The Issue The issue for consideration in this case is whether Respondent's license as a registered nurse in Florida should be disciplined because of the matters alleged in the Administrative Complaint filed herein.
Findings Of Fact At all times pertinent to the issues herein, the Department of Health, Board of Nursing, was the state agency in Florida responsible for the licensing of nurses and the regulation of the nursing profession in this state. Respondent was a registered nurse licensed in Florida with license number RN 2561322, which she obtained by endorsement in 1991. Respondent, using the name Michele Draper, applied for licensure as a registered nurse by endorsement by application filed on October 7, 1991. On that application, she listed 340-22-0150 as her social security number and June 22, 1954, as her date of birth. Attached to the licensure application was a copy of Respondent's Illinois driver's license which reflected her date of birth as June 22, 1951. The application form reflects that at some point, the name "Draper" was struck through and the name "Jackson" written in, but Respondent's signature on the application form reflects Michele Draper Jackson. This same application form reflects that Respondent answered "No" to the question, "Have you ever been convicted or have you a no-contest or guilty plea-regardless of adjudication-for any offense other than a minor traffic violation." Respondent had been arrested and, on June 8, 1988, convicted of a felony charge of "Deceptive Practices over $150" in McLean County, Illinois, and on July 1, 1988, was convicted of three misdemeanor charges of "Deceptive Practices under $150" in the same county. On the felony charge she was sentenced to serve 10 days in the McLean County Jail, to pay a fine of $300 plus court costs, and to serve 30 months' probation. On the misdemeanor charges, she was sentenced to 12 months' conditional discharge and to pay court costs. She was ordered to make restitution in both cases. No reference was made to this conviction by Respondent on her application for a Florida nurse's license. In 1993, Respondent was again arrested and indicted, tried, and convicted in Sarasota County on a third-degree felony charge of grand theft. She was sentenced to imprisonment for that offense, but the sentence was suspended and she was placed on probation for four years. The evidence reflects that as a part of the offense with which Respondent was charged was her use of three different social security numbers, to-wit: 344-33-4188; 360-22-0150; and 310-22-0150; and a date of birth of June 22, 1951. Respondent has a Florida driver's license number D616-540-57-722, bearing a Social Security Number 310-22-0150. She also has a Florida driver's license which bears the Social Security Number 360-40-8146. Both driver's licenses reflect Respondent's date of birth as June 22, 1957, yet the records of the Florida Division of Motor Vehicles reflect Respondent's date of birth as June 22, 1951. Respondent at one time also used an Illinois driver's license which bore the Social Security Number 360-42-4186, and a date of birth of June 24, 1954. In 1995, Respondent was charged in Sarasota County with a second-degree felony of scheme to defraud by using false pretenses, representations, or promises with a credit card to defraud a credit union, several banks, and an individual, of between $20,000 and $50,000 in July of that year. The court records relative to that incident indicate that Respondent stole the identity and social security number of her employer and used that number to secure a credit card and loans used to purchase two vehicles on which she failed to make the appropriate payments. Respondent was found guilty of this charge and of violation of her previously imposed probation and was, in March 1996, sentenced to five years in prison, which she served at the North Florida Reception Center beginning on March 8, 1996. Both felony convictions and the misdemeanor conviction were violations of Chapter 817, Florida Statutes, which deals with fraudulent practices. Before going to prison, between August 21, 1995, and February 28, 1996, Respondent was employed as a registered nurse at Hospice. When asked on her application for employment if she had ever been convicted of a felony, Respondent answered "No" when, in fact, she had been so convicted in 1988 and in 1993. On the application for employment, Respondent listed Social Security Number 306-44- 4186 and a driver's license bearing number D616-540-57-177. She also indicated on her résumé which she had submitted with the application that she held a bachelor of science degree from Northwestern University from which she had allegedly graduated with a 3.1 grade point average. Respondent did not hold a degree of any sort from Northwestern, having attended that institution's school of journalism for only a short period in 1972-1974. Respondent's résumé also reflected she had received a nursing diploma from Lewis University through the On Site Little Company of Mary Hospital in 1980, earning a grade point average of 3.0. In fact, Respondent did not earn a degree of any sort from that institution, having attended for only one year. Her grade point average when she left was 1.77. Her résumé also reflects she was employed in increasingly responsible nursing positions at Cook County Hospital in Illinois from 1980 to 1987. In fact, she did not receive her nursing license until 1984 and was never employed by Cook County Hospital. Respondent was sentenced to prison on March 1, 1996. That day she was scheduled to work at Hospice, but she did not appear for work as scheduled. Later that day she called in to advise she had been called away on a family emergency. Thereafter, she resigned her position with Hospice with no advance notice, and gave false reasons for leaving. Once Respondent was released from prison, on June 1, 1998, she filed an application for employment with Hospice on which she again denied ever having been convicted of a felony, and reiterated her false educational claims. In addition, she gave a false driver's license number and date of birth. There are several other inconsistencies running throughout Respondent's employment history. On her Florida nursing license application she was asked to list the names she has used during her lifetime and the name under which she received her nursing education. Respondent did not list the name Shepard in either response. The records of the Little Company of Mary Hospital Nursing School reflect that at no time was there a student at that school with the name Michele Nash, Michele Jackson or Michele Draper. At one point there was a student with the name Michele Shepard, but no social security number is on file for her. The former registrar of the nursing school testified that she received a telephone call from someone purporting to be Ms. Michele Shepard who requested a certification of graduation be issued in the name of Michele Jackson, which was supposed to be her new name. The registrar at no time saw any documentation to indicate Ms. Draper and Ms. Jackson were one and the same person, and she cannot say with any certainty that Respondent is a graduate of Little Company of Mary Hospital Nursing School. Nonetheless, she issued the letter of certification in June 1984, and that letter was forward to the Florida Board of Nursing in support of Respondent's application for licensure. Respondent submitted an Illinois nursing license as support for her application for licensure by endorsement in Florida. The application for the Illinois license is in the name of Michele Nash, and bears the Social Security Number 366-42-4116 as well as a birth date of June 22, 1954. The application also shows a date of graduation from the Little Company of Mary Nursing School of June 16, 1984. In her application for licensure by endorsement to Florida, Respondent used the Social Security Number 340-22- 0152, a birth date of June 22, 1954, a high school graduation date of 1965, a nursing school graduation date of May 1984, and a date of May 1982 as the date she took the nursing licensure examination in Illinois. She also used the names Draper, Jackson, and Nash, and she provided a copy of her Illinois driver's license showing a birth date of June 22, 1951. Because of the myriad contradictions in her application history, it is impossible to tell whether Respondent is the individual who graduated from Little Company of Mary Nursing School in June 1984. Respondent filed an application for employment with LifePath Hospice in Tampa on June 25, 1998, using the name Michele R. Draper, a Social Security Number of 261-40-6814, and a Florida Driver's license number D616-5154-671772. Neither that social security number nor a driver's license bearing that number was issued to Respondent. She also indicated she had not been convicted of a crime within the past seven years. That answer was false. Respondent also indicated in her employment application that she held a bachelor of science degree in education from Northwestern University with an earned grade point average of 3.5, and a degree in nursing from Lewis University/Little Company of Mary Hospital with an earned grade point average of 3.0. Both representations are false. Ms. Draper also outlined an employment history in this application which was false in many respects. She did not work for Nurse, Inc. from May 1993 to January 1996, as claimed; she did not work for Cook County Hospital from February 1980 to August 1983, as claimed; and she did not even hold a nursing license until 1984. When LifePath attempted to verify the information submitted by Respondent, it determined that the social security number she had given was incorrect; a second social security card presented in place thereof was false; and she provided a Florida driver's license which, though the number is correct, bears an incorrect and altered date of birth. Nonetheless, Respondent was hired by LifePath. Sometime after being hired by LifePath, Respondent presented them with a new social security card bearing the name Michele Ann Draper, and the number 570-83-2297. She said that she had married and the Social Security Administration had given her a new number. This is untrue. Respondent has been married to Al Draper since before 1978, and the Social Security Administration ordinarily does not issue a new social security number to a woman when she marries. When LifePath learned of Respondent's concealed criminal record, the numerous misrepresentations as to her education, experiences, and references, and of the numerous different social security numbers, they terminated her employment on July 2, 1999. This was approximately one year after she had been hired and placed in patient's homes by the company. Commencing in the Fall of 1980, while a student at Lewis University, until 1998, Respondent used fourteen different social security numbers and six different birth dates in her dealings with educational institutions, licensing officials, and employers. Records of the Social Security Administration indicate that only two Social Security Numbers, 360-42-4186, used at Lewis University in 1980, and 590-83- 2297, used in the last LifePath application in 1998, were issued to Respondent. None of the other numbers she used was ever issued to her under any of the names she used. By the same token, Respondent has used various dates of birth in her educational career, on driver's licenses, and on applications for licensure and employment. Birth records of the state of Illinois indicate that Michele Ann Jackson, Respondent herein, was born in Illinois on June 22, 1951. Until just recently, Respondent appears to have continued to show evidence of dishonesty and misrepresentation in her dealing with authorities. Significant among these are, for example, in her response to a complaint against her license filed in Illinois, she falsely asserted she had been cleared of any wrongdoing in Florida, and that the allegations of criminal convictions are incorrect. Further, during the Florida investigation into the instant allegations, Respondent advised the investigator she had resigned from Hospice in 1996 with proper notice and that she had not had any legal problems prior to her employment by Hospice in 1995. No evidence was presented that Respondent has ever physically harmed or neglected a patient in her care or stolen from a patient.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Board of Nursing enter a final order finding Respondent guilty of the matters alleged in the Administrative Complaint and revoking her license to practice nursing in Florida. DONE AND ENTERED this 25th day of January, 2001, in Tallahassee, Leon County, Florida. ___________________________________ ARNOLD H. POLLOCK Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6947 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 25th day of January, 2001. COPIES FURNISHED: Diane K. Kiesling, Esquire Agency for health Care Administration 2727 Mahan Drive Fort Knox Building Three Room 3231A Tallahassee, Florida 32308 Michele Jackson Draper 4645 Flatbush Avenue Sarasota, Florida 34233 Ometrias Deon Long, Esquire Long & Perkins, P.A. 390 North Orange Avenue Suite 2180 Orlando, Florida 32801 Ruth R. Stiehl, Ph.D. R.N. Executive director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way Bin A02 Tallahassee, Florida 32399-1701
Findings Of Fact Based upon the Stipulation of the parties, the following facts are found: Joel Davis Laton and Christine Anne Laton are the parents and legal guardians of Rose, and are the “Claimants” as that term is defined in section 766.302(3). On or about August 17, 2019, Rose incurred a “birth-related neurological injury” as that term is defined in section 766.302(2), which was the sole and proximate cause of Rose’s medical condition. David Miller, M.D., rendered obstetrical services in the delivery of Rose and, at all material times, was a “participating physician” as defined in section 766.302(7). SVMCR is a hospital located in Jacksonville, Florida, and is the “hospital” as that term is defined in section 766.302(6), where Rose was born. At birth, Rose weighed 4,650 grams. Rose died on August 17, 2019. Petitioners filed a Petition pursuant to section 766.305, seeking compensation from NICA, and that Petition is incorporated herein by reference in its entirety, including all attachments. Any reference made within this document to NICA encompasses, where appropriate, the Florida Birth-Related Neurological Injury Compensation Plan (the Plan).
The Issue Whether George Houvardas (George), a minor, qualifies for coverage under the Florida Birth-Related Neurological Injury Compensation Plan (Plan). Whether Katharine Weinstock, M.D., the participating physician who provided obstetrical services at George's birth, gave the patient notice, as required by Section 766.316, Florida Statutes.
Findings Of Fact Findings related to compensability Simone Houvardas and Paul Houvardas are the natural parents of George Houvardas, a minor. George was born a live infant on September 29, 2003, at Morton Plant/Mease Hospital, a licensed hospital located in Clearwater, Florida, and his birth weight exceeded 2,500 grams. Obstetrical services were provided during George's birth by Katharine Weinstock, M.D., who, at all times material hereto, was a "participating physician" in the Florida Birth- Related Neurological Injury Compensation Plan, as defined by Section 766.302(7), Florida Statutes. Pertinent to this case, coverage is afforded by the Plan for infants who suffer a "birth-related neurological injury," defined as an "injury to the brain . . . caused by oxygen deprivation . . . occurring in the course of labor, delivery, or resuscitation in the immediate postdelivery period in a hospital, which renders the infant permanently and substantially mentally and physically impaired." § 766.302(2), Fla. Stat. See also §§ 766.309(1) and 766.31(1), Fla. Stat. Here, the parties have stipulated, and the proof is otherwise compelling, that George suffered an injury to the brain caused by oxygen deprivation during the course of labor, delivery, or resuscitation in the immediate postdelivery period in the hospital, which rendered him permanently and substantially mentally and physically impaired. Consequently, the record demonstrated that George suffered a "birth-related neurological injury," and since obstetrical services were provided by a "participating physician" at birth the claim is compensable. §§ 766.309(1) and 766.31(1), Fla. Stat. The notice issue While the claim qualifies for coverage under the Plan, Petitioners would like an opportunity to pursue their civil remedies, and avoid a claim of Plan immunity. Therefore, Petitioners have averred and requested a finding that Dr. Weinstock failed to comply with the notice provisions of the Plan. See Galen of Florida, Inc. v. Braniff, 696 So. 2d 308, 309 (Fla. 1997)("[A]s a condition precedent to invoking the Florida Birth-Related Neurological Injury Compensation Plan as a patient's exclusive remedy, health care providers must, when practicable, give their obstetrical patients notice of their participation in the plan a reasonable time prior to delivery."). Consequently, it is necessary to resolve whether Dr. Weinstock complied with the notice provisions of the Plan. Florida Birth-Related Neurological Injury Compensation Association v. Florida Division of Administrative Hearings, 948 So. 2d 705, 717 (Fla. 2007)("[W]hen the issue of whether notice was adequately provided pursuant to section 766.316 is raised in a NICA claim, we conclude that the ALJ has jurisdiction to determine whether the health care provider complied with the requirements of section 766.316."). Accord O'Leary v. Florida Birth-Related Neurological Injury Compensation Association, 757 So. 2d 624, 627 (Fla. 5th DCA 2000)("All questions of compensability, including those which arise regarding the adequacy of notice, are properly decided in the administrative forum."); University of Miami v. M.A., 793 So. 2d 999 (Fla. 3d DCA 2001); Tabb v. Florida Birth-Related Neurological Injury Compensation Association, 880 So. 2d 1253 (Fla. 1st DCA 2004). The notice provisions of the Plan In pertinent part, Section 766.316, Florida Statutes, prescribes the notice requirements of the Plan, as follows: Each hospital with a participating physician on its staff and each participating physician . . . shall provide notice to the obstetrical patients as to the limited no- fault alternative for birth-related neurological injuries. Such notice shall be provided on forms furnished by the association and shall include a clear and concise explanation of a patient's rights and limitations under the plan. The hospital or the participating physician may elect to have the patient sign a form acknowledging receipt of the notice form. Signature of the patient acknowledging receipt of the notice form raises a rebuttable presumption that the notice requirements of this section have been met . . . . The NICA brocure Responding to Section 766.316, Florida Statutes, NICA developed a brochure (as the "form" prescribed by the Plan), titled "Peace of Mind for an Unexpected Problem" (the NICA brochure), and distributed the brochure to the participating physicians and hospitals so they could furnish a copy of it to their obstetrical patients. (Exhibit 1 to Intervenors' Exhibit 1). The NICA brochure included the following statement: If your health care provider has provided you with a copy of this informational form, your health care provider is placing you on notice that one or more physician(s) at your health care provider participates in the NICA plan. Findings related to the participating physician and notice Mrs. Houvardas received her prenatal care at Rosewater, Lerner, Rudolph & Associates, M.D., P.A. (hereinafter "RLR"), a division of Tampa Bay Women's Care, a group practice that was, at the time of her initial visit, composed of five physicians that practiced obstetrics and gynecology: Doctors Stanley Rosewater, Saul Lerner, Richard Rudolph, GiGi McCance, and Katherine Weinstock.3 Notably, all of the physicians were participating physicians in the Plan. On January 30, 2003, Mrs. Houvardas presented to RLR for her initial prenatal visit. At the time, consistent with established practice for new prenatal patients, Mrs. Houvardas was given a copy of the NICA brochure, together with a Notice to Obstetric Patient form. The Notice to Obstetric Patient form provided: NOTICE TO OBSTETRIC PATIENT (See Section 766.316, Florida Statutes) I have been furnished information by Tampa Bay Women's Care that was prepared by the Florida Birth-Related Neurological Injury Compensation Association, and have been advised that Dr. Rosewater, Dr. Rudolph, Dr. Lerner and Dr. McCance are participating physicians in that program. I understand that under this program certain limited compensation is available in the event certain neurological injury may occur during labor, delivery or resuscitation. For specifics on the program, I understand I can contact the Florida Birth-Related Neurological Injury Compensation Association (NICA) at P.O. Box 14567, Tallahassee, FL 32317-4567, 1-800-398-2129. I further acknowledge that I have received a copy of the brochure prepared by NICA. DATED this day of , 200 . Signature (Name of Patient) Please Print Social Security No. Attest: Signature of employee Date: The notice was printed on RLR stationery, with the names of four of the physicians associated with the practice (Doctors Rosewater, Lerner, Rudolph, and McCance) listed along the upper left side of the stationery. Dr. Weinstock was not named on the letter head or identified in the notice as a participating physician.4 Mrs. Houvardas signed the form, acknowledging notice of Doctors Rosewater's, Rudolph's, Lerner's, and McCance's participation in the Plan, and receipt of the NICA brochure. Brandy Clark, an employee of RLR who conducted the initial interview, witnessed Mrs. Houvardas' signature. Here, there is no dispute that Mrs. Houvardas signed the Notice to Obstetric Patient form or that she received a copy of the NICA brochure during her initial visit. (Petitioners' Amended Pre-Hearing Stipulation, filed October 5, 2007, Stipulated Facts (c) and (d); Respondent's and Intervenors' Amended Pre-Hearing Stipulation, filed October 4, 2007, Stipulated Facts (c) and (d)). But, since Dr. Weinstock was not identified as a participating physician, the Notice to Obstetric Patient form was inadequate to satisfy Dr. Weinstock's obligation to provide pre-delivery notice of her participation in the Plan, as mandated by Galen, supra. See also Jackson v. Florida Birth- Related Neurological Injury Compensation Association, 932 So. 2d 1125, 1129 (Fla. 5th DCA 2006)("[S]ince the [Notice to Obstetric Patient] form had a blank space where the names of the physicians should have been filled in, the notice was inadequate to give rise to the statutory rebuttable presumption that PAF [the obstetrical practice] provided proper notice as outlined in the statute . . . [or that] 'any obstetrician associated with PAF was a participating physician in the Plan.'"). While the Notice to Obstetric Patient form was inadequate to provide notice of Dr. Weinstock's participation, Intervenors have, during the course of this proceeding, advanced two bases which they contend support the conclusion that proper notice was provided. First, Intervenors contended that Mrs. Houvardas was told, during her initial visit, that all of the physicians participated with NICA, and therefore proper notice of Dr. Weinstock's participation was provided.5 See Jackson v. Florida Birth-Related Neurological Injury Compensation Association, 932 So. 2d at 1129 ("[V]erbal notice that all of PAF's physicians were participants in the NICA plan" was adequate notice.). Consequently, it must be resolved whether the proof demonstrates, more likely than not, that Mrs. Houvardas was so informed and, if so, whether given the language of the notice (which named only Doctors Rosewater, Rudolph, Lerner, and McCance), such a statement was adequate to provide notice of Dr. Weinstock's participation. Tabb v. Florida Birth-Related Neurological Injury Compensation Association, 880 So. 2d 1253, 1260 (Fla. 1st DCA 2004)("[A]s the proponent of the issue, the burden rested on the health care providers to demonstrate, more likely than not, that the notice provisions of the Plan were satisfied."). To support their contention, Intervenors offered the testimony of Melissa Rudolph, the practice administrator for RLR and the wife of Dr. Rudolph. (Intervenors' Exhibit 1). According to Mrs. Rudolph, the nurses who conduct the initial prenatal evaluation are trained, as a part of their routine, to . . . give . . . [the patient] the NICA notification, . . . show them the notification and let them know if they have any questions whatsoever there is an 800 number on the back of the pamphlet. They can always ask the physician if they have any questions, and they are notified that all of the physicians are participating with NICA. They ask them to sign the notification that they've been informed that we are participating with NICA, and then they are moved onto the back where they then meet with the physician. (Intervenors' Exhibit 1, pages 7 and 8). Notably, Intervenors did not call Brandy Clark, the nurse responsible for Mrs. Houvardas' initial prenatal visit, or account for her unavailability, and did not call any nurse or other staff to substantiate that such a routine was in place on September 30, 2003. Contrasted with the proof offered by Intervenors, Petitioners offered the testimony of Dawanna Bunting, R.N., the clinical coordinator at RLR, and the person responsible for training all new nurses, including Brandy Clark.6 (Petitioners' Exhibit 14). Under the procedure described by Nurse Bunting, patients were not routinely advised that all the physicians in the group were participants in the Plan. Rather, Nurse Bunting described the routine, as follows: Q. Okay. What specifically did you train Ms. Clark to do with regard to NICA information? A. Well, we offer them the NICA pamphlet, the brochure, and then we give them the notice to sign, stating that they are aware that they have received this pamphlet. And that there is a 1-800 number on the back of that pamphlet, and if they have any questions, they should call, and they're signing that they're receiving the brochure. Q. Okay. Anything other than that? A. No, not unless they ask. (Petitioners' Exhibit 14, pages 10 and 11). According to Nurse Bunting, 99.9 percent of the patients do not ask questions, but simply sign the notice form and hand it back. (Petitioners' Exhibit 14, page 26). As between, Mrs. Rudolph and Nurse Bunting, the testimony of Nurse Bunting was, overall, the most candid and compelling. Therefore, it must be resolved that the proof failed to establish, with the requisite degree of certainty, that at the time of Mrs. Houvardas' initial prenatal visit RLR had an established routine whereby obstetrical patients were informed that all the physicians associated with the practice were participating physicians in the Plan. Moreover, were such a routine established, it would not have been adequate to inform Mrs. Houvardas of Dr. Weinstock's participation. In so concluding, it is noted that given the format of the notice (which named only Doctors Rosewater, Rudolph, Lerner, and McCance) a reasonable person, similarly situated, would unlikely place any significance on such a general comment regarding participation, beyond the physicians identified in the notice.7 Finally, Intervenors contend that the Notice to Obstetric Patient form is optional, and that delivery of the NICA brochure to the patient by the participating physician or an employee of the practice is the sole requirement for compliance with Section 766.316, Florida Statutes. Intervenors reason, as follows: 2. §766.316, Florida Statutes, refers to two separate and distinct types of forms. The first is a Notice Form furnished by the Florida Birth-Related Neurological Injury Compensation Association. The Notice Form is otherwise known as [the] NICA Brochure. * * * This Notice Form (NICA Brochure) was provided to SIMONE HOUVARDAS on January 30, 2003. The second form referred to in §766.316 is an Acknowledgment Form. The Acknowledgment Form is optional and if used by the participating physician serves to raise a rebuttable presumption that the Notice Form (NICA Brochure) was delivered to the patient. In the instant case, the rebuttable presumption is not an issue since Petitioners have stipulated that the Notice Form (NICA Brochure) was delivered to SIMONE HOUVARDAS. * * * Delivery of the Notice Form (NICA Brochure) by the participating physician or an employee of the practice to the obstetrical patient is the sole requirement for compliance under §766.316, Florida Statutes. The Notice Form (NICA Brochure) contains the following language: "If your healthcare provider has provided you with a copy of this informational form, your health care provider is [p]lacing you on notice that one or more physician(s) at your health care provider participates in the NICA plan["]. Accordingly, delivery of the Notice Form (NICA Brochure) with the language encompassed therein, serves as notice that one or more of the health care providers in the practice participates in the NICA and of the patient's rights and limitations under the plan. Therefore, delivery of the Notice Form (NICA Brochure) to SIMONE HOUVARDAS on January 30, 2003, by a nurse employee of RLR, in the office [of] RLR, was sufficient compliance with §766.316, Florida Statutes, and therefore, KATHARINE WEINSTOCK, M.D. and RLR are entitled to immunity under §766.316, Florida Statutes. Intervenors are correct that use of the Notice to Obstetric Patient form is optional, but are incorrect to conclude that its utility is limited to raising a rebuttable presumption that the NICA brochure was given to the patient. Rather, if properly used, the Notice to Obstetric Patient form is persuasive evidence that the named physicians gave notice of their participation in the Plan. Apparently, that was Intervenors' intention in this case, but because RLR used the wrong form it failed to give notice on Dr Weinstock's behalf. Intervenors may also be correct that under certain circumstances (i.e., when the participating physician gives the patient the brochure) delivery of the brochure provides proper notice of a physician's participation in the Plan. However, those are not the facts of this case. Rather, here an employee of RLR gave the patient a NICA brochure, together with a Notice to Obstetric Patient form that identified Doctors Rosewater, Rudolph, Lerner, and McCance, but not Dr. Weinstock, as participating physicians in the Plan. Under these circumstances, delivery of the NICA brochure, giving due consideration to the wording of the provision relied upon by Intervenors, would not have placed Mrs. Houvardas on notice of Dr. Weinstock's participation in the Plan. Accordingly, it must be resolved that, although it was practicable to have done so, Mrs. Houvardas was not provided notice of Dr. Weinstock's participation in the Plan.8
The Issue At issue is whether Samer Abifaraj, a deceased minor, qualifies for coverage under the Florida Birth-Related Neurological Injury Compensation Plan (Plan). If so, whether the notice requirements of the Plan were satisfied. If so, whether the Division of Administrative Hearings has the exclusive jurisdiction to resolve or, alternatively, must preliminarily resolve, whether there is "clear and convincing evidence of bad faith or malicious purpose or willful and wanton disregard of human rights, safety, or property" before a claimant may elect (under the provisions of Section 766.303(2), Florida Statutes) to reject Plan benefits and pursue a civil suit.
Findings Of Fact Fundamental findings Petitioners, Bassam Abifaraj and Rayya Abifaraj, are the parents and natural guardians of Samer Abifaraj (Samer), a deceased minor, and co-personal representatives of their deceased son's estate. Samer was born October 30, 1997, at Plantation General Hospital, a hospital located in Broward County, Florida, and died December 4, 1997. At birth, Samer's weight exceeded 2,500 grams. The physician providing obstetrical services at Samer's birth was John L. Rinella, M.D., who was at all times material hereto a "participating physician" in the Florida Birth-Related Neurological Injury Compensation Plan, as defined by Section 766.302(2), Florida Statutes. Coverage under the Plan Pertinent to this case, coverage is afforded by the Plan for infants who suffer a "birth-related neurological injury," defined as an "injury to the brain . . . caused by oxygen deprivation . . . occurring in the course of labor, delivery, or resuscitation in the immediate post-delivery period in a hospital, which renders the infant permanently and substantially mentally and physically impaired." Sections 766.302(2) and 766.309(1)(a), Florida Statutes. Here, NICA has concluded, and the parties agree, that Samer suffered a "birth-related neurological injury." Consequently, since obstetrical services were provided by a "participating physician" at birth, NICA proposes to accept the claim as compensable under the Plan. NICA's conclusion is consistent with the proof, and its proposal to accept the claim as compensable is approved. Notice of Plan participation While the claim qualifies for coverage under the Plan, Petitioners have responded to the health care providers' claim of Plan immunity by contending that the hospital and participating physician failed to comply with the notice provisions of the Plan. Consequently, it is necessary to resolve whether, as alleged by the health care providers, appropriate notice was given. O'Leary v. Florida Birth-Related Neurological Injury Compensation Association, 757 So. 2d 624 (Fla. 5th DCA 2000). Regarding the notice issue, it is resolved that on June 3, 1997, Mrs. Abifaraj was provided timely notice that Dr. Rinella was a participating physician in the Plan, together with notice as to the limited no-fault alternative for birth- related neurological injuries provided by the Plan. Such conclusion is based on the more credible proof which demonstrates that on such date, when Mrs. Abifaraj presented to Dr. Rinella's office, Belinda Jill Pettitt, a medical assistant at the time, gave Mrs. Abifaraj a brief explanation of the Plan, as well as a form titled INFORMED CONSENT OF MY PHYSICIAN'S PARTICIPATION IN THE FLORIDA BIRTH-RELATED NEUROLOGICAL INJURY COMPENSATION PLAN (NICA). The form further provided: I hereby acknowledge that: I have been advised that Dr. John Rinella (OB), MD is a participant in the NICA Plan; I have been furnished with a copy of the NICA brochure which describes the NICA Plan and my rights and limitations under the NICA Plan; I understand that the no-fault aspects of the NICA Plan will serve as an exclusive remedy for injury which qualifies under the NICA Plan and that as a result I am forfeiting any and all rights to bring legal action in a Court of Law for damages in connection with such injuries; Any questions I may have had regarding my physician's participation in the NICA Plan and my rights and limitations under the NICA Plan have been answered to my satisfaction; I hereby consent to obstetrical services having been given notice pursuant to Florida Statutes 766.316 by my physician of the applicability of NICA upon such obstetrical services. Contemporaneously, Ms. Pettitt gave Mrs. Abifaraj a copy of the brochure (prepared by NICA) titled "Peace of Mind for an Unexpected Problem," which contained a concise explanation of the patient's rights and limitations under the Plan. Ms. Abifaraj acknowledged her understanding of the form, as well as receipt of the NICA brochure, by dating and signing the form.3 While Mrs. Abifaraj received notice on behalf of the participating physician, the proof failed to demonstrate that Plantation General Hospital provided any pre-delivery notice, as envisioned by Section 766.316, Florida Statutes. Moreover, there was no proof offered to support a conclusion that the hospital's failure to accord Mrs. Abifaraj pre-delivery notice was occasioned by a medical emergency or that the giving of notice was otherwise not practicable. Rather, the health care providers contend that the hospital's failure to give notice is inconsequential when, as here, the patient's obstetrician has accorded notice of his participation in the Plan. Whether, as contended by the health care providers, the hospital's failure to accord Mrs. Abifaraj notice should be overlooked, as harmless, is addressed in the Conclusions of Law.
The Issue The issues in this case are whether Respondent violated section 458.331(1), Florida Statutes, by committing medical malpractice or by failing to keep legible medical records that justify the course of treatment of a patient, as set forth in the Amended Administrative Complaint, and, if so, what is the appropriate sanction.
Findings Of Fact The Department is the state agency charged with regulating the practice of medicine pursuant to section 20.43, chapter 456, and chapter 458, Florida Statutes (2015). The Board of Medicine is charged with final agency action with respect to physicians licensed pursuant to chapter 458. At all times material to the complaint, Dr. Tsinker was a licensed medical doctor within the state of Florida, having been issued license number ME 39408. Dr. Tsinker's address of record is 2500 East Hallandale Beach Boulevard, Suite 207, Hallandale Beach, Florida 33160. D.G. was pregnant and sought care from Bellymama Midwifery Services (Bellymama Midwifery). On May 16, 2013, she signed a Bellymama Midwifery Services VBAC Consent Form. It generally advised of risks and benefits in attempting a vaginal birth after having had a cesarean section (VBAC). It included the following statements, among others: 3. I understand that 70-80% of women who undergo VBAC will successfully deliver vaginally, and that this percentage increases in relation to the amount of support women receive in making the decision to try a VBAC. * * * 7. The exact frequency of death or permanent injury to the baby when the uterus ruptures is uncertain, but has been reported to be as high as 50% in cases of complete rupture. * * * 9. Probable contraindications to VBAC include a classical uterine incision, multiple gestations, and breech. Each of these statements on the form was initialed by D.G. At the end of the form was a place for the patient to choose to either attempt VBAC or elect a repeat cesarean, as well as a place to explain that choice. After the form's statement "I want to attempt a VBAC because," the following entry was made in script, "I don't agree that my previous C-section was necessary and I disagree w/ interventions for the sake of convenience." D.G.'s printed name and her signature appear at the bottom of the form. At hearing, D.G. testified that the cesarean section with her first daughter had been a difficult experience. The baby had complications arising from induction which led to the emergency cesarean. D.G. stated that she wished to avoid interventions unless they were medically necessary. D.G.'s first prenatal visit was conducted on May 17, 2013, by Corina Fitch, R.N., a licensed midwife. Nurse Fitch has a degree in midwifery and provides prenatal care and assistance with home deliveries. She has worked with many patients wanting to attempt a VBAC. D.G. testified that after it was determined, at about 35 and one-half weeks gestation, that the fetus was in breech position, she had a discussion with Nurse Fitch as to the best way to proceed. They decided that they should wait to see if the baby changed position. Nurse Fitch testified that the baby did change to vertex position, but then changed again, back to breech. Nurse Fitch testified that she had advised D.G. generally of the risks and benefits of a vaginal delivery and that she specifically briefed D.G. about some of the additional risks of TOLAC1/ with a breech presentation, but not completely: Well, I think that I-–according to what I told you before, I didn't give her all the risks. I talked about cord prolapse, and I talked about head entrapment. So, potentially, no, she did not receive enough information. At slightly over 40 weeks, D.G. telephoned Nurse Fitch to advise that her water had broken (spontaneous rupture of membrane (SROM)). D.G. and Nurse Fitch decided that D.G. should to go to the hospital to deliver there. Based upon information that Dr. Tsinker had successfully delivered breech babies vaginally, D.G. and her husband had decided to seek care from Dr. Tsinker. Nurse Fitch called Dr. Tsinker. She told Dr. Tsinker that D.G. was a 37-year-old pregnant woman at 40 weeks and four days gestation, that D.G. had previously undergone a cesarean section with her first child, that the fetus was in frank breech presentation, and that she wished to deliver vaginally if possible. Nurse Fitch testified that she did not believe that her conversation with Dr. Tsinker included discussion about consent forms or whether the patient had been advised of the risks of attempting a VBAC under all of these circumstances. However, Nurse Fitch testified that Dr. Tsinker had accepted patients from her before and that she always provided a copy of the consent form that her patients signed to him on those occasions, so he was generally familiar with the consent form. Dr. Tsinker agreed to accept D.G. as a patient. Records of Bellymama Midwifery dated December 10, 2013, indicate: Received T.C. from pt reporting SROM @ 10 a.m., mild cramping. Home visit made. FHT's 140's, all VS WNL, baby in breech presentation, VE done to report findings to OB for transfer of care, 1 cm, 100%, 0 station. Dr. Tsinker called as pt desires vaginal birth, he agreed to do delivery, pt transported to hospital in own car in stable condition for augmentation and delivery, CF. At about 1247 hours on December 10, 2013, D.G. presented to the Broward Health Medical Center in Fort Lauderdale with ruptured membrane and fetus in breech position. Her husband was with her. Based upon communications from Dr. Tsinker, she was expected, and the hospital had the admissions paperwork ready for her. D.G. signed a General Consent form at the time of her admission. At about 1320 hours, a labor assessment was conducted by nursing staff. It indicated, among other things, that the reason for admission was spontaneous rupture of membrane, that D.G. was calm, and that her obstetrical history included a previous cesarean section due to low amniotic fluid at 37 weeks. Electronic fetal monitoring begun at 1317 hours showed no decelerations and active movement. Examination confirmed that the fetus was in breech presentation. D.G. told the nursing staff that she wanted to labor without pain medications. The LD-Flowsheet BG indicates that at about 1334 hours, Dr. Tsinker was made aware of the examination and that he issued orders. Dr. Tsinker testified that he was told that the baby was in frank breech position and that there was only "mild" labor activity. Dr. Tsinker testified that he gave the order to start D.G. on oxytocin (or Pitocin). A Maternal Child Inter-Disciplinary Patient Education Record indicates that D.G. was advised of potential side effects from the use of Pitocin at about 1400 hours. This was the only entry in the "Medications" content area. The form contains the initials "SY" and contains a signature that appears to read "Simone Young, RN." The form contains no mention of misoprostol (or Cytotec). D.G. signed a Vaginal Delivery Consent form at about 1410 hours on December 10, 2013. The form had Dr. Tsinker's name filled in and, in a typed line which had been added, indicated that he was authorized to perform "delivery of baby, possible cesarean section, possible use of forceps or vacuum extractor, possible episiotomy." The form itself contained no information about the risks of vaginal delivery, no information about the risks of vaginal delivery after cesarean section, and no information about the risks of vaginal delivery after cesarean section with a baby in breech presentation. The only provision related to risks stated: The Physician has explained to me, and I understand, the potential benefits, risks, or side effects of the procedure, including potential problems related to recuperation; the likelihood of achieving goals; the reasonable alternatives to the procedure; and the relevant risks, benefits, and side effects related to alternatives, including the possible results of not having the procedure. The document contains a signature in the "witness" space which appears to read "S. Young, RN." It was uncontroverted, however, that D.G. had not actually talked with the attending physician about anything before she signed the form. Dr. Tsinker testified that it is his signature which appears at the bottom of the form in the "Physician Signature" space. While there was some question about the date Dr. Tsinker signed the form, this is of no significance. The form does not show that Dr. Tsinker advised D.G. of the risks of TOLAC under her circumstances, and its statement that this had been done was completely rebutted by all of the other evidence, including testimony of Dr. Tsinker. Dr. Tsinker never advised D.G. of the particular risks involved in a vaginal delivery, given her previous cesarean section and breech presentation. He never advised her that a cesarean section was indicated. Further, he admitted that D.G. never told him she was unwilling to have a cesarean section. He simply assumed, based upon the information that had been provided to him by others, that she would decline a cesarean section even if he strongly recommended it to her. He testified that he came to that conclusion because: The patient never, A, asked me any additional questions that she may have had--you know I'm not her mind reader--at time when she was admitted and I showed up after that, right. She knew about her right to ask these questions and to have them answered to her full satisfaction. When I showed up, she didn't have that opportunity when she came in because I wasn't there. But when I showed up, she had all in the world opportunity, if she was even a little bit still in the dark or had reservations or any problems, she had the opportunity to ask me that and I would have definitely given her a complete answer. She never mentioned she had regret her opinion or she wants to stop and revert to a cesarean section, or to do anything but to continue the trial of TOLAC. Some of D.G.'s medical records, such as the medications list, suggest that misoprostol, a drug used to make the patient more receptive to oxytocin, was never ordered in D.G.'s case. Other records suggest that it may have been administered to D.G. Dr. Tsinker stated in response to interrogatories and testified at hearing that misoprostol was not used in D.G.'s case. As for entries appearing to indicate that misoprostol was discontinued, Dr. Tsinker's uncontroverted testimony was that you cannot "discontinue" misoprostol because it is introduced intravaginally in the form of a small pill. The only drug that could be discontinued is oxytocin, which is introduced intravenously. Dr. Tsinker maintained that any references to "discontinue" are references to oxytocin, not misoprostol. He further maintained that misoprostol is used when the cervix needs ripening and noted that, in this case, it was already thinned, with D.G's records showing 100 percent effacement, so that there would have been no need to order misoprostol. Hospital records of Pharmacy Orders reference that administration of Pitocin through continuous infusion began at 1514 hours. An accompanying note provided, "6 milliunit/min = 0.3 mL/min = 18 mL/hr – Start at 6 milliunit/min. Increase by 3 milliunit Q15 min until contractions are Q2 min apart, 40 sec in duration & moderate to strong by palpation – continuous infusion (not to exceed 20 MU/min). Hold for non reassuring FHR pattern or tachysystole." Dr. Tsinker did not perform an examination of D.G. in order to determine whether D.G.'s fetus was in frank, footling, or some other breech position prior to the administration of Pitocin to D.G. As Dr. Tsinker testified, he had been informed that the fetus was in frank breech position. There was some conflicting evidence as to whether the fetus was in frank breech or in foot breech position. The Discharge Summary form, dictated by Dr. Siegel and signed by Dr. Tsinker, indicates that the "patient was delivered vaginally, foot breech," and the Newborn Consultation form of Dr. Otero similarly had a block indicating "foot breech" checked. However, Nurse Fitch testified that she determined the baby was in frank breech position earlier, and, consistent with the testimony of Dr. Tsinker, the Baby's Delivery Record indicated "Breech Position: Frank." Norman Donald Diebel, M.D., later testified that although he could not be sure, he concluded that the baby was in frank breech position. Dr. Tsinker had never met D.G. in person, or spoken to D.G. prior to December 10, 2013. He saw her for the first time around 1635 hours on that day. At some point, Dr. Tsinker prepared an OB/GYN History and Physical form. It was dated December 10, 2013, but no time was given. No pelvic examination was recorded which could be used to determine when it was prepared. As Dr. Tsinker admitted, the notes are untimed and mostly abbreviated. It records the presentation as "breech" and the membranes as "ruptured." While it has a few spaces left blank, it was substantially completed, albeit with little detail. During D.G.'s labor, Dr. Tsinker did not dictate or write any progress notes. Dr. Tsinker maintained that because he believed everything was progressing well, he did not think it necessary. At 2031 hours, the flowsheet records Dr. Tsinker at bedside and indicates that he reviewed the fetal strip. At 2051 hours, the flowsheet records that Dr. Tsinker responded to a page and was "notified/updated" and notes that there were "no new orders." Nurse Radhiya Walther could not remember these entries when asked about them, or recall if they were in fact entered about ten hours after the events they describe. Dr. Tsinker disputed that he was ever contacted at this time. At 2130 hours, the flowsheet records that "augmentation D?c'd unable to continuously monitor doula and pt instructed to assist with FHR monitoring while on ball." Nurse Walther stated she discontinued oxytocin because the patient was sitting on the ball, and she was unable to monitor the strip. She admitted in cross-examination that if oxytocin was discontinued, the physician should be notified. She admitted that the records did not indicate that Dr. Tsinker was notified. The fetal monitor strip indicates noticeable loss of variability in the trace and some early decelerations. These were not yet clear signs of fetal distress, but as Dr. Diebel testified, would have caused a reasonably prudent obstetrician/gynecologist to remain with the patient. At 2203 hours, the flowsheet records a vaginal exam by Dr. Tsinker, with dilatation at 10 cms, and effacement at 100 percent. Dr. Tsinker requested that D.G. demonstrate how she was going to push so that he could evaluate the effectiveness of her pushing. D.G. testified later, "Dr. Tsinker asked me to push, I attempted to push with all of my might, they were unproductive pushes. He told me continue to labor, I'll come back later and he left the room." Dr. Tsinker testified that at that time he directed the delivery nurse to have D.G. start pushing, but neither D.G. nor Nurse Walther recall that order. Additional comments recorded for this time indicate "Dr. Tsinker at bedside strip reviewed Pt attempted pushing will labor down." Nurse Fitch, who had arrived in the labor and delivery room about 2000 hours, did not recall Dr. Tsinker ever telling D.G. or the labor and delivery nurse that D.G. could "labor down." As Nurse Fitch testified: I don't recall that. What I do recall is, when [Dr. Tsinker] left the room, she was very distraught because the exam was extremely painful and she didn't have a sensation to push that was very-–she tried. She gave it her best. And she said "Corina, I don't know if I can do this." And the nurse-—I remember the nurse saying, "Don't worry. There's no urgency. We'll just let her wait till she has the urge. Nurse Walther recalled that D.G. stated she did not want to push because she did not feel any pressure, which is why Nurse Walther recorded the "labor down" comment. Nurse Walther testified she would have called Dr. Tsinker if she had felt this was contrary to his orders in any way, but she did not, because she had not been told to make the patient push. D.G. spent much of her labor on the birthing ball, next to the bed. With D.G. in this position, it was more difficult to monitor fetal heart rate because the monitoring belts can more easily shift and not provide clear readings. Also, D.G., who declined a bedpan, made several trips to the bathroom. Portions of the fetal monitor strips have missing or sketchy readings. By 2230 hours on December 10, 2013, D.G.'s fetal monitor had begun to show clear signs of fetal distress, evidenced by late decelerations. D.G. was never advised by anyone that there were signs of fetal distress, or told of the advisability of having a cesarean section in light of that new information. At 2300 hours, under "Interventions," in D.G.'s records, it is stated that "IV Bolus; Discontinue Uterine Stimulants; O2 On; other Interventions – Please Annotate Annotation: Pitocin remains off O2 remains in place." At 2304 hours, the flowsheet records "MD notified that patient is on ball and unable to get cont tracing and having variable decelerations. Pt instructed to return to bed." Under care provider status it is recorded, "Responded to Page; Report Given; In Department; Notified/Updated See SBAR; No New Orders." Dr. Tsinker again disputes that he was given this notification. Nurse Walther stated she could not remember how Dr. Tsinker was notified. She could not recall if Dr. Tsinker showed up personally in response, or called. She could not remember if she repeated the call to him. The flowsheet records a late deceleration at 2316 hours and another at 2320 hours. As Nurse Walther acknowledged in cross-examination, repetitive late decelerations are dangerous and constitute "category 3," the most serious category. Nurse Walther stated she did not know if she notified Dr. Tsinker after these decelerations. She later conceded that three late decelerations constitute an emergency that required that the attending physician be notified. Nurse Walther testified she walked outside to tell the charge nurse, but could not recall what the charge nurse told her in response. There was no evidence of any actions taken by the charge nurse. Under Additional Comments at 2330 hours, it is noted, "Pt found off monitor in restroom, family at bedside safety precautions maintained. Pt instructed to return to bed, assisted to Labor Bed." Nurse Walther's testimony was generally not very clear or credible and many of the entries in the flowsheet record are found to be unreliable, especially those concerning events that supposedly took place after the visit at 2203 hours by Dr. Tsinker. The stored fetal strip, incomplete in places as it is, is the best evidence of the progress of labor. It was not clearly shown that Dr. Tsinker ever reviewed the fetal monitor strip or was otherwise made aware of the late decelerations occurring after 2200 hours at any time before his return to the room shortly before midnight. When Dr. Tsinker returned to the room before midnight, D.G. and Nurse Fitch were in the bathroom. He asked D.G. to come out. The patient was returned to bed. At about 0003 hours, D.G. was placed in foot pedals and partially elevated. Under Additional Comments, it is noted "audable fhr 147 pt prepped for pushing Dr. Tsinker." The Mother's Delivery Record prepared by Nurse Walther indicated that the Neonatal Intensive Care Unit (NICU) was called at midnight and arrived at 0005 hours. Dr. Tsinker asked D.G. to push. There was some difficulty in hearing the fetal heart monitor. It was a fairly quick delivery, taking about 11 minutes or so. On December 11, 2013, around 0014 hours, D.G. delivered a stillborn male infant. NICU recorded "0" for all Apgar score factors at both one minute and five minutes after birth. Despite multiple efforts, the NICU was unable to resuscitate the baby. The efforts of the NICU team caused D.G. to have feelings of panic; she testified that she was expecting to hear a baby crying and did not realize until then that there was any issue. After about 20 minutes or half an hour, the NICU team came to D.G.'s bedside and informed her that they were unable to resuscitate the baby. A Vaginal Delivery Summary form completed by Dr. Tsinker and dated December 11, 2013, at 1214 hours, briefly described the placenta, blood loss, laceration, and suturing after delivery, as well as the failure of the NICU team to resuscitate the stillborn child, but it said almost nothing of the labor and delivery itself, noting only that Dr. Tsinker "assisted breech delivery" and that the Apgar scores were "0" at one and five minutes. There was no evidence of any other delivery note prepared by Dr. Tsinker. Dr. Tsinker did not talk with D.G. after the delivery, or at any time on December 11, 2013, although D.G. had been requesting to speak with him to find out what had happened. On the morning of December 12, 2013, Dr. Tsinker came to D.G.'s hospital room, but D.G. was in the bathroom. Dr. Tsinker told D.G.'s husband that he would return. D.G. came out of the bathroom and waited for Dr. Tsinker to return. When he did not, D.G. went to the nurse's station and again asked to see him. When D.G. learned that he was no longer in the ward, she asked for her discharge papers. Dr. Tsinker appeared, and they returned to D.G.'s room. In the brief discussion about the course of labor and delivery which followed, D.G. believed that Dr. Tsinker was insensitive and blamed her for the outcome. After receiving further care not relevant to this case, D.G. was discharged from Broward General Medical Center at 1220 hours on December 12, 2013. Standards Dr. Diebel is an obstetrician/gynecologist who has been licensed in Florida since 1977. He is board-certified by the American Board of Obstetrics and Gynecology and was an examiner for the board for 18 years. He has previously served as an expert witness in administrative proceedings for the state of Florida. Dr. Diebel is an expert in obstetrics/gynecology and has knowledge, skill, experience, training, and education in the prevailing professional standard of care recognized as acceptable and appropriate by reasonably prudent obstetricians/gynecologists in Florida. Dr. Diebel reviewed D.G.'s medical records from Broward Health, the fetal monitor tracings, the midwife records, the autopsy report, and the Amended Administrative Complaint filed in this case. As Dr. Diebel testified, a vaginal delivery after cesarean section has some risks, but they are still performed. A vaginal delivery with breech presentation has some risks, but they are performed. However, he testified that to attempt a VBAC with a breech presentation was below the standard of care recognized as acceptable and appropriate by reasonably prudent obstetricians/gynecologists in Florida. As Dr. Diebel testified, you have two risky procedures, and "nobody would recommend" doing TOLAC and breech together. While Dr. Diebel acknowledged that this standard of care was not expressly set forth in American Congress of Obstetricians and Gynecologists' Practice Bulletin Number 115, August 2010, entitled "Vaginal Birth After Previous Cesarean Delivery," Dr. Diebel's testimony was clear and convincing and is credited.2/ Dr. Diebel credibly testified that it was below the standard of care to place the burden on the patient to "ask" about a cesarean section. The standard of care in labor and delivery requires that there be an agreement between the physician and the patient, as a part of which the patient is clearly presented with the potential hazards of what she is about to undertake. Dr. Tsinker should have discussed the potential benefits and risks of D.G. undergoing TOLAC, as well as the option to elect a repeat cesarean delivery, with D.G. as soon as possible after her arrival at the hospital. As Dr. Diebel testified, Dr. Tsinker should have advised D.G. that it was a very risky procedure for D.G. to undergo TOLAC because the baby was in breech position, that this is not currently an acceptable procedure, and that she should have a cesarean section. The standard of care required Dr. Tsinker to advise D.G. of the additional risks involved in attempting a VBAC due to her breech presentation. It was Dr. Tsinker's responsibility to fully explain those risks, recommend a cesarean section, and affirmatively ascertain and document her response. Dr. Diebel testified that if a patient refused to follow the physician's recommendations or was uncooperative in this regard: You would document it profusely if a patient- –you know, I explain to the patient that this is what's happening, this is what can happen, this is what the effects can be. I explained all that, she expressed understanding. Yeah, if only to cover myself, I want it to be very clear that we had this discussion and still her decision was otherwise. Dr. Tsinker's testimony that he believed that others had previously had discussions with D.G. about these risks and benefits did not satisfy this standard of care. Dr. Tsinker failed to have the appropriate discussions with D.G. or to document them, as he was required to do. Dr. Diebel's testimony that misoprostol should not be used to induce labor in patients who have had an earlier cesarean delivery was unrefuted and is accepted. Dr. Diebel also testified that the ordering of Pitocin for D.G. violated the standard of care. This conclusion was contested, however, and the basis for Dr. Diebel's conclusion was not carefully explained. While Dr. Diebel did describe risks of uterine rupture, as well as risks of causing contractions to be too close together, it was not explained in what way these risks were unique or increased with a TOLAC with breech presentation. Dr. Diebel testified: Q. Are there any risks associated with administering Pitocin to a patient attempting trial of labor after cesarean with breech presentation? A. Well, you won't find papers devoted to that particular thing, because it is not done. It's not-–breeches are not allowed to have a TOLAC. * * * Q. Why would it not be done? Why would Pitocin not be given in that situation? A. Well, because you wouldn't allow the situation to happen to begin with. Q. Right. A. Where you've got a breech and a previous cesarean section. So there'd be no reason to give Pitocin. This explanation does not provide a logical basis to support a separate charge of medical malpractice. Accepting Dr. Diebel's position that simply undertaking a TOLAC with breech constitutes medical malpractice, it does not follow that every other related, but distinct, element in the labor and delivery procedure would necessarily constitute a separate violation of the standard of care. Dr. Diebel acknowledged that it was appropriate to use a little Pitocin in a (non-breech) TOLAC where the patient is not having any contractions, but that it is run for only a short time, and then once the patient is in labor, discontinued. Dr. Diebel then contrasted that limited use with what was done in this case: In this situation, it was continued all day, even though she was having, in some place on the tracing, contractions a minute to a minute and a half apart, which are too close together. The basis of Dr. Diebel's concern with the use of Pitocin in this case thus appears to be that it was used for too long. However, that was not the charge in this case. The evidence was not clear or convincing that initially ordering Pitocin for D.G., as opposed to continuing its administration for too long, constituted medical malpractice. Dr. Diebel's testimony that D.G.'s admission history and physical was inadequately documented was not clear and convincing. He noted that the form was not properly timed, but the form itself appeared to be substantially completed, and Dr. Diebel did not sufficiently elaborate on what additional information should have been present. Dr. Diebel testified that the standard of care requires that a physician keep progress notes during the labor of their patients. Under cross-examination, Dr. Diebel admitted that as long as everything was going well, there was no need to write a progress note. However, he also testified that the fetal monitor indicated that after 1700 hours, everything was not going well in D.G.'s case. There were missed signals on the monitor, a loss of variability in the trace, and some decelerations before 2200 hours. It was undisputed that Dr. Tsinker failed to keep any progress notes on D.G.'s labor. Under these circumstances, Dr. Diebel's testimony that Dr. Tsinker failed to maintain adequate progress notes was clear and convincing. Dr. Diebel also credibly testified that Dr. Tsinker's delivery note describing what took place during D.G.'s delivery was inadequate. The stillborn child created a duty for Dr. Tsinker to fully document what took place during the course of labor and delivery, with careful attention to documentation of any possible factors that it might appear in retrospect to have contributed to the tragic outcome. Dr. Tsinker's Vaginal Delivery Summary, while briefly describing the placenta, blood loss, laceration, and suturing after delivery, as well as the failure of the NICU team to resuscitate the stillborn child, says almost nothing of the labor and delivery itself, noting only that Dr. Tsinker "assisted breech delivery" and that the baby was stillborn. This was not sufficient under the circumstances. Dr. Tsinker was charged with violating the standard of care in performing as an obstetrician/gynecologist during D.G.'s labor and delivery, and he failed to keep medical records reflecting his participation in the treatment of D.G. during that time. Prior Discipline No evidence was introduced to show that Dr. Tsinker has had any prior discipline imposed upon his license. Dr. Tsinker was not under any legal restraints on December 10, 2013. It was not shown that Dr. Tsinker received any special pecuniary benefit or self-gain from his actions on December 10, 2013. It was not shown that the actions of Dr. Tsinker on December 10, 2013, involved any trade or sale of controlled substances. On August 25, 2014, Dr. Tsinker completed an independent self-study course in Advanced Electronic Fetal Monitoring offered by PESI, Inc., consisting of 6.25 hours of instructional content. On April 6, 2015, Dr. Tsinker completed medical continuing education courses Documentation 154 and Documentation 155, consisting of one hour and two hours of instructional content, respectively, offered by OnlineContinuingEd, LLC.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by the Board of Medicine finding that Dr. Simion Tsinker violated sections 458.331(1)(m) and (t), Florida Statutes (2013), as charged in the Amended Administrative Complaint; suspending his license to practice medicine for a period of four months; imposing an administrative fine in the amount of $20,000; and requiring that he complete continuing medical education as deemed appropriate by the Board. DONE AND ENTERED this 12th day of February, 2016, in Tallahassee, Leon County, Florida. S F. SCOTT BOYD Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 12th day of February, 2016.
