certified in Orthopaedic Surgery.
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 7315 Hudson Avenue, Hudson, Florida, 34667-1158.
On or about August 25, 2005, Patient JLR, a 58-year-old female, presented to the Gulf Coast Orthopedic Center (''Gulf Coast'') at the above-mentioned address in Hudson, Florida, complaining of lower back pain and bilateral leg pain. Respondent is the founder and chief orthopedic surgeon at Gulf Coast and Patient JLR's orthopedic surgeon.
Upon Patient JLR's presentation to Gulf Coast, Mr. KC, Respondent's advanced registered nurse practitioner associate at Gulf Coast, evaluated Patient JLR and offered an initial impression of lumbar spine pain with symptoms of radiculopathy, rule out ·lumbar disc disease and spinal stenosis.
KC set forth a treatment plan to have Patient JLR undergo an MRI scan and x-rays of the lumbar spine, a nerve conduction evaluation, and evaluation by a surgeon.
The Gulf Coast radiology MRI report dated August 25, 2005, revealed no disc bugle or significant central spinal stenosis and patent neural foramina at the L3-4 level; loss of disc hydration, disc bulge,
spondylosis, bilateral facet arthroplasty, and bilateral foramina stenosis at the L4-5 level; and patent neural foramina at the LS-S1 level.
Neural foramina are spaces between the vertebrae where nerve roots exit the spinal canal. These spaces sometimes narrow (stenosis), causing irritation to the nerve. The term "patent" describes unobstructed neural foramina.
On or about August 29, 2005, Patient JLR presented to Respondent at Gulf Coast for an evaluation. At that time, Respondent reviewed the August 25, 2005, diagnostic images and diagnosed a laminectomy defect at the LS-S1 spinal segment; foraminal narrowing at the L3-4, L4-5, and L5-S1 spinal segments; degenerative facet syndrome at the L4-5 and LS-S1 spinal segments; scar tissue at the L4-5 and LS-51 spinal segments; and nerve impingement at the L3-4 and L4-5 spinal segments.
. 11. Respondent set forth a course of treatment to have Patient JLR undergo diagnostic facet injections on the left L4-5 and LS-S1 spinal segments and, assuming Patient JLR obtained relief, subsequently undergo bilateral L4-5 and L5-S1 microsurgical debridement of the facet joints with rhizolysis.
Facet joints are the articulations or connections between the vertebrae in the spine that enable the bending or twisting movements of the spine, which may become inflamed secondary to injury or arthritis and cause pain and stiffness. Rhizolysis is a surgical procedure that utilizes radiofrequency to produce an irreversible destructive lesion of the medial branch nerve, which blocks the passage of painful messages from the affected facet joint to the rest of the central nervous system.
On or about September 14, 2005, Patient JLR presented to Dr.
KG, Respondent's associate at Gulf Coast, for the diagnostic facet injections on the left L4-5 and L5-S1 spinal segments.. Dr. KG diagnosed bilateral facet joint syndrome at the L3-4, L4-5, and LS-Sl spinal segments.
On or about September 15, 2005, Patient JLR presented to Dr.
JW, Respondent's associate at Gulf Coast, to undergo microsurgical debridement with rhizolysis of the facet joints at the L3-4, L4-5, and L5-S1 levels, with arthrotomy with thermocoalgulation of the dorsal rami innervating the facet joints at the L3-4, L4-5, and L5-S1 levels.
Arthrotomy with thermocoagulation of the dorsal rami is the incision into the joint in order to congeal the tissues of the branches of the spinal nerves.
On or about September 21, 2005, Patient JLR presented to Respondent with complete resolution of her back and buttock pain, but complained of "surgical pain only" and pain in her left leg. Medical records indicate that JLR denied any incontinence of bowel or bladder.
Respondent reviewed Patient JLR's MRI images from August 25, 2005, and diagnosed foraminal narrowing, post-operative changes with scar tissue, and bilateral nerve impingement at the L4-5 level.
Later that day, Respondent performed L4-L5 arthroscopic re exploration with foraminotomy, partial facetectomy, perineurectomy, and laminectomy scar debridement to further decompress the nerve and relieve JLR's symptoms.
A foraminotomy is the removal of bone or tissue in an effort to enlarge one or more neural foramina, which alleviates pressure and irritation of the nerve root. A partial facetectomy is the removal of 1/3 to 1/2 of the medial facet joint in order to decompress the nerve root. A perineurectomy is the surgical removal of neural scar tissue that can cause narrowing of the spinal canal and press against nerve roots. Often, scar tissue results from previous back surgeries. A laminectomy (decompression) involves the removal of a portion of the bony arch, or
lamina, on the dorsal surface of a vertebra that covers the spinal canal. The laminectomy is typically performed to enlarge the spinal canal and relieve pressure on the spinal cord and nerve roots caused by spinal stenosis (narrowing).
During the L4-5 re-exploration and laminotomy performed by Respondent on or about September 21, 2005, Respondent punctured Patient JLR's dura, which is a watertight sac of tissue that covers and protects the spinal cord and the spinal nerves, resulting in a dural leak of cerebrospinal fluid. The possibility of a dural tear increases with repeated spinal surgeries.
On or about September 22, 2005, Patient JLR received an in home, post-operative follow-up evaluation. At that time, Patient JLR stated that her pre-surgical pain was resolved, but complained of headache, vomiting, and nausea.
Medical records indicate that Patient JLR was utilizing a Foley catheter for urination and suppositories. However, medical records do not indicate a justification for the use of the Foley catheter, the nature of the patient's complaints of headache, nausea, and vomiting, or the patient's use of suppositories.
On or about September 23, 2005, Patient JLR received an in home, post-operative follow-up evaluation. At that time; Patient JLR stated that her headache was mild and improved. Medical records indicate that Patient JLR was still utilizing a Foley catheter to drain urine.
A "late entry" in Patient JLR's medical records indicate that on or about September 25, 2005, Patient JLR discontinued the use of the catheter, was unable to void urine, and contacted Gulf Coast by telephone, at which time she was instructed to present to the emergency department of a hospital for catheter reinsertion. At this time, Patient JLR also informed an associate of Gulf Coast of numbness in her rectal area.
On or about September 26, 2005, Patient JLR presented to Respondent at Gulf Coast for a follow-up evaluation with complaints of bilateral pain in her lower-mid buttocks and numbness. In particular, Respondent's medical records state, in part:
... The patient states that the pain felt affecting the LS nerve root on the left side is totally resolved; however, she continues to have some pain in the lower mid buttocks bilaterally. The patient has some perirectal numbness that she did not have prior to surgery. Dr. Bonati stated that was (sic) possibly from injury to the nerve and may resolve within time. ...
Medical records indicate that Respondent reviewed a post operative x-ray and MRI to confirm the correct level of the procedure, to
determine that the surgical site was free of bone fragments, to confirm the resection of tissue, and complete decompression. However, the records do not indicate that Respondent ordered or reviewed any diagnostic imaging related to the possible injury to Patient JLR's nerve.
Respondent's medical records indicate that JLR continued to utilize an indwelling Foley catheter, however, the record·s fail to document the date or justification for the catheter insertion; fail to indicate that Respondent assessed Patient JLR's removal of the catheter, urinary retention, and presentation to the hospital for reinsertion of the catheter the day before. In addition, Respondent's medical records erroneously · indicate that the patient denied bowel dysfunction.
On or about September 26, 2005, Patient JLR presented to Dr.
LL, Respondent's associate at Gulf Coast for a follow-up neurological consultation. Medical records indicate that Dr. LL diagnosed urinary retention but no "new deficits postoperatively."
Medical records for Patient JLR indicate that the patient left Gulf Coast on or about September 26, 2005, after several days of bed rest and was unable to void her urine.
Medical records indicate that an individual from Respondent's office contacted Patient JLR on or about September 30, 2005, at which time the patient stated that she continued to suffer from urinary retention, continued to utilize the Foley catheter to void urine, and continued to have numbness in the perianal area. In addition, Patient JLR stated that she had been constipated and unable to have a bowel movement and had taken several laxatives resulting in stool incontinence. Patient JLR also stated that she would follow-up with her primary care physician.
Patient JLR's symptoms indicate Cauda Equina Syndrome, which is the compression of the nerve roots that extend below and branch off from the bottom of the spinal cord. Cauda Equina Syndrome is a serious condition, and the possibility of a positive outcome and regaining one's normal function is dependent upon how quickly remedial surgical efforts are commenced.
On or about October 5, 2005, an associate from Respondent's office contacted Patient JLR regarding her recovery. At that time, Patient JLR stated ttiat she continued to retain urine; utilized a straight catheter as needed to void urine; continued to have numbness in her vaginal area; continued to feel numbness in the rectal area; felt weak in the perianal
area; and continued to have pain her legs and hips. Medical records indicate that Respondent's associate would inform Respondent of Patient JLR's continued complaints.
On or about October 13, 2005, an associate from Respondent's
office contacted Patient JLR regarding her recovery. At that time, Patient JLR stated that she continued to retain urine; utilized a catheter four to five times per day in order to void urine; continued to have difficulties with bowel movements, requiring the use of suppositories and ·enemas in order to have bowel movements at least twice per week; continued to have numbness in the perianal area; was unable to feel the insertion of the catheter; and was nauseated and vomiting. Medical records indicate that Respondent's associate discussed Patient JLR's continued complaints with Respondent.
On or about November 7, 2005, an associate from Respondent's office contacted Patient JLR regarding her recovery. At that time, Patient JLR stated that she continued to retain urine; continued to utilize a catheter four to five times per day in order to void urine; and continued to have numbness in the perianal area.
COUNT ONE
Petitioner realleges and incorporates Paragraphs 1 through 34, as if fully set forth herein.
_ Section 458.331(1)(t), Florida Statutes (2005), subjects a physician to discipline for committing medical malpractice as defined in Section 456.50, Florida Statutes. Medical malpractice is defined in Section 456.50, Florida Statutes, 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), Florida Statutes (2005), the board shall give great weight to the provisions of Section 766.102, Florida Statutes (2005), 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 meet the prevailing standard of care in
regard to Patient JLR in one or more of the following ways:
Respondent failed to order a post-operative MRI subsequent to Patient JLR's surgery on or about September 15, 2005;
Respondent reviewed Patient JLR's MRI dated August 25, 2005, rather than an up-to-date MRI prior to performing the surgery on or about September 21, 2005;
Respondent performed surgery on Patient JLR on or
about September 21, 2005, despite Patient JLR complaining of post surgical pain, only;
After the surgery performed on or about September 21, 2005, Respondent failed to adequately follow up with Patient JLR;
After the surgery performed on or about September 21, 2005, Respondent failed to adequately assess Patient JLR's complaints;
After the surgery performed on or about September 21, 2005, Respondent failed to consider that Patient JLR may have suffered from cauda equina syndrome;
After the surgery performed on or about September 21, 2005, Respondent failed to order an MRI to specifically evaluate Patient JLR's possible nerve damage and complaints of urine retention, numbness, and bowel dysfunction; and/or
Respondent failed to initiate or refer Patient JLR to undergo emergency surgery after the procedure performed on or about September 21, 2005.
Based on the foregoing, Respondent has violated Section 458.331(1)(t)l., Florida Statutes (2005), by committing medical malpractice.
COUNT TWO
Petitioner realleges and incorporates Paragraphs 1 through 34, as if fully set forth herein.
Section 458.331(1)(m), Florida Statutes (2005), 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.
Respondent failed to keep legible medical records of Patient JLR in one or more of the following ways:
By failing to adequately justify the procedure performed
on or about September 21, 2005;
By failing to document the date of or justification for the catheter insertion;
By failing to document the nature of the patient's complaints of headache, .naus ea, and vomiting, or the patient's use of suppositories subsequent to the September 21, 2005, procedure;
- d. By failing to document Respondent's assessment of Patient JLR's removal of the catheter, urinary retention, and presentation to the hospital for reinsertion of the catheter, on or about September 26, 2005;
By erroneously documenting that Patient JLR denied bowel dysfunction on or about September 26, 2005;
By failing to document conversations with his medical associate regarding the telephone follow-up consultation with Patient JLR performed on or about October 5, 2005; and/or
By failing to document conversations with his medical associate regarding the telephone follow-up consultation with Patient JLR performed on or about October 13, 2005.
Based on the foregoing, Respondent has violated Section
458.331(1)(m), Florida Statutes (2005), by failing to keep legible medical records medtcal 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.
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.
SIGNED this @ "f"_,,day o-f - -,
c; _r·-_
_,, 2011.
H. Frank Farmer, Jr., MD, PhD, FACP State Surgeon General
Assistant General Counsel Florida Bar # 622338
- - -- ··
Gavin D. Burgess Assistaht General Counsel Florida Bar# 013311
DOH Prosecution Services Unit 4052 Bald Cypress Way-Bin C-65 Tallahassee, Florida 32399-3265
(850) 245-4640 Office
(850) 245-4681 Facsimile
PCP Members: El-Bahri, Nuss, Mullins PCP: August 26, 2011
DOH vs. Alfred 0. Bonati, M.D. DOH CASE NO.: 2008-12432
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_ invest igat ion 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.
