STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH, Petitioner, v. CASE NUMBER 2010-09252 ALFRED O. BONATI, M.D., Respondent. ee ADMINISTRATIVE COMPLAINT Petitioner, Department of Health , files this Administrative Complaint . before the Board of Medicine against Respondent, Alfred O. Bonati, M.D., and in support thereof alleges: 1. 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. 2. Respondent's address of record is 7315 Hudson Avenue, Hudson, Florida 34667-1158. | 3. At all times material to this Complaint, Respondent was licensed to practice as a physician. in the State of Florida, pursuant to Filed December 3, 2013 5:00 PM Division of Administrative Hearings Chapter 458, Florida Statutes, having been issued license number ME 38324. 4. On or about October 17, 2007, Patient K.S. presented to Gulf Coast Orthopaedic Center (*“GCOC”) with complaints of upper thoracic pain and upper trunk numbness. After an initial evaluation, Patient K.S. was diagnosed with thoracic and lumbar spine pain with symptoms of radiculopathy. Magnetic resonance imaging (“MRI”) studies of Patient K.S.’s thoracic and lumbar spine were ordered. 5. On or about October 18, 2007, a MRI study of Patient K.S.'s thoracic spine revealed degenerative disc disease at T2/T3, stenosis at T2/T3 and herniation at T2/T3. 6. On or about October 18, 2007, Respondent recommended Patient K.S. undergo thoracic arthroscopic surgery at T2/T3 right, with laminotomy, foraminotomy and discectomy. 7. Laminotomy is the partial removal of the lamina of the vertebral arch of the spine for purposes of decompressing the spinal cord and/or spinal nerve root. DOH v. Alfred O. Bona, MD DOH Case Number 2010-09252 8. | Foraminotomy is the widening of the foramina, openings in the spine where the nerve roots leave the spinal cord, for purposes of decompressing the spinal nerve root. 9. Discectomy is the removal of herniated disc material that presses on a nerve root or the spinal cord. 10. After receiving surgical clearance, Patient K.S. was scheduled to undergo thoracic arthroscopic surgery at T2/T3 right with partial facetectomy, and foraminotomy on November 5, 2007. 11. ‘Facetectomy is the removal of a facet joint of the spine for purposes of decompressing a nerve root. - 12. On or about November 5, 2007, Patient K.S. presented to GCOC for the scheduled surgery. During the surgery, Patient K.S. experienced paralysis of both legs and weakness in the right arm. Patient K.S. also became tachycardic and experienced a drop in blood pressure and oxygen saturation. Respondent terminated the surgery after noting that Patient K.S. lost 1.2 liters of blood within the first thirty minutes of surgery. 13. Patient K.S. was then removed from the surgical table and placed in the supine position. At that time, Patient K.S. lost consciousness DOH v. Alfred 0. Bonati, MD DOH Case Number 2010-09252 and went into respiratory distress. After being resuscitated by the anesthesiologist, Patient K.S. was transferred to the recovery room where she was intubated. 14. In his operative report, Respondent noted that Patient K.S. had massive epidural veins, He further noted that he felt Patient K.S.’s sudden paralysis was due to an embolism to the anterior spinal artery. 15. The prevailing standard of care required Respondent to transfer Patient K.S. to an inpatient acute care facility immediately following the surgery. 16. Respondent failed to transfer Patient K.S. to an inpatient acute care facility immediately following the surgery. . | 17. On or about November 6, 2007, Respondent performed a second surgery on Patient K.S. to further decompress the nerve and to remove packing that was placed during the first surgery. 18. Patient K.S. lost an additional 600 milliliters of blood during the second surgery. 19. According to Respondent’s operative report of the second surgery, Patient K.S. was able to move her upper extremities following the DOH v. Alfred 0, Bonatl, MD OOH Case Number 2010-09252 second surgery; however she continued to experience numbness and weakness in both legs. ' 20. The prevailing standard of care required Respondent to obtain additional imaging studies that would show the extent of damage to Patient K.S.’s spinal cord or the spread of hematoma before performing the second surgery. 21. Respondent failed to obtain additional imaging studies before performing the second surgery. - 22, On or about November 7, 2007, Patient K.S. was discharged from GCOC to a local Comfort Inn motel where Patient K.S. remained until she was transferred by air ambulance to her home in Kansas City on or about November 21, 2007. 23. Section 458.331(1)(t)1, Florida Statutes (2007), subjects a physician to discipline for committing medical malpractice as defined in Section 456.50, Florida Statutes (2007). “Medical malpractice” is defined by Section 456.50(1)(g), Florida Statutes (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.” Section 456.50(1)(e), Florida Statutes (2007), provides that the “level of care, skill, 5 DOH v. Alfred 0. Bonati, MD DOH Case Number 2010-09252 and treatment recognized in general law related to health care licensure” means the standard of care that is specified in Section 766.102(1), Florida Statutes (2007), which states 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. | 24. Section 458,331(1)(t)1, Florida Statutes (2007), directs the Board of Medicine to give “great weight” to this provision of Section 766.102, Florida Statutes (2007). 25. Respondent failed to meet the prevailing standard of care in one or more of the following manners: a. By failing to transfer Patient K.S. to an inpatient acute . caré facility immediately following the first surgery; and/or b. By falling to obtain additional imaging studies before performing the second surgery. - 26. Based on the foregoing, Respondent violated Section 458.331(1)()1, Florida Statutes (2007), by committing medical malpractice. DOH v. Alfred 0. Bonati, MD DOH Case Number 2010-09252 ’ 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, 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_[€! day or _(Octdoer , 2013. John H. Armstrong, MD, FACS Surgeon General and Secretary of Health Alicia E Adams, Esquire Florida Bar No. 0065248 Assistant General Counsel FILED Department of Health, DEPARTMENT OF HEALTH Prosecution Services Unit DEPUTY CLERK 4052 Bald Cypress Way, Bin C-65 CLERK Angel Sanders Tallahassee, Florida 32399-3265 _ DATE OCT 18 7013 | (P) 850/245-4444 (F) 850/245-4684 (E) Alicia_Adams@doh.state.fl.us PCP Date: October 18, 2013 PCP Members: Fuad Ashkar, M.D.; Nabil El-Sanadi, M.D. DOH v. Alfred 0. Bonati, MD DOH Case Number 2010-09252 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 to any other discipline imposed. DOH v. Alfred 0. Bonati, MD DOH Case Number 2010-09252

Docket for Case No: 13-004667PL