The Issue Is Petitioner entitled to receive a passing score on the June 2001 dental licensure examination?
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of fact are made: The Department is the agency of the State of Florida responsible for administering the dental licensure examination. Petitioner was an unsuccessful candidate for the June 2001 dental licensure examination in that she failed the clinical portion of the June 2001 dental examination. Originally Petitioner received a score 1.89 on the Clinical portion, but on re-grade received a score of 2.10. However, a score of 3.00 was required to pass the Clinical portion. The June 2001 dental licensure examination consists of two parts: (1) the Clinical portion; and (2) the Laws and Rules portion. The Clinical portion consists of nine procedures. Petitioner challenges five of the nine procedures, which are: (1) Periodontal procedure; (2) Class IV Composite Restoration; (3) Class II Composite Restoration; (4) preparation for a three- unit fixed partial denture; and (5) Class II Amalgam Restoration on a model. The Department selects three examiners to independently grade each candidate’s performance, and the average of the three scores from each examiner produces the overall grade for that procedure. The average grade for each procedure is then weighted in accordance with Rule 64B5-2.013, Florida Administrative Code, which produces an overall score for the entire Clinical portion of the examination. This procedure provides for a more reliable indication of the candidate’s competency. Each examiner must be a licensed dentist for a minimum of five years without having any complaints or disciplinary actions against the examiner’s license. The examiners are not allowed to have any contact with the candidates they are grading. Each examiner must attend, and successfully complete, a standardization session, which trains each examiner to use the same internal grading criteria. In this standardization session, the examiners are thoroughly taught specific grading criteria, which instruct the examiners on how to evaluate the work of the candidates. 8. Examiners numbers 005, 316, 346, 360, 361, and 375, who graded Petitioner’s examination, successfully completed the standardization session. The Department’s post-exam check found these examiners' grading to be reliable. Petitioner received a score of 1.66 on the Class IV Composite Restoration. Petitioner contested this score contending that she was downgraded on this procedure because she mistakenly stained that procedure. The Class IV Composite Restoration consists of the restoration of a chipped tooth. The grading is based on the candidate’s ability to restore the tooth as it appeared before restoration. The goal is to restore the tooth to its proper contact and to restore the contact between the teeth. The fact that Petitioner stained the Class IV Composite Restoration did not result in the examiners downgrading the Petitioner’s procedure. Examiner 005 gave Petitioner a score of 2.00, which was based on the contact being open and not having a flushed fit (marginal error). Examiner 316 gave Petitioner a score of 2.00, which was based on Petitioner’s problems with the functional anatomy, the proximal contour, and with the margin. Examiner 346 gave Petitioner a score of 1.00, which was based on Petitioner’s problems with functional anatomy, proximal contour, and mutilation of opposing or adjacent teeth. Petitioner received a score of 0.00 on the Class II Composite Restoration. Petitioner contested this score contending that she was downgraded twice for the same mistake. A Class II Composite Restoration is a procedure that involves the candidate’s ability to fill an opening inside the tooth with composite, which is a tooth-colored filling. The Candidates were instructed, for security reasons, to place dye in the composite and that failure to place dye in the composite would result in a failing grade. Petitioner failed to place dye in the composite. In addition to his comment concerning no dye in the composite, Examiner 005 also commented that Petitioner’s occlusion was very high, which would result in the premature failure of the restoration. Examiner 005 gave Petitioner a score of 0.00. Examiner 316 also gave Petitioner a score of 0.00, which was based on the absence of dye in the composite and the occlusion being high, which would result in the premature failure of the restoration. Examiner 346 also gave Petitioner a score of 0.00, which was based on the absence of dye in the composite. Petitioner contested the score she received on the Preparation for a 3-unit Fixed Partial Denture procedure claiming that the examiners’ comments regarding insufficient and excessive reduction were conflicting comments. The Preparation for a 3-unit Fixed Partial Denture procedure is a procedure that involves the candidate’s ability to replace a missing tooth with a fixed partial denture or fixed bridge. Petitioner received a score of 2.00 on this procedure. A tooth has five surfaces (front, back, top, inside and outside). Therefore, one surface of the tooth may have insufficient reduction, while another surface of the tooth may have excessive reduction. It is not unusual for examiners to see and comment on different errors. Examiner 316 gave Petitioner a score of 2.00 on this procedure because there was a problem with the outline form, insufficient reduction on the preparation and errors on the marginal finish. Examiner 005 gave Petitioner a score of 2.00 on this procedure because there was a problem with the outline form and there was both insufficient reduction and excessive reduction on the preparation. Examiner 346 gave Petitioner a score of 2.00 on this procedure because there was excessive reduction on the preparation, marginal finish, and mutilation of opposing or adjacent teeth. Petitioner contested the score of 0.66 that she received on the Class II Amalgam Restoration on a model procedure. This procedure is similar to Class II Composite, which involves the candidate’s ability to restore a cavity in the tooth so that the finished product restores proper form and function to the tooth. The difference is that amalgam rather than composite is used for the restoration. The restored tooth should closely resemble its original size and shape. Examiner 316 gave Petitioner a score of 1.00 on this procedure because there was a gingival overhang on the distal lingual aspect of the restoration, which could cause tooth decay and gingivitis. Examiner 346 also gave Petitioner a score of 1.00 because of problems with functional anatomy, proximal contour, margin, and gingival overhang. Examiner 005 gave Petitioner a score of 0.00 because of problems with proximal contour and gingival overhang. Petitioner contested the score of 1.66 that she received on the Periodontal procedure alleging that she was graded unfairly because she could not remove all of the calculus on this procedure, and that one examiner gave her a score of 3.00. The Periodontal procedure involves the candidate’s ability to completely remove any stains, calculus deposits or any foreign debris from the surface of the tooth. Patient selection is very important for the periodontal procedure. It is the candidate’s responsibility to select a suitable patient as clearly outlined in the Candidate’s Information Booklet, which is mailed to the candidate prior to the examination. Petitioner chose a difficult patient, considered to have heavy calculus deposits and severe periodontal disease. Petitioner admitted that she did not remove all of the calculus deposits on her patient. Petitioner failed to present sufficient evidence to show that it was impossible to remove all of the calculus on the patient she had chosen. Examiner 360 gave Petitioner a score of 3.00, but commented that sub-gingival calculus remained on the tooth, and there was root roughness. Examiner 375 gave Petitioner a score of 2.00 because sub-gingival calculus remained on the tooth and there was root roughness. Examiner 361 gave Petitioner a score of 0.00. The basis for this score was that there were heavy deposits of calculus and root roughness on teeth number 19, 29, and 30, and that the procedure was of little value to the patient. The Department provides a re-grade process for all candidates who timely request a hearing. The purpose of the re- grade is to determine if any of the grades rendered were inconsistent. The Department selects the top three examiners who had the highest reliability from that examination to participate in the re-grade. On re-grade, Petitioner’s overall grade increased slightly from 1.89 to 2.10 but not enough for Petitioner to receive a passing grade. The Department’s post-standardization statistics of the examiners’ performance indicated that Petitioner’s examiners graded reliably. The post-standardization statistics indicate the examiner’s performance on grading of models during standardization. In addition, the Department calculates post- examination statistics for the examiners who graded the Petitioner’s challenged procedures. They are: Examiner Accuracy Index & Rating 361 94.2 – Very Good 360 95.1 – Excellent 375 96.0 – Excellent 005 94.3 – Very Good 316 97.0 – Excellent 346 97.2 – Excellent All examiners’ reliability was significantly above the minimum acceptable accuracy index of 85.00.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is accordingly Recommended that the Board of Dentistry enter a Final Order dismissing Petitioner’s challenge to the grades she received on the Clinical portion of the June 2001 dental licensure examination and denying Petitioner licensure as a dentist in the State of Florida due to her failure to receive a passing grade on the June 2001 dental licensure examination. DONE AND ENTERED this 31st day of January, 2002, in Tallahassee, Leon County, Florida. WILLIAM R. CAVE 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) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 31st day of January, 2002. COPIES FURNISHED: Cecilia Diaz 8810 Memorial Highway Tampa, Florida 33615 Cherry A. Shaw, Esquire Department of Health Office of the General Counsel BIN A02 4052 Bald Cypress Way Tallahassee, Florida 32399-1703 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way BIN A02 Tallahassee, Florida 32399-1701 William H. Buckhalt, Executive Director Board of Dentistry Department of Health 4052 Bald Cypress Way BIN C06 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way BIN A02 Tallahassee, Florida 32399-1701
The Issue This matter arose when the claimant applied for in line of duty disability retirement and was advised of the denial of his application of in line of duty disability benefits. The claimant was advised of his right to a hearing pursuant to Chapter 120, Florida Statutes, and filed a Petition for a hearing to determine whether he was entitled to disability in line of duty benefits. The matter was referred to the Division of Administrative Hearings for hearing pursuant to Chapter 120, Florida Statutes.
Findings Of Fact The Petitioner, Pat Q. Trocci, is a 59 year old, white male, whose formal education is limited, and whose primary work experience outside military service in World War II was as a mechanic. The Petitioner was first injured on December 2, 1972, as hereinafter described. Between the date of his injury and 1974 he returned to work several times. During the period May 1973 to June 1974 the Petitioner returned to work on several occasions. The longest period which he worked continuously was six weeks, and during the entire period he worked 100 days. On December 2, 1972, Petitioner, Pat Q. Trocci, was installing a large hydraulic cylinder weighing approximately seven hundred (700) pounds in the back of a garbage truck. Trocci was attempting to push the cylinder into place when it shifted on the chain holding it, sheared the retaining bolt and struck Trocci in turn knocking him into other solid structures in the truck. Trocci, in fear, leaped from the truck and fell again striking himself on objects in the garage. Trocci continued to work, but later that evening began to experience pain. Trocci did not report for work for the next two days which were his regular days off. On the third day, he called in sick and went to the doctor. Dr. Talan administered a pain killing injection to Trocci and gave him oral pain killers. Trocci returned to his house, did some light work, such as watering the lawn, but later that evening experienced severe pain. Trocci was admitted to the hospital within several days suffering from back pain. The tentative diagnosis of the injury was a ruptured disc to Trocci's back with nerve root compression. Trocci was treated conservatively and released for bed rest at home. Thereafter, Trocci returned to work after a lengthy recuperation. Trocci was alternately at work and off work for the next year and a half. He would return to work and perform his duties, but eventually reinjure his back. From May 1973 until June 1974 Trocci worked 100 days of which the longest consecutive period on the job was six weeks. During this period, Trocci was in the care of Dr. Talan and thereafter Dr. Drucker. Trocci suffered primarily from his back ailment during that period. Dr. Drucker's deposition was presented in evidence and considered. Dr. Drucker, an orthopedic, had first seen Trocci in 1972 on referral from Dr. Talan. Dr. Drucker diagnosed Trocci's problem as am inflammation of the nerve root in the lower back. Dr. Drucker had treated Trocci until May 1974, but had last seem Trocci on February 1975. Trocci's medical history included Trocci's description of the accident. Dr. Drucker felt that the trauma was the result of Trocci's accident. Dr. Drucker stated that Trocci's condition was complicated by degenerative back disease, but that the disease was not the cause of Trocci's problems, but adversely affected his response to treatment and rehabilitation. Dr. Drucker indicated that Trocci's problems could be neurological rather than a nerve compression syndrome although he felt his diagnosis was accurate and the best he could make without the further tests to include a myelogram, which he had recommended but which to his knowledge Trocci had not had. Dr. Drucker stated his diagnosis was based on the fact Trocci had no neurological deficits which seemed to eliminate neurological damage. Dr. Drucker felt that Trocci's urological problems were due to extended bed rest, but that he would defer his opinion to the treating doctors. Dr. Drucker stated that in his opinion Trocci could not perform the duties he had performed prior to his injury because he could do no heavy lifting, could not bend, sit, or stand for long periods. Dr. Drucker did feel that Trocci could physically perform sedentary work, but was not aware of Trocci's educational background. Dr. Steinsnyder's report was introduced into evidence as Exhibit 1 and considered. Dr. Steinsnyder had first seem Trocci in August of 1974. At that time Trocci was hospitalized from August 15, 1974 until August 18, 1974 for back pain and bladder retention. Dr. Steinsnyder had treated Trocci from August 15, 1974 until February 12, 1975. The reports in Exhibit 1 indicate that Trocci had had a history of bladder retention during the period of Steinsnyder's treatment. Dr. Steinsnyder urged Trocci on January 22, 1975 to seek a fellow up on his nerve root compression with an orthopedic surgeon or neurelogic surgeon. Trocci was hospitalized on January 31, 1975 in Osteopathic General Hospital, North Miami Beach under Dr. Steinsnyder. Dr. Gonyaw was called in as a neurological consultant at that time. 10 Dr. Gonyaw had a myelogram performed on Trocci shortly after first seeing Trocci on February 2, 1975. Dr. Gonyaw expressed his opinion that at that date Trocci had reached maximum medical improvement. Based upon the results of the myelogram, Dr. Gonyaw eliminated nerve root compression resulting from a ruptured disc as a cause of Trocci's problems. This meant, in Dr. Gonyaw's opinion, that Trocci's problems were the result of a trauma of the spinal cord which had left Trocci with permanent damage. Dr. Gonyaw explained that such an injury is sometimes followed by a slow deterioration of the spinal cord which causes progressively severe symptoms. Dr. Gonyaw found that Trocci had impaired control of his legs, a continually worsening urological condition, and probably worsening neurological condition. Dr. Gonyaw felt that Trocci's real problem was neurological and not urological, but clearly indicated that in his condition Trocci could not perform any real work beyond some sort of hand piece work at his home. The deposition of Dr. Gilbert was also introduced into evidence and considered. Dr. Gilbert saw Trocci on August 22, 1973, at which time Trocci advised Dr. Gilbert of his earlier treatment by Drs. Drucker, Steinsynder, and Gonyaw. Dr. Gilbert stated that Trocci's symptoms were pains radiating from the lower back and buttocks into the legs and urinary retention and bladder infection. Dr. Gilbert's examination revealed that Trocci's movements were abnormally diminished, he exhibited bilateral sciatic tenderness, but that Trocci had had no sensory loss and his deep tendon reflexes were normal. Dr. Gilbert's medical opinion was that Trocci should not do any heavy lifting, no prolonged standing or sitting and no climbing. Because of his urological problems, Dr. Gilbert felt Trocci's ability to work is even more restricted. Dr. Gilbert's prognosis was one of continuing worsening of Trocci's condition, with the spread of infection eventually to his kidneys. The doctors involved have indicated in the fashion used in Workman's Compensation cases that the Petitioner is between 60 percent and 80 percent permanently partially disabled. They have all indicated that Trocci is not totally immobile and could do some light work with his hands. A listing of various job descriptions and positions was introduced by the Division as Exhibit 2 together with the affidavit of the head of the State's classification branch. The Hearing Officer finds having reviewed these descriptions and considered the obvious physical requirements of the various positions that the Petitioner could not perform any of these duties on a day in and day out basis based on the doctors' evaluations of his limitations.
Recommendation Based upon the preceding findings of fact and conclusions of law, it is recommended that the Petitioner receive disability in line of duty retirement benefits. DONE and ORDERED this 16th day of February, 1976. STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: L. Keith Pafford, Esquire Counsel for Respondent Albert E. Harum, Jr., Esquire Counsel for Petitioner
Findings Of Fact The Department hereby adopts and incorporates by reference the findings of fact set forth in the Recommended Order.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health and Rehabilitative Services enter a Final Order directly Children's Medical Services for District VII to authorize coverage for the reconstructive surgery recommended and proposed by J. Barry Boyd, M.D. DONE and ORDERED this 6th day of November, 1985, in Tallahassee, Florida. DIANE K. KIESLING Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 6th day of November, 1985. COPIES FURNISHED: Gerry L. Clark, Esquire HRS District Seven Assistant Legal Counsel 400 West Robinson Street Orlando, Florida 32801 Ms. Cynthia Thibeault 1415 Overdale Street Orlando, Florida 32817 David Pingree Secretary 1323 Winewood Boulevard Tallahassee, Florida 32301 ================================================================ =
The Issue Whether Respondent violated Subsections 466.028(1)(m) and 466.028(1)(x), Florida Statutes (2001), and, if so, what discipline should be imposed.
Findings Of Fact The Department is charged with regulating the practice of dentistry pursuant to Section 20.43 and Chapters 456, 466, and 120, Florida Statutes (2003). At all material times to this proceeding, Dr. Nguyen was a licensed dentist in the State of Florida, having been issued license number DN0014768. On April 17, 2002, Patient J.N. presented to Dr. Nguyen complaining with pain from a broken tooth. She brought a full set of x-rays taken by another dentist approximately a year before her visit to Dr. Nguyen. J.N. filled out a form entitled "Health Questions." J.N. indicated on the form that her teeth were sensitive to cold. He examined J.N.'s teeth and saw that tooth 30 was fractured to the gum line. J.N. complained that the broken area of the tooth was sharp and was rubbing against her tongue causing irritation. His examination further revealed that she had some slight gum disease in the upper right side. J.N. was not experiencing a throbbing pain from tooth 30, and tooth 31 was not giving her any discomfort. Her discomfort was due to the inflammation of her gums and her tongue. Dr. Nguyen did a percussion test, i.e. tapping on the tooth, and probed in her mouth, measuring the tooth. Dr. Nguyen did not do any vitality testing and did not perform any periodontal charting of the teeth. J.N. did not want Dr. Nguyen to take any additional x-rays since she had brought a full set of x-rays with her. Dr. Nguyen felt that the set of x-rays that J.N. provided was sufficient for him to be able to treat J.N. for her fractured tooth. The x-rays did not show the fracture, but fractures may not necessarily show up on an x-ray. Dr. Nguyen told J.N. that she may or may not need a root canal. Dr. Nguyen discussed treatment options with J.N., and she decided to have a three-quarter crown on one tooth and an overlay on the other tooth. He removed all of the fracture of tooth 30 and made impressions for the three-quarter crown and inlay, which were sent to the laboratory for the fabrication of the crown and inlay. She left the office with temporary teeth on teeth 30 and 31. Dr. Nguyen made the following progress note concerning his treatment of J.N. on April 17, 2002: pt came in w/ fmx from another DDS. Dr. Richardt in Bonita. Both 30 & 31 have very large old fractured decay amalgam. Both lingual cusps #30 fractured to gingival line. Complaint of "uncomfortable." #30 prep for crown / 3/4 crown. #31 prep for MOB onlay. Composite provisional. A few days later, J.N. called Dr. Nguyen's office complaining of a lot of pain. J.N. was given a prescription for penicillin and Tylenol No. 3. On April 26, 2002, J.N. returned to Dr. Nguyen's office complaining of pain. She had taken the prescribed pain medication prior to her visit so that it was difficult for Dr. Nguyen to assess the pain. Dr. Nguyen made an adjustment to her bite and told her that if the pain continued that he would refer her to an endodontist. Dr. Nguyen asked J.N. to stop taking the pain medication and return to his office after 5 p.m. that day so that he could accurately assess her pain without having the pain medication masking the pain. She did not return to his office. On May 1, 2002, J.N. went to see another dentist, who referred J.N. to Juan Pablo Rodriguez, D.D.S. (Dr. Rodriquez), who specializes in root canals. J.N. complained to Dr. Rodriguez that she was having pain in tooth 30 and it was waking her up at night. Tooth 31 did not respond to cold. Dr. Rodriguez diagnosed J.N. with irreversible pulpitis for tooth 30, which means that the nerve of the tooth had inflammation, and that the nerve would not get better, but would die. He determined that tooth 31 was non- vital or necrotic. On May 8, 2002, J.N. called Dr. Nguyen's office and stated that she wanted to have her tooth extracted rather than have to pay for a root canal. She indicated she wanted her money back. The next day, J.N. came to Dr. Nguyen's office demanding her money back and wanting her x-rays. Dr. Nguyen kept the original x-rays and provided J.N. a copy of the x-rays which she had furnished him on her initial visit. J.N. had paid Dr. Nguyen a portion of his fees by credit card, and a portion of his fees had been paid by J.N.'s dental insurance plan. Dr. Nguyen refunded all fees paid to him. Melvin A. Platt, D.D.S., testified as an expert witness for the Department. It is Dr. Platt's opinion that Dr. Nguyen, in relation to his treatment of J.N., did not practice dentistry within the minimum standards of performance in diagnosis and treatment when measured against generally prevailing peer performance. His opinion is based on Dr. Nguyen's failure to determine the need for a root canal prior to preparing the teeth for restoration. According to Dr. Platt, Dr. Nguyen should haven taken an x-ray of teeth 30 and 31, performed vitality testing, and done periodontal charting. Dr. Platt was also of the opinion that the dental records maintained by Dr. Nguyen regarding his care of J.N. failed to justify his course of treatment. According to Dr. Platt there was nothing in the progress notes to justify going ahead with the restorations without any prior testing of any kind. Dr. Nguyen's license has previously been disciplined by the Department for failing to include in an advertisement the statement required by Section 456.062, Florida Statutes (1999). Department of Health v. Luyen Nguyen, D.D.S., Case No. 2000- 01848 (Dept. of Health 2002).
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered finding that Luyen Nguyen, D.D.S., did not violate Subsection 466.028(1)(m), Florida Statutes, but did violate Subsection 466.028(1)(x), Florida Statutes; imposing a $1,000 administrative fine; and issuing a reprimand. DONE AND ENTERED this 4th day of March, 2004, in Tallahassee, Leon County, Florida. S SUSAN B. KIRKLAND 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) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 4th day of March, 2004.
The Issue Whether Petitioner is entitled to licensure as an orthotic fitter.
Findings Of Fact Chapter 468, Florida Statutes, regulates miscellaneous professions and occupations in Florida. Chapter 97-284, Laws of Florida, created Sections 468.80-468.813, Florida Statutes. These provisions, referred to as Part XIV of Chapter 468, regulate the practice of orthotics, prosthetics, and pedorthics. Respondent is the agency of the State of Florida responsible for administering the provisions of Chapter 468, Florida Statutes. Section 468.80(5), Florida Statutes, provides the following definition pertinent to this proceeding: (5) "Orthotic fitter" means a person who is licensed to practice orthotics, pursuant to a licensed physician's written prescription, whose scope of practice is limited to fitting prefabricated cervical orthosis 1/ not requiring more than minor modification; pressure gradient hose; trusses; custom-molded therapeutic footwear; prefabricated spinal orthoses, except for those used in the treatment of scoliosis, rigid body jackets made of thermoformable materials, and "halo" devices; and prefabricated orthoses of the upper and lower extremities, except for those used in the treatment of bone fractures. Section 468.803, Florida Statutes, sets forth certain criteria for licensure as an orthotic fitter. The parties to this proceeding stipulated that Petitioner has met all criteria for licensure as an orthotic fitter except the criteria found at Section 468.803(3)(c)3., Florida Statutes, which requires two years of experience in orthotics, as approved by the board. Section 468.805, Florida Statutes, is the following grandfathering provision: A person who has practiced orthotics in this state for the required period since July 1, 1990, who, before March 1, 1998, applies to the department for a license to practice orthotics may be licensed as a orthotic fitter, as determined from the person's experience, certification, and educational preparation, without meeting the educational requirements set forth in s. 468.803, upon receipt of the application fee and licensing fee and after the board has completed an investigation into the applicant's background and experience. The board shall require an application fee not to exceed $500, which shall be nonrefundable. The board shall complete its investigation within 6 months after receipt of the completed application. The period of experience required for licensure under this section is 2 years for an orthotic fitter. On July 21, 1998, Petitioner filed an application for licensure as an orthotic fitter. The application, on a form adopted by Respondent as a rule, required the applicant to state whether the applicant was seeking licensure based on examination (pursuant to Section 468.803, Florida Statutes) or pursuant to Section 468.805, Florida Statutes. Since the deadline for filing pursuant to the grandfathering provision expired March 1, 1998, Petitioner marked the application to reflect that the licensure was to be based on examination, the only option available to her at that time. Along with the application form, Respondent sends to applicants for licensure copies of the relevant statutes and rules with instructions that an applicant should read those statutes and rules prior to completing the application. Petitioner admitted that she had received those statutes and rules and that she had read them before completing her application for licensure. Chapter 99-158, Laws of Florida, became effective on May 13, 1999, and provides as follows: Any person who met the period of experience requirement set forth in section 468.805(1), Florida Statutes, prior to March 1, 1998, may apply for licensure pursuant to section 468.805(1), Florida Statutes, prior to July 1, 1999. This provision was the basis for the Order of Abeyance entered May 5, 1999, which placed the proceeding in abeyance until July 1, 1999. Petitioner did not apply for licensure pursuant to the provisions of Section 468.805(1), Florida Statutes, after the enactment of Chapter 99-158, Laws of Florida, nor did she request that her pending application be amended to reflect that she was seeking licensure pursuant to the grandfathering provision. 2/ At the final hearing, Petitioner, through counsel, asserted that her application should be considered to be pursuant to either examination or to the grandfathering provision. Under the grandfathering provision, an applicant must demonstrate that he or she had practiced orthotics in the State of Florida for two years between July 1, 1990, and March 1, 1998. At all times pertinent to this proceeding, Petitioner has been the owner and operator of Ultra Tech Medical Supply and Equipment, Inc., a company she founded in 1991. Ultra Tech's primary business is the selling and renting of durable medical equipment such as wheelchairs, canes, and crutches to patients and to physicians. As will be discussed in more detail below, Ultra Tech occasionally sells orthotic devices. On those occasions, Petitioner has served as the fitter for those devices. Ultra Tech has never had a licensed or certified orthotist or medical doctor on its staff. Petitioner has never worked under the direct supervision of a certified orthotist or medical doctor. At the times pertinent to this proceeding, Petitioner never worked under anyone else's supervision. She has never served as an orthotic fitter assistant. 3/ Petitioner's exhibits include numerous invoices, some of which represent orthotic devices she purchased and subsequently fitted between November 1994 and January 2000. Some of the invoices in the composite exhibits are duplicates while others are for purchases of supplies or equipment that are not orthotic devices. The invoices for orthotic devices established that fitting orthotic devices was a very minor part of Petitioner's work week in that she fitted an average of less than two orthotic devices per week. The testimony established that Petitioner spent much less than thirty hours per week fitting orthotic devices.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Respondent enter a final order denying Petitioner's application for licensure as an orthotic fitter. DONE AND ENTERED this 19th day of April, 2000, in Tallahassee, Leon County, Florida. CLAUDE B. ARRINGTON 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) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 19th day of April, 2000.
The Issue Whether Respondent committed the violations alleged in the Amended Administrative Complaint? If so, what disciplinary action should be taken against him?
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: The Agency is a state government licensing and regulatory agency. Respondent is now, and has been since approximately 1968 or 1969, a physician licensed to practice medicine in the State of Florida. He holds license number ME 0014162. 3/ Since the completion of his residency in December of 1971, Respondent has specialized in orthopedics. He currently is chief of orthopedics at Broward General Hospital. Respondent has not had any training in psychotherapy other than that which he received in a psychiatry class that he was required to take in medical school. His training in biofeedback is limited to that which he received during his residency over a period of three or four years as a result of his involvement in the treatment, with biofeedback, of approximately 15 or 20 patients. Deborah F. Cowart has a M.S. degree in counseling/guidance that she received from Nova University in 1981 and a Ph.D. degree in clinical psychology that she received from Kensington University in California in 1985. Although she is now, and has been since January 31, 1991, licensed as a mental health counselor in the State of Florida, at no time material to the instant case did Dr. Cowart hold a license to engage in mental health counseling or any profession regulated by the state. In 1986, Dr. Cowart opened the Center for Psychological and Diagnostic Services (hereinafter referred to as the "Center") in Fort Lauderdale. The Center provided pain management counseling and biofeedback services to those suffering from chronic pain. (Biofeedback is recognized in the medical community as an acceptable therapeutic modality for the treatment of chronic pain.) Dr. Cowart was the operator and sole owner, through a professional association, of the Center. In addition to her administrative duties, she worked at the Center as a therapist directly providing pain management counseling and biofeedback services to patients. At all times material to the instant case, Respondent was the Center's medical director. Initially, he served in this capacity pursuant to an oral agreement that he had with Dr. Cowart. In or around the latter part of 1990, the agreement was reduced to writing. As medical director, Respondent was a member of the Center's pain management team. He did orthopedic consultations. In addition, he conferred with the Center's two therapists, Dr. Cowart and Philip Schmidt, concerning the progress of their patients and, based upon the information they furnished him, determined, with regard to each patient discussed, whether the course of treatment and therapy the patient was receiving was medically appropriate and necessary and should continue. In this respect, Respondent "supervised" Dr. Cowart and Schmidt. At no time, however, did Respondent ever advise Dr. Cowart or Schmidt as to how they should perform the pain management counseling and biofeedback services they provided their patients, nor was he physically present when these services were rendered. Respondent himself never provided such services to any of the Center's patients. In his role as the Center's medical director, Respondent was not required to, nor did he, perform any task he was not qualified to perform. When Dr. Cowart first approached Respondent about becoming the Center's medical director, she offered to pay him a "stipend" of $1,000.00 a month for his services. Dr. Cowart, however, subsequently determined that she was not able to pay Respondent that large a stipend. She and Respondent thereafter agreed that she would pay him whatever she deemed to be appropriate, given the number of hours Respondent devoted to his medical director duties and her ability to pay him. 4/ In 1988 and 1989, Dr. Cowart paid Respondent $2,970.00 and $7,475.00, respectively, for serving as the Center's medical director. During the time that he was the Center's medical director, Respondent referred orthopedic patients of his to the Center. He did not receive a kickback from Dr. Cowart for making these referrals. While Dr. Cowart made payments to Respondent, these payments were made to compensate Respondent for performing his duties as the Center's medical director, not for referring patients to the Center. One of the patients that Respondent referred to the Center was W.K., a thirty-year old man suffering from arm, neck and back pain as a result of an on- the-job injury. W.K. had been referred to Respondent by his employer's workers' compensation insurance carrier "for a second opinion." Respondent first saw W.K. on April 8, 1986. On this initial visit, he took a history from W.K. and examined him. Respondent's impression was that W.K. had an "acute cervical sprain resolving" and "acute lumbar sprain resolving." Respondent referred W.K. to the Center on May 20, 1986, after determining that W.K.'s problem was more of a "psychological" one and that there was little, if anything, that he was able to do orthopedically to help W.K. Respondent made the referral, not for his own or Dr. Cowart's personal gain, but because he reasonably believed that it was in W.K.'s best interest to receive the services that the Center provided. At the time he made the referral, as well as at all other times material to the instant case, Respondent did not know, nor did he have reason to believe, that Dr. Cowart was not qualified, by training, experience or licensure, to perform these services. 5/ Pursuant to Respondent's authorization, Dr. Cowart held a total of approximately 111 or 116 pain management counseling and biofeedback therapy sessions with W.K., for which she sought and received payment from Cigna Insurance Company. With Respondent's permission, Dr. Cowart put Respondent's Florida medical license number on the insurance claim forms she submitted to Cigna. In filling out the claim forms, Dr. Cowart used the procedure code for "psychotherapy," 90844, to bill for the pain management counseling services provided W.K. She believed that, in so doing, she was using the correct procedure code to describe these services. 6/ Respondent did not have any reason to believe that any of the information on the forms Dr. Cowart filled out was false. Throughout the period that W.K. received treatment at the Center, Dr. Cowart and Respondent conferred on a regular basis to discuss W.K.'s case. Based upon what Dr. Cowart told him about the progress W.K. was making and what he knew about W.K. as a result of his contact with the patient, Respondent authorized the continuation of the pain management counseling and biofeedback therapy W.K. was receiving at the Center.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby recommended that the Board of Medicine enter a final order dismissing the Amended Administrative Complaint issued against Respondent in its entirety. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 23rd day of May, 1995. STUART M. LERNER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 23rd day of May, 1995.
Findings Of Fact Respondent is a chiropractic physician licensed by the Florida State Board of Chiropractic Examiners, who practices in Cape Coral, Florida. In the Sunday, August 6, 1978, edition of the Fort Myers News-Press there was published an advertisement which was headlined "Chiropracters Seek Research Volunteers." The text of this advertisement read as follows: The International Pain Control Institute is presently engaged in what is the most extensive research program ever undertaken by the chiropractic profession. This research is directed toward determining the relationship between health problems and spinal misalignments and utilizes a screening process called Contour Analysis. Volunteers are being sought for screening. Contour Analysis enables taking a three- dimensional picture (called Moire photography) of the topography of the surface of the spine to detect spinal stress deviations. This analysis will be correlated with leg deficiency, patient symptomatology, and levels of spinal tenderness. An analysis of this type can reveal such things as normal and abnormal stress paterns [sic], spinal curvature, muscle spasms, muscle imbalance, spinal distortions, and scoliosis. This is a public service program for participating volunteers. The doctors are contributing their time, service, and facilities for the program. Anyone wishing to be a volunteer may tele- phone participating doctors directly for information or an appointment. In the above-quoted advertisement, readers were directed to contact the office of Respondent ". . . for free consultation, preliminary exam and Contour Analysis . . ." Peggy Mills, and her husband, Harry Mills, both of Cape Coral, Florida, read the above-quoted advertisement on or about August 6, 1978. Mr. and Mrs. Mills each made an appointment with Respondent for Contour Analysis on August 12, 1978. Mr. and Mrs. Mills both appeared at Respondent's office on August 12, 1978, and advised Respondent that they had come in response to his advertisement in the Fort Myers News-Press. Respondent performed a Contour Analysis on both Mr. and Mrs. Mills. Respondent advised Mrs. Mills that the Contour Analysis indicated some physical problem in her neck, which was consistent with the medical history given by Mrs. Mills. Respondent advised Mrs. Mills that, since she had volunteered to participate in the Contour Analysis program, that he would perform an additional X ray and would allow her three additional office visits for a charge of $75.00. Respondent also advised Mr. Mills that his condition did not appear to be as bad as that of his wife, and that Respondent would perform the same procedures on Mr. Mills for only $50.00. Respondent left Mr. and Mrs. Mills alone to discuss whether they wished to avail themselves of the proffered additional treatments. Mr. and Mrs. Mills apparently decided to proceed with treatment and, on August 12, 1978, gave to Respondent a post-dated check in the amount of $125 to cover the cost of that treatment. Payment in the form of the post-dated check was made after Mr. and Mrs. Mills had requested that they be allowed to pay Respondent for the continued treatments on an installment basis after each office visit. Both Mr. and Mrs. Mills testified that they made their initial appointment in response to the advertisement assuming that the "research program" was a government funded program and that they would, in effect, be getting "something for nothing" in that they would obtain a diagnosis of their condition at no charge. In fact, Respondent performed a Contour Analysis on both Mr. and Mrs. Mills, showed them the photograph resulting from this analysis, discussed the photograph with them, and performed a gross physical examination, including palpation of their spines, on both of them. In addition, both Mr. and Mrs. Mills were furnished with research questionnaires which they filled out on their initial visit to Respondent's office. Respondent charged, and received, nothing from either Mr. or Mrs. Mills for the services performed during the August 12, 1978, visit. In the course of discussing the results of the Contour Analysis with Mr. and Mrs. Mills, Respondent informed Mr. Mills that there appeared to be little that he could do for him, but that there was a possibility that he could help Mrs. Mills with her neck problems. Respondent further advised both Mr. and Mrs. Mills that for a total of $125, he would see both of them for an additional three office visits, the first of which would involve the taking of additional X rays, followed by a second visit for a thorough physical examination, and a final appointment to discuss additional findings and a recommended course of treatment, if necessary. Respondent also advised both Mr. and Mrs. Mills that he could refer them to another doctor should he conclude that he could do nothing further for them at the end of the third visit. Although Mr. and Mrs. Mills agreed to pursue this course of treatment, and delivered a post-dated check to Respondent for $125, they apparently later had second thoughts about the advisability of receiving further treatment from Respondent. Mrs. Mills apparently checked with other chiropractic physicians and determined that she could obtain the type of diagnostic procedures offered by Respondent at a cheaper price. In fact, it appears from the evidence in the record in this proceeding that Mr. and Mrs. Mills' chief complaint was not that Respondent proposed to charge them for the three follow-up consultations, but that the amount which he proposed to charge was too high. Mr. and Mrs. Mills stopped payment on the post-dated $125 check and declined to keep the appointments which they had initially scheduled with Respondent. No testimony was offered in this proceeding regarding the existence, location or function of the International Pain Control Institute. No testimony was offered by Petitioner in this proceeding to indicate that Petitioner gave notice to Respondent of facts which the agency contends warrant the revocation, suspension, annulment or withdrawal of his license to practice chiropractic, or that Respondent was given an opportunity, prior to the filing of the Administrative Complaint in this cause, to demonstrate compliance with all lawful requirements for the retention of his license.
Findings Of Fact Dr. Jones is and at all times relevant has been licensed as a physician in the State of Florida, holding license No. ME 0017106. Following his medical training, internship, and residencies, Dr. Jones entered the private practice of orthopedic surgery in Inverness, Florida in 1976. He is board certified by the American Board of Orthopaedic Surgeons and is a Fellow of the American Academy of Orthopaedic Surgeons. Dr. Jones practiced medicine in his specialty of orthopedic surgery in Inverness from 1976 to 1987. Thereafter he has had the same type of practice in the State of Georgia. He has treated thousands of patients and this case is the only disciplinary action ever brought against Dr. Jones. By its Administrative Complaint, DPR charged Dr. Jones with two counts against two patients. As to Patient 1, C.D., DPR charged Dr. Jones with violating Section 458.1201(1)(aa), Florida Statutes (1978), by "being guilty of immoral or unprofessional conduct, incompetence, negligence, or willful misconduct" in his treatment of C.D. in 1978. There is no such section in the 1978 statutes. While DPR stated at hearing that this was a typographical error and should say Section 458.1201(1)(m), no motion to amend was filed. As to Patient 2, D.S. (who was incorrectly called D.C. throughout the transcript), DPR charged Dr. Jones with violation of Section 458.331(1)(t), Florida Statutes (1985), by "gross and repeated malpractice or the failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances." He treated D.S. in 1985. The only evidence offered by DPR to prove its allegations was that of Donna Shortreed, current records custodian at Citrus Memorial Hospital, and D.S. DPR's only expert, Dr. Zeide, testified by deposition which was filed after the hearing. Ms. Shortreed has only been employed at the hospital since October, 1988, which is years after the hospitalizations of these two patients. Ms. Shortreed had no knowledge of how hospital records were maintained before she was hired. She was not able to testify about the completeness of the records provided, but did know that x-rays taken more than five years ago were purged and x-rays no longer existed for these two patients. All she could state was that she had brought all the medical records she could find on these two patients. Patient 1, C.D. On August 4, 1978, C.D. was injured in a one-car accident and sustained numerous injuries, including what initially appeared to be a simple intertrochanteric fracture. Dr. Jones was called in for the orthopedic consultation and he scheduled surgery for the next day for an open reduction and reposition of the fracture. Once the site was viewed in the course of surgery, it became apparent that there were serious comminuted fractures, both intertrochanteric and subtrochanteric, of the right proximal femur. One fracture was a varus displaced intertrochanteric fracture between the trochanters. A trochanter is one of the bony prominences near the upper extremity of the femur. A varus displaced intertrochanteric fracture is one where the broken bone is moved out of its normal placement and is bent inward. Going into the operation, Dr. Jones had planned to use a Massey nail, but during the operation it was determined that the Massey nail did not come in the angle which was required to repair that fracture. Citrus Memorial was a rural hospital in 1978 and Dr. Jones was the only orthopedic surgeon. The hospital's inventory of orthopedic devices was scant. Given the limited choices available to him, Dr. Jones decided to repair the fracture with an Jewett nail which is a fixed angle nail plate device. Dr. Jones knew that such a device had a potential for bending if the patient attempted to bear weight too soon, but he used the Jewett nail and wires and screws because it was the only realistic choice available to him. C.D. had a seizure disorder which she apparently attempted to hide in order to protect her job as a nurse at Three Rivers Hospital. C.D.'s recovery was not progressing well as a result of a pulmonary embolism which occurred subsequent to the surgery. Additionally, on August 28, 1978, C.D. suffered a grand mal seizure and fell out of bed. X-rays after this fall showed that the internal fixation which had been accomplished by Dr. Jones had failed. A second operation was necessary, but could not occur until she was cleared of the blood thinners she was on for the pulmonary embolism. On September 7, 1978, Dr. Jones performed the second surgery. He was in the operating room unassisted by any other doctor because there was no other orthopedic surgeon, anesthesiologist or neurologist in the area. Dr. Jones had ordered a Zickel fracture repair device so that the patient could achieve immediate weight bearing and thereby attempt to fend off another embolism. When Dr. Jones opened the surgical site, he found a comminution fracture, or one in which the bones were in pieces. By the time he had been able to clean out all of the previous repair material and bone fragments and to attempt the fracture repair, C.D. had been in the operation five hours and had needed 5 units of blood. While a bone graft would have been the best solution to this difficult problem, Dr. Jones believed that he needed a faster way to fixate the bone and get her off the operating table. A bone graft would have required assistance from other doctors who simply did not practice in the area and would be a long and bloody operation in itself. Because of all these factors, Dr. Jones opted to fixate the fracture using a Zickel rod and a Zickel screw together with bone cement. He thought that was the only available option except for a bone graft. He knew that his treatment was not customary, but it was all he could do at the moment. Knowing that bone cement could not be expected to take the place of natural bone, Dr. Jones placed many restriction on C.D.'s activity, including no return to work for at least six months and no going up or down stairs. C.D. did not comply with these restrictions, but instead returned to work and used stairs. While using the stairs, the repair failed and C.D. had to have another repair. That repair was done at another hospital by other physicians and consisted of the bone graft. That bone graft and another one attempted by even another doctor both failed. DPR's only charge against Dr. Jones for his treatment of C.D. is that he used bone cement to maintain the length of the femur instead of an autologous or heterogeneous bone graft and that use of bone cement to maintain length is below the acceptable level of care. Patient 2, D.S. Patient 2, D.S. (referred to as D.C. throughout the transcript), was brought to Citrus Memorial Hospital on October 29, 1985. She was 56 years old and had a 30-year history of brittle, insulin dependent diabetes which was very poorly managed. D.S. was admitted by her regular doctor with a confusing history of unknown, but significant, trauma. She was suffering from a compression fracture of the twelfth thoracic vertebrae and compound fractures of both shoulders. In both shoulders, the top of the arm bone, the humerus, was broken and the ball or humeral head was broken into multiple pieces. Both shoulders were dislocated. Dr. Jones was called in for an orthopedic consultation. He determined that surgery was necessary, but proceeded cautiously because D.S. was a high risk patient. On consultation with D.S. and her physician, it was decided that two surgeries would be performed, first on the right shoulder and second on the left. The first operation occurred on November 4, 1985, but was very difficult. Dr. Jones managed to put the pieces back together with screws. With difficulty, Dr. Jones was able to get the shoulder aligned and to maintain the position, but he suspected that it may still be dislocated anteriorly. Surgical x-rays showed proper alignment and position. X-rays later showed that the right shoulder was dislocated and that further reduction was necessary. On November 7, 1985, Dr. Jones took D.S. back to the operating room and first attempted a closed reduction of the right shoulder dislocation. The closed reduction was unsuccessful so Dr. Jones had to reopen the surgical site. D.S. had signed a release for this procedure and Dr. Jones considered it to be an emergency, not elective, surgery. Once Dr. Jones had reopened the right shoulder, he determined that the screw fixations were not working, so he removed the screws and removed the pieces of bone. He removed the humeral head and knowingly created a "hanging shoulder" or one without a ball, because he believed that would leave D.S. pain free. Dr. Jones then performed the same type of procedure on the left shoulder and excised the humeral head. Dr. Jones considered reconstructive surgery at that time, but decided that insertion of prosthetic devices would require a lengthy surgery, which was unacceptable in this high risk patient. Instead, his goal was to relieve the pain which D.S. was suffering as quickly as possible. If D.S. made it through that surgery with no significant problems, Dr. Jones then planned to do the reconstructive surgery later, one arm at a time. He thought that the reconstructive surgery was better done in a high risk patient as staged elective procedures. D.S. did develop problems while she was hospitalized. She developed a pneumothorax (free air in the chest cage which compresses the lung) on the right and pneumonia on the left. D.S. did not follow through with Dr. Jones, but later she did have reconstructive surgery on both shoulders which was not successful. DPR charged Dr. Jones with failing to met the standard of care because he "performed a bilateral excision of Patient #2's humeral heads without considering other options, specifically prosthetic replacements." DPR's Expert, Dr. Zeide The only evidence against Dr. Jones was the deposition testimony of Dr. Zeide. It must be found that Dr. Zeide's opinions are unsupported by the record and are entirely incompetent to support the charges against Dr. Jones. Apparently, Dr. Zeide considered "a whole stack of records and x- rays." But no where in his deposition does he identify with specificity what he relied on in reaching his opinions. In fact, it is clear that he considered numerous documents which are not admissible in this proceeding, including the entire DPR case file which contained inadmissible letters from lawyers, articles from unidentified journals, insurance company reports, documents obtained from lawyers' offices, pleadings and documents from civil court files, statements from people gathered by DPR, etc. DR. Zeide also apparently said he reviewed hospital records, but as was apparent from Donna Shortreed's testimony, those records are not complete and do not contain any x-rays. Additionally, no credible evidence was offered to establish that the records reviewed by Dr. Zeide were the same as the hospital records introduced into evidence as Petitioner's Exhibits 4 and 5. Further, Dr. Zeide said he reviewed x-rays which he had then "returned." No evidence established what these x-rays were of or where they are now. In fact, the only credible testimony is that no x-rays exist for either of these patients. Throughout his deposition, Dr. Zeide read from documents which are not in evidence and for which no proper predicate was laid. Finally, Dr. Zeide clearly had absolutely no idea what the applicable standard of care was in rural Citrus county in either 1978 or 1985. For 1978, Dr. Zeide said the standard of care in Citrus County "was the standard of care that prevailed in communities that were for any orthopedic surgeon in the State of Florida. . . . That was--those procedures that were appropriate based on basic science and based on the treatment of patients who had similar--who had certain particular types of problems." For 1985, Dr. Zeide said the prevailing standard of care in Citrus County was "that type of orthopedics that would be practiced by orthopedic surgeons in Citrus County, in the State of Florida." When asked if that was his definition, Dr. Zeide then said "I don't think I have an exact definition that I--in terms of, you know, to espouse it to you. It's just what would be acceptable practice of care or those that would not be acceptable practices of care." These standards as articulated by Dr. Zeide bear no relationship to the standards of care as defined by relevant statutes or by his understanding of those standards. Hence, his opinions are entitled to no weight and are not competent proof. Additionally, Dr. Zeide is not a comparable physician because he has no knowledge or understanding of orthopedic practice in a small fifty-bed rural hospital with little or no assistance from other medical doctors. One more problem exists with the DPR proof and the entire prosecution of this case, especially as it relates to C.D. That problem is that these events occurred in 1978 and only partial records exist. No x-rays exist and no reliable expert opinion can be expressed regarding orthopedic procedures absent the x-rays made at the time. Such a delay in prosecution by DPR results in an infringement on Dr. Jones' rights to adequately prepare a defense to such stale charges.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Professional Regulation, Board of Medicine, enter a Final Order dismissing the charges against R. Dewitt Jones, M.D. DONE and ENTERED this 5th day of October, 1992, in Tallahassee, Florida. DIANE K. KIESLING Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 5th day of October, 1992. APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 91-4549 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on the proposed findings of fact submitted in this case. Specific Rulings on Proposed Findings of Fact Submitted by Petitioner, Department of Professional Regulation 1. Each of the following proposed findings of fact is adopted in substance as modified in the Recommended Order. The number in parentheses is the Finding of Fact which so adopts the proposed finding of fact: 1(1). 2. Proposed findings of fact 2-18, 25, 29, 30, 33-41, 43-49, 54 and 56 are subordinate to the facts actually found in this Recommended Order. 3. Proposed findings of fact 19-24, 26-28, 42, 50, 52, 53, and 57-62 are unsupported by the credible, competent and substantial evidence. 4. Proposed findings of fact 31, 32, 51, and 55 are irrelevant. Specific Rulings on Proposed Findings of Fact Submitted by Respondent, R. Dewitt Jones, M.D. 1. Because of Dr. Jones' failure to number his findings of fact and failure to make citations to the record, specific rulings are impossible. Generally stated, Respondent's proposed findings of fact are subordinate to the facts actually found in this Recommended Order, except that those proposed findings which are not even mentioned in this Recommended Order are rejected as irrelevant, unnecessary or unsupported by the evidence. COPIES FURNISHED: Francesca Plendl Senior Attorney Department of Professional Regulation 1940 N. Monroe St., Suite 60 Tallahassee, FL 32399-0792 W. Marvin Hardy, III Attorney at Law Gurney & Handley, P.A. 225 E. Robinson St., Suite 450 Post Office Box 1273 Orlando, FL 32802-1273 Jack McRay, General Counsel Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Dorothy Faircloth Executive Director Board of Medicine Northwood Centre 1940 North Monroe Street Tallahassee, FL 32399-0792
The Issue The issues to be determined are whether Respondent violated the applicable standard of care in the practice of dentistry in violation of section 466.028(1), Florida Statutes, as alleged in the Administrative Complaints filed in each of the consolidated cases; and, if so, the appropriate penalty.
Findings Of Fact The Department of Health, Board of Dentistry, is the state agency charged with regulating the practice of dentistry in the state of Florida, pursuant to section 20.43, and chapters 456 and 466, Florida Statutes. Stipulated Facts Respondent is a licensed dentist in the state of Florida, having been issued license number DN14223 on or about December 1, 1995. Respondent’s address of record is 530 East Howard Street, Live Oak, Florida 32064. Respondent was licensed to practice dentistry in the state of Florida during all times relevant to the administrative complaints underlying this case. Patient T.C. was a patient of Respondent. Patient S.S. was a patient of Respondent. Patient G.H. was a patient of Respondent. Patient J.D. was a patient of Respondent. Patient J.A.D. was a patient of Respondent. Other Findings of Fact On July 23, 2004, Respondent entered into a Stipulation in Department Case No. 2002-25421 to resolve an Administrative Complaint which alleged violations of section 466.028(1)(m), (x), and (z). The Stipulation was adopted by a Final Order, dated January 31, 2005, which constitutes a first offense in these cases as to each of the sections cited. On September 21, 2007, the Department issued a Uniform Non-disciplinary Citation for an alleged violation of section 466.028(1)(n), related to the release of patient dental records. The Department offered no evidence of its disposition and, in any event, since these cases do not involve alleged violations of section 466.028(1)(n), the citation is of no consequence in establishing a penalty in these cases under Florida Administrative Code Rule 64B5-13.005(1). On January 19, 2017, the Department issued an Administrative Complaint in Case No. 2015-10804 for alleged violations of section 466.028(1)(m), (x), and (mm). The Department offered no evidence of its disposition of the Administrative Complaint and, as a result, the Administrative Complaint is of no consequence in establishing a penalty in these cases under rule 64B5-13.005(1). On January 19, 2017, the Department issued an Administrative Complaint in Case No. 2015-23828 for alleged violations of section 466.028(1)(m), (x), and (z). The Department offered no evidence of its disposition of the Administrative Complaint and, as a result, the Administrative Complaint is of no consequence in establishing a penalty in these cases under rule 64B5-13.005(1). Case No. 19-2898PL - The T.C. Administrative Complaint Patient T.C. was a patient of Respondent from June 14, 2011, to on or about August 12, 2013. During the period in question, Respondent owned Smile Designs, a dental practice with offices in Jacksonville, Lake City, and Live Oak, Florida. The Department, in the T.C. Administrative Complaint, recognized that “Respondent, along with an associate, [Dr. Morris], are . . . licensed dentists known to work at Respondent’s practice.” The Department’s expert witness, Dr. Brotman, was also aware that Dr. Morris practiced with Respondent. Patient T.C. suffered a stroke in 2009. During the period that she was seen by Respondent, she was in “decent health,” though she was on medication for her post-stroke symptoms, which included a slight problem with aphasia, though she was able to communicate. The stroke and the aphasia are neurological issues, not mental health issues. Patient T.C. was accompanied by her husband, L.C. during her visits to Respondent’s practice. He generally waited in the waiting area during Patient T.C.’s procedures though, as will be discussed herein, he was occasionally brought back to the treatment area. L.C. testified that he had never been advised that Patient T.C. experienced a seizure while under Respondent’s care, and had no recollection of having been told that Patient T.C. ever became unresponsive. Patient T.C. died in 2015. Count I Case No. 19-2898PL, Count I, charges Respondent with failing to immediately refer Patient T.C. to a medical professional or advise Patient T.C. to seek follow-up care for the management of what were believed to be seizures while Patient T.C. was in the dental chair. From Patient T.C.’s initial visit on June 14, 2011, through her visit on September 23, 2011, Patient T.C. was seen at Respondent’s practice on five occasions. Respondent testified that the office was aware of Patient T.C.’s history of seizures because the medical history taken at her first visit listed Diazapam, Levetiracetam, Diovan, and Lyrica as medications being taken by Patient T.C., all of which are seizure medications. Nonetheless, the dental records for the four visits prior to September 23, 2011, provide no indication that Patient T.C. suffered any seizure or period of non- responsiveness during those visits. On September 23, 2011, Patient T.C. presented at Smile Designs for final impressions for crowns on teeth 20, 21, 28, and 29. Respondent testified that she was not the treating dentist on that date. Patient T.C. was given topical anesthetics, and her pulse and blood pressure were checked. The treatment notes then provide, in pertinent part, the following: Patient had seizures on the dental chair - may be due to anxiety. Seizures last 2-3 minutes. No longer. After 30 minutes, patient was calm. Able to proceed with dental procedure . . . . During seizures pt. was responsive; she was able to respond to our commands. The medical records substantiate Respondent’s unrebutted testimony that she was not the treating dentist at the September 23, 2011, appointment. The June 14, July 19, and October 7, 2011, treatment notes made by Respondent all start with “Dr. Gerry,” and are in a notably different style and format from the September 23, 2011, treatment notes. The preponderance of the evidence establishes that Dr. Morris, and not Respondent, was the treating dentist when Patient T.C. experienced seizures on September 23, 2011. Much of Dr. Brotman’s testimony as to Respondent’s violation of a standard of care was based on his interpretation that, since the September 23, 2011, notes did not specifically identify the treating dentist (as did the other treatment notes described above), the notes must be presumed to be those of the business owner. Neither Dr. Brotman nor the Department established a statutory or regulatory basis for such a presumption and, in any event, the evidence adduced at hearing clearly rebutted any such presumption. Dr. Brotman testified that if another dentist had been identified in the records as having performed the treatment on September 23, 2011, that may have changed his opinion. The evidence established that Dr. Morris performed the treatment on September 23, 2011. Thus, Dr. Brotman’s opinion that Respondent violated the applicable standard of care was effectively countered. The T.C. Administrative Complaint charged Respondent with failing to comply with the applicable standard of care on September 23, 2011. The Department failed to establish that Respondent was the treating dentist on September 23, 2011, and, in fact, a preponderance of the evidence demonstrated that she was not. Thus, the Department failed to establish that Respondent violated the standard of care for failing to refer Patient T.C. to an appropriate medical professional for her seizures as alleged in Count I of the T.C. Administrative Complaint. Count II Case No. 19-2898PL, Count II, charges Respondent with delegating the task of intraoral repair of Patient T.C.’s partial denture to a person not qualified by training, experience, or licensure to perform such intraoral repair. July 17, 2012 Repair On July 17, 2012, Patient T.C. presented to Respondent because her lower partial denture was broken and the O-ring was out. The device included a female end within Patient T.C.’s jaw, and a male end with a plastic “gasket” on the denture. Respondent testified that the repair of the partial denture was performed outside of Patient T.C.’s mouth. Then, at the next scheduled visit, the treatment plan was for Respondent to “eval/repair partial denture on lower arch.” Respondent offered unrebutted testimony that “Tia of precision attachments” performed no work in Patient T.C.’s mouth. Dr. Brotman testified that, in his opinion, any repair of a precision attachment must be done by placing the attachment in the patient’s mouth to align with the teeth. However, Dr. Brotman did not know what kind of repair was done on July 17, 2012. He indicated that if a gasket or housing is missing, it can be repaired with an acrylic. Dr. Brotman testified that if acrylic was placed in the denture outside of the patient’s mouth, it would not be a violation of Florida law. The Department failed to prove, by clear and convincing evidence, that Respondent delegated the task of adjusting or performing an intraoral repair of Patient T.C.’s partial denture to “Tia” or any other unlicensed person on July 17, 2012, as alleged in Count II of the T.C. Administrative Complaint. June 11, 2013 Repair On June 11, 2013, Patient T.C. presented to Respondent for an evaluation of her lower precision partial denture. Patient T.C. complained that the partial denture did not have the metal housing to connect it with the bridges to its sides. Patient T.C. was a “bruxer,” i.e. she ground her teeth, and had worn out the denture’s metal attachment. Respondent evaluated the situation, and decided to attempt a chairside repair or replacement of the denture’s male attachments. If the chairside repair was unsuccessful, a complete new partial denture would have to be prepared by a dental laboratory. Respondent attempted the chairside repair. Respondent testified that she instructed her dental assistant to add acrylic into the slot where the male attachment was to be placed in the denture. There was no evidence of any kind to suggest that the dental assistant then placed the denture into Patient T.C’s mouth. Because too much acrylic was placed in the denture, it became stuck in Patient T.C.’s mouth. Patient T.C. became understandably upset. Her husband, L.C., was brought into the room, Patient T.C. was administered local anesthesia, and the precision partial denture was removed. Respondent’s testimony regarding the incident was generally consistent with her prior written statement offered in evidence. Dr. Brotman testified that making repairs to a precision denture must be performed by a licensed dentist, except for placing acrylic into the denture outside of the patient’s mouth, which may be done by a non-dentist. The evidence was insufficient to demonstrate that Respondent’s dental assistant did anything more than place acrylic into the denture outside of Patient T.C.’s mouth. The Department failed to prove, by clear and convincing evidence, that Respondent delegated the task of adjusting or performing an intraoral repair of Patient T.C.’s partial denture to her dental assistant on June 11, 2013, as alleged in Count II of the T.C. Administrative Complaint. Case No. 19-2899PL - The S.S. Administrative Complaint Count I Case No. 19-2899PL, Count I, charges Respondent with violating section 466.028(1)(m) by: Failing to keep a written record of Patient S.S.’s medical history; and/or Failing to keep an accurate written record of any consent forms signed by Patient S.S. Count II Case No. 19-2899PL, Count II, charges Respondent with violating section 466.028(1)(x) by: Failing to adequately diagnose decay in tooth 30; Failing to adequately diagnose the condition of the roots of tooth 30; Failing to adequately obturate the canals of tooth 30 during root canal treatment; Failing to adequately obturate the canals of tooth 31 during root canal treatment; Failing to take a new crown impression of tooth 31 following changes to the tooth’s margins; and/or Failing to adequately assess and correct the crown on tooth 31 when the fit was compromised. On May 15, 2014, Patient S.S. presented to Respondent for a root canal and crown on tooth 30. Upon examination, Respondent advised Patient S.S. that she also needed a root canal and a crown on tooth 31. Patient S.S. denied that she was required to provide her medical history at the May 15, 2014, office visit, or that she was provided with an informed consent form prior to the root canal on tooth 30. Respondent’s records do not include either a medical history or an informed consent form. However, the records, which were offered as a joint exhibit, were not accompanied by a Certificate of Completeness of Patient Records, including the number of pages provided pursuant to Respondent’s investigatory subpoena, as is routine in cases of this sort, and which was provided with the records of the subsequent dentists involved in Patient S.S.’s care. Many of the records offered in these consolidated cases, including Respondent’s licensure file, include the certification attesting to their completeness. The records for Patient S.S. do not. Petitioner elicited no testimony from Respondent establishing the completeness of the records. The records offered were, by appearance, not complete. Respondent indicated that medical history and consent forms were obtained. Entries in the records introduced in evidence indicate “[m]edical history reviewed with patient” or the like. Entries for May 16, 2014, provide that “[c]rown consent explained and signed by patient” and “root canal consent explained and signed by patient.” The record for June 4, 2014, indicates that “[r]oot canal consent form explained to and signed by patient.” Patient S.S. testified that she had no recollection of having filled out a medical history, or of having signed consent forms after having Respondent’s recommended course of treatment explained to her. However, Patient S.S.’s memory was not clear regarding various aspects of her experience with Respondent and with subsequent providers. Much of her testimony was taken from notes she brought to the hearing, and some was even based on what she read in the Administrative Complaint. Her testimony failed to clearly and convincingly establish that Respondent failed to collect her medical history or consent to treatment. Respondent testified that, at the time Patient S.S. was being seen, her office was in the midst of switching its recordkeeping software and converting records to digital format. The new company botched the transition, and by the time the issue was discovered, many of the records being converted to digital format were lost, in whole or in part. Respondent surmised that, to the extent the records were not in her files provided to the Department, that they were affected by the transition. The greater weight of the evidence suggests that medical history and signed consent forms were provided. Given the issues regarding the records as described by Respondent, and given the Department’s failure to produce a certification or other evidence that the records it was relying on to prove the violation were complete, the Department failed to meet its burden to prove, by clear and convincing evidence, that Respondent failed to keep a written record of Patient S.S.’s medical history and signed consent forms. Respondent also testified that the office notes were supplemented with handwritten notations made when a patient returned for a subsequent appointment. Several of Patient S.S.’s printed records carried handwritten notes. Respondent testified that those notes were made at some time in 2014 after Patient S.S.’s first office visit up to the time of her last visit, and were based on further discussion with Patient S.S. However, those records, Joint Exhibit 2, pages 1 through 17, bear either a date or a “print” date of March 12, 2015. Dr. Brotman testified that he knew of no software on the market that would allow contemporaneous handwriting on electronic records. Thus, the evidence is compelling that the handwritten notes were made on or after the March 12, 2015, date on which the records were printed, well after Patient S.S.’s last office visit. A root canal involves removing a tooth’s pulp chamber and nerves from the root canals. The root canals are smoothed out and scraped with a file to help find and remove debris. The canals are widened using sequentially larger files to ensure that bacteria and debris is removed. Once the debris is removed, an inert material (such as gutta percha) is placed into the canals. A “core” is placed on top of the gutta percha, and a crown is placed on top of the core. The risk of reinfection from bacteria entering from the bottom of an underfilled tooth is significantly greater than if the tooth is filled to the apex of the root. Patient S.S. returned to Respondent’s office on May 16, 2014, for the root canal on tooth 30 and crown preparations for teeth 30 and 31, which included bite impressions. Temporary crowns were placed. Respondent’s printed clinical notes for May 16, 2014, gave no indication of any obstruction of the canals, providing only the lengths of the two mesial and two distal root canals. Respondent’s hand-written notes for May 16, 2014 (which, as previously explained, could have been made no earlier than March 12, 2015), stated that the canals were “[s]ealed to as far as the canal is open. The roots are calcification.” Dr. Brotman indicated that the x-rays taken on May 15, 2014, showed evidence of calcification of the roots. However, Dr. Brotman convincingly testified that the x-rays taken during the root canal show working-length files extending to near the apices of the roots. Thus, in his opinion, the canals were sufficiently open to allow for the use of liquid materials to soften the tooth, and larger files to create space to allow for the canals to be filled and sealed to their full lengths. His testimony in that regard is credited. Patient S.S. began having pain after the root canal on tooth 30 and communicated this to Respondent. On June 5, 2014, Patient S.S. presented to Respondent to have the crowns seated for teeth 30 and 31. Patient S.S. complained of sensitivity in tooth 31. The temporary crowns were removed, and tooth 31 was seen to have exhibited a change in color. The area was probed, which caused a reaction from Patient S.S. Respondent examined the tooth, and noted the presence of soft dentin. A root canal of tooth 31 was recommended and performed, which included removal of the decay in the tooth’s dentin at the exterior of the tooth. Respondent’s removal of decay changed the shape of tooth 31, and would have changed the fit of the crown, which was made based on the May 16, 2014, impressions. There were no new impressions for a permanent crown taken for tooth 31 after removal of the decayed dentin. Respondent testified that she could simply retrofill the affected area with a flowable composite, which she believed would be sufficient to allow for an acceptable fit without making new bite impressions and ordering a new crown. There was no persuasive evidence that such would meet the relevant standard of performance. Temporary crowns were placed on teeth 30 and 31, and placement of the permanent crowns was postponed until the next appointment. Upon completion of the tooth 31 root canal on June 5, 2014, x-rays were taken of the work completed on teeth 30 and 31. Dr. Brotman testified that the accepted standard of care for root canal therapy is to have the root canal fillings come as close to the apex of the tooth as possible without extending past the apex, generally to within one millimeter, and no more than two millimeters of the apex. His examination of the x-rays taken in conjunction with Respondent’s treatment of Patient S.S. revealed a void in the filling of the middle of the distal canal of tooth 31, an underfill of approximately five millimeters in the mesial canal of tooth 31, an underfill of approximately four millimeters in the distal canal of tooth 30, and an underfill of approximately six millimeters in the two mesial root canals of tooth 30. The x-ray images also revealed remaining decay along the mesiobuccal aspect of the temporary crown placed on tooth 31. His testimony that the x-ray images were sufficiently clear to provide support for his opinions was persuasive, and was supported by the images themselves. A day after the placement of the temporary crowns, they came off while Patient S.S. was having dinner in Gainesville. She was seen by Dr. Abolverdi, a dentist in Gainesville. Dr. Abolverdi cleaned the teeth, took an x-ray, and re-cemented the temporary crowns in place. Patient S.S. next presented to Respondent on June 10, 2014. Both of Patient S.S.’s permanent crowns were seated. The permanent crown for tooth 31 was seated without a new impression or new crown being made. Patient S.S. was subsequently referred by her dentist, Dr. James Powell, to be seen by an endodontist to address the issues she was having with her teeth. She was then seen and treated by Dr. John Sullivan on July 25, 2014, and by Dr. Thomas Currie on July 29, 2014, both of whom were endodontists practicing with St. Johns Endodontics. As to the pain being experienced by Patient S.S., Dr. Sullivan concluded that it was from her masseter muscle, which is consistent with Respondent’s testimony that Patient S.S. was a “bruxer,” meaning that she ground her teeth. Dr. Sullivan also identified an open margin with the tooth 31 crown. His clinical assessment was consistent with the testimony of Dr. Brotman. The evidence was clear and convincing that the defect in the tooth 31 permanent crown was an open margin, and not a “ledge” as stated by Respondent. The evidence was equally clear and convincing that the open margin was the result of performing a “retrofill” of the altered tooth, rather than taking new bite impressions to ensure a correct fit. As a result of the foregoing, Respondent violated the accepted standard of performance by failing to take a new crown impression of tooth 31 following the removal of dentin on June 4, 2014, and by failing to assess and correct the open margin on the tooth 31 crown. Radiographs taken on July 25, 2014, confirmed that canals in teeth 30 and 31 were underfilled, as discussed above, and that there was a canal in tooth 31 that had been missed altogether. On July 29, 2014, Dr. Currie re-treated the root canal for tooth 31, refilled the two previously treated canals, and treated and filled the previously untreated canal in tooth 31. The evidence, though disputed, was nonetheless clear and convincing that Respondent failed to meet the standard of performance in the root canal procedures for Patient S.S.’s teeth 30 and 31, by failing to adequately diagnose and respond to the condition of the roots of tooth 30; failing to adequately fill the canals of tooth 30 despite being able to insert working-length files beyond the area of calcification to near the apices of the roots; and failing to adequately fill the canals of tooth 31 during root canal treatment. The Administrative Complaint also alleged that Respondent failed to adequately diagnose decay in tooth 30. The evidence was not clear and convincing that Respondent failed to adequately diagnose decay in tooth 30. Case No. 19-2900PL - The G.H. Administrative Complaint Case No. 19-2900PL charges Respondent with violating section 466.028(1)(x) by failing to adequately diagnose issues with the crown on tooth 13 and provide appropriate corrective treatment. On May 15, 2014, Patient G.H. presented to Respondent with a complaint that she had been feeling discomfort on the upper left of her teeth that was increasingly noticeable. Respondent diagnosed the need for a root canal of tooth 13. Patient G.H. agreed to the treatment, and Respondent performed the root canal at this same visit. Patient G.H. also had work done on other teeth to address “minor areas of decay.” On July 7, 2014, Patient G.H.’s permanent crowns were seated onto teeth 8, 9, and 13, and onlay/inlays placed on teeth 12 and 14. On July 29, 2014, Patient G.H. presented to Respondent. Respondent’s records indicate that Patient G.H. complained that when she flossed around tooth 13, she was getting “a funny taste” in her mouth. Patient G.H.’s written complaint and her testimony indicate that she also advised Respondent that her floss was “tearing,” and that she continued to experience “pressure and discomfort” or “some pain.” Respondent denied having been advised of either of those complaints. Respondent flossed the area of concern, and smelled the floss to see if it had a bad smell. Respondent denied smelling anything more than typical mouth odor, with which Patient G.H. vigorously disagreed. Respondent took a radiograph of teeth 11 through 15, which included tooth 13 and the crown. The evidence is persuasive that the radiograph image revealed that the margin between tooth 13 and the crown was open. An open margin can act as a trap for food particles, and significantly increases the risk for recurrent decay in the tooth. Respondent adjusted the crown on tooth 9, but advised Patient G.H. that there was nothing wrong with the crown on tooth 13. She offered to prescribe a rinse for the smell, but generally told Patient G.H. that there were no complications. Patient G.H. began to cry and, when Respondent left the room, got up from the chair and left the office. Respondent indicated in her testimony that she would have performed additional investigation had Patient G.H. not left. The contemporaneous records do not substantiate that testimony. Furthermore, Respondent did not contact Patient G.H. to discuss further treatment after having had a full opportunity to review the radiograph image. On March 10, 2015, after her newly-active dental insurance allowed her to see a different in-network provider, Patient G.H. sought a second opinion from Dr. Ada Y. Parra, a dentist at Premier Dental in Gainesville, Florida. Dr. Parra identified an open distal margin at tooth 13 with an overhang. Dr. Parra recommended that Patient G.H. return to Respondent’s practice before further work by Premier Dental. Patient G.H. called Respondent’s office for an appointment, and was scheduled to see Dr. Lindsay Kulczynski, who was practicing as a dentist in Respondent’s Lake City, Florida, office. Patient G.H. was seen by Dr. Kulczynski on March 19, 2015. Upon examination, Dr. Kulczynski agreed that the crown for tooth 13 “must be redone” due to, among other defects, “[d]istal lingual over hang [and] open margin.” The open margin was consistent with Patient G.H.’s earlier complaints of discomfort, floss tearing, and bad odor coming from that tooth. The evidence was persuasive that further treatment of Patient G.H. was not authorized by Respondent after the appointment with Dr. Kulczynski. Dr. Brotman credibly testified that the standard of care in crown placement allows for a space between the tooth and the crown of between 30 and 60 microns. Dr. Brotman was able to clearly identify the open margin on the radiograph taken during Patient G.H.’s July 29, 2014, appointment, and credibly testified that the space was closer to 3,000 microns than the 30 to 60 microns range acceptable under the standard of performance. His testimony is accepted. An open margin of this size is below the minimum standard of performance. The evidence was clear and convincing that Respondent fell below the applicable standard of performance in her treatment of Patient G.H., by seating a crown containing an open margin and by failing to perform appropriate corrective treatment after having sufficient evidence of the deficiencies. Case No. 19-2901PL - The J.D. Amended Administrative Complaint Case No. 19-2901PL charges Respondent with violating section 466.028(1)(x) by: Failing to obtain sufficient radiographic imaging showing Patient J.D.’s sinus anatomy, extent of available bone support, and/or root locations; Failing to lift, or refer for lifting of, Patient J.D.’s sinus before placing an implant in the area of tooth 14; Failing to appropriately place the implant by attempting to place it into a curved root, which could not accommodate the implant; Failing to react appropriately to the sinking implant by trying to twist off the carrier instead of following the technique outlined in the implant’s manual; and/or Paying, or having paid on her behalf, an indemnity in the amount of $75,000 as a result of negligent conduct in her treatment of Patient J.D. Patient J.D. first presented to Respondent on June 28, 2014. At the time, Respondent was practicing with Dr. Jacobs, who owned the practice. Patient J.D. had been a patient of Dr. Jacobs for some time. Respondent examined Patient J.D. and discovered problems with tooth 14. Tooth 14 and tooth 15 appeared to have slid into the space occupied by a previously extracted tooth. As a result, tooth 14 was tipped and the root curved from moving into the space. Tooth 14 had been filled by Dr. Jacobs. However, by the time Respondent examined it, the tooth was not restorable, and exhibited 60 percent bone loss and class II (two millimeters of movement) mobility. Respondent discussed the issue with Patient J.D., and recommended extraction of the two teeth and replacement with a dental implant. Patient J.D. consented to the procedure and executed consent forms supplied and maintained by Dr. Jacobs. The teeth at issue were in the upper jaw. The upper jaw consists of softer bone than the lower jaw, is more vascular, and includes the floor of the nose and sinuses. The periapical radiographs taken of Patient J.D. showed that he had a “draped sinus,” described by Respondent as being where “the tooth is basically draped around the sinuses. It’s almost like they’re kind of one.” Prior to Patient J.D., Respondent had never placed an implant in a patient with a draped sinus. The x-rays also indicated that, as a result of the previous extraction of teeth and the subsequent movement of the remaining teeth, the roots of tooth 14 were tipped and curved. The evidence was persuasive that Respondent did not fail to obtain sufficient radiographic imaging showing Patient J.D.’s sinus anatomy, the extent of available bone support, and the configuration of the roots. Dr. Kinzler testified credibly that the pneumatized/draped sinus, the 60 percent bone loss around tooth 14, and the tipped and curved roots each constituted pre- operative red flags. Respondent extracted teeth 14 and 15. When she extracted the teeth, she observed four walls. She was also able to directly observe the floor of the sinus. She estimated the depth of the socket to be 12 millimeters. Sinus penetration is a potential complication of implant placement. Being able to see the sinus floor was an additional complicating factor for implant placement. Dr. Kinzler credibly testified that if Respondent was going to place an implant of the size she chose (see below), then the standard of care required her to first do a sinus lift before placing the implant. A sinus lift involves physically lifting the floor of a patient’s sinus. Once the sinus has been lifted, material typically consisting of granulated cortical bone is placed into the space created. Eventually, the bone forms a platform for new bone to form, into which an implant can be inserted. The evidence established that the standard of care for bone replacement materials is to place the material into the space, close the incision, and allow natural bone to form and ultimately provide a stable structure to affix an implant. The implant may then be mechanically affixed to the bone, and then biologically osseointegrate with the bone. In order to seal off Patient J.D.’s sinus, Respondent used Bond Bone, which she described as a fast-setting putty-like material that is designed to protect the floor of the sinus and provide a scaffold for bone to grow into. She did not use cortical bone, described as “silly sand,” to fill the space and provide separation from the sinus because she indicated that it can displace and get lost. Respondent’s goal was to place the implant so that it would extend just short of the Bond Bone and Patient J.D.’s sinus. She also intended to angle the implant towards the palate, where there was more available bone. Bond Bone and similar materials are relatively recent innovations. Dr. Fish was encouraged by the possibilities of the use of such materials, though he was not familiar with the Bond Bone brand. The evidence was clear and convincing that, although Bond Bone can set in a short period, and shows promise as an effective medium, it does not currently meet minimum standards of performance for bone replacement necessary for placement and immediate support of an implant. Bond Bone only decreases the depth of the socket. It does not raise the floor of the sinus. As such, the standard practice would be to use a shorter implant, or perform a sinus lift. Respondent was provided with an implant supplied by Dr. Jacobs. She had not previously used the type of implant provided. The implant was a tapered screw vent, 4.7 millimeters in diameter, tapering to 4.1 millimeters at the tip with a length of 11.5 millimeters. Respondent met with and received information from the manufacturer’s representative. She used a 3.2 millimeter drill to shape the hole, as the socket was already large enough for the implant. The 3.2 millimeter drill was not evidence that the receiving socket was 3.2 millimeters in diameter. Respondent then inserted the implant and its carrier apparatus into the hole. The implant did not follow the root, and had little bone on which to affix. The initial post-placement periapical radiograph showed “placement was not correct.” Despite Respondent’s intent, the implant was not angled, but was nearly vertical, in contrast with the angulation of the socket which was tipped at least 30 degrees. Given the amount of bone loss, and the other risk factors described herein, the risk of a sinus perforation, either by having the implant extend through the root opening or by a lateral perforation through one of the sides of the socket, was substantial. After adjusting the implant, Respondent went to remove the carrier. The carrier would not release, and the pressure exerted caused the implant to loosen and begin to sink through the Bond Bone. Dr. Kinzler testified credibly that, because of the mechanics of the implant used, had it been surrounded by bone, it would not have been possible for the implant to become loose. In his opinion, which is credited, the loosening of the implant was the result of the lack of bone to hold it in place. Respondent was so intent on removing the carrier that she was not paying attention to the implant. As a result, she screwed the implant through the Bond Bone and into Patient J.D.’s sinus. By the time she realized her error, the implant had sunk in to the point it was not readily retrievable. She was hesitant to reaffix the carrier “because [she] knew [she] had no support from the bone, that it was just a matter of air.” Nonetheless, she “stuck the carrier back in, but it would not go back in.” She then turned to get forceps or a hemostat but, by that time, the implant was irretrievably into Patient J.D.’s sinus. At the hearing, Respondent testified that she could have retrieved the implant but for Patient J.D. doing a “negative pressure sneeze” when the implant was already into the sinus. At that point, she stated that the implant disappeared into Patient J.D.’s sinus, where it can be seen in Petitioner’s Exhibit 9, page 35. There is nothing in Respondent’s dental records about Patient J.D. having sneezed. Respondent further testified that Patient J.D. “was very jovial about it,” and that everyone in the office laughed about the situation, and joked about “the sneeze implant.” That the patient would be “jovial” about an implant having been screwed into his sinus, resulting in a referral to an oral surgeon, and that there was office-wide joking about the incident is simply not credible, particularly in light of the complete absence of any contemporaneous records of such a seemingly critical element of the incident. Respondent believed that the implant must have been defective for her to have experienced the problem with removing the carrier, though her testimony in that regard was entirely speculative. There is no competent, substantial, or persuasive evidence to support a finding that the implant was defective. After determining that the implant was in Patient J.D.’s sinus, Respondent informed Patient J.D. of the issue, gave him a referral to an oral surgeon, prescribed antibiotics, and gave Patient J.D. her cell phone number. Each of those acts was appropriate. On July 29, 2014, an oral surgeon surgically removed the implant from Patient J.D.’s sinus. Patient J.D. sued Respondent for medical malpractice. The suit was settled, with the outcome including a $75,000.00 indemnity paid by Respondent’s insurer on her behalf. The Office of Insurance Regulation’s Medical Malpractice Closed Claims Report provides that the suit’s allegations were based on “improper dental care and treatment.” The evidence was not clear and convincing that Respondent failed to meet the minimum standards of performance prior to the procedure at issue by failing to obtain sufficient radiographic imaging showing Patient J.D.’s sinus anatomy, extent of available bone support, and/or root locations prior to the procedure. The evidence was clear and convincing that Respondent failed to meet the minimum standards of performance by failing to lift, or refer for lifting of, Patient J.D.’s sinus before placing the implant in the area of tooth 14, and by placing the implant into a curved root which could not accommodate the implant. The placement of Bond Bone was not adequate to address these issues. The evidence was clear and convincing that Respondent failed to meet the standard of care by failing to pay attention while trying to twist off the carrier and by failing to appropriately react to the sinking implant. The evidence was clear and convincing that Respondent paid, or had paid on her behalf, an indemnity of $75,000 for negligent conduct during treatment of Patient J.D. The perforation of Patient J.D.’s sinus was not, in itself, a violation of the standard of care. In that regard, Dr. Kinzler indicated that he had perforated a sinus while placing an implant. It was, however, the totality of the circumstances regarding the process of placing Patient J.D.’s implant that constituted a failure to meet the minimum standards of performance as described herein. Case No. 19-2902PL - The J.A.D. Amended Administrative Complaint Count I Case No. 19-2902PL, Count I, charges Respondent with violating section 466.028(1)(x) by: Failing to take adequate diagnostic imaging prior to placing an implant in the area of Patient J.A.D.’s tooth 8; Failing to pick an appropriately-sized implant and placing an implant that was too large; and/or Failing to diagnose and/or respond appropriately to the oral fistula that developed in the area of Patient J.A.D.’s tooth 8. Count II Case No. 19-2902PL, Count II, charges Respondent with violating section 466.028(1)(m) by: Failing to document examination results showing Patient J.A.D. had an infection; Failing to document the model or serial number of the implant she placed; and/or Failing to document the results of Respondent’s bone examination. Patient J.A.D. first presented to Respondent on March 3, 2016. His first appointment included a health history, full x-rays, and an examination. Patient J.A.D.’s complaint on March 3, 2016, involved a front tooth, tooth 8, which had broken off. He was embarrassed by its appearance, and desired immediate care and attention. Respondent performed an examination of Patient J.A.D., which included exposing a series of radiographs. Based on her examination, Respondent made the following relevant diagnoses in the clinical portion of her records: caries (decay) affecting tooth 7, gross caries affecting fractured tooth 8, and caries affecting tooth 9. Patient J.A.D. was missing quite a few of his back teeth. The consent form noted periodontal disease. The evidence is of Patient J.A.D.’s grossly deficient oral hygiene extending over a prolonged period. A consent form signed by Patient J.A.D. indicates that Patient J.A.D. had an “infection.” Respondent indicated that the term indicated both the extensive decay of Patient J.A.D.’s teeth, and a sac of pus that was discovered when tooth 8 was extracted. “Infection” is a broad term in the context of dentistry, and means any bacterial invasion of a tooth or system. The consent form was executed prior to the extraction. Therefore, the term “infection,” which may have accurately described the general condition of Patient J.A.D.’s mouth, could not have included the sac of pus, which was not discovered until the extraction. The sac of pus was not otherwise described with specificity in Respondent’s dental records. A pre-operative radiograph exposed by Respondent showed that tooth 8 had a long, tapering root. Respondent proposed extraction of tooth 8, to be replaced by an immediate implant. The two adjacent teeth were to be treated and crowned, and a temporary bridge placed across the three. Patient J.A.D. consented to this treatment plan. The treatment plan of extracting tooth 8 and preparing the adjacent teeth for crowns was appropriate. Respondent cleanly extracted tooth 8 without fracturing any surrounding bone, and without bone adhering to the tooth. When the tooth came out, it had a small unruptured sac of pus at its tip. Respondent irrigated and curretted the socket, and prescribed antibiotics. Her records indicated that she cleaned to 5 millimeters, although a radiograph made it appear to be a 7 millimeter pocket. She explained that inflammation caused the pocket to appear larger than its actual 5 millimeter size, which she characterized as a “pseudo pocket.” She recorded her activities. The response to the sac of pus was appropriate. Respondent reviewed the earlier radiographs, and performed a physical examination of the dimensions of the extracted tooth 8 to determine the size of the implant to be placed into the socket. Dr. Kinsler and Dr. Fish disagreed as to whether the radiographic images were sufficient to provide adequate information as to the implant to be used. Both relied on their professional background, both applied a reasonable minimum standard of performance, and both were credible. The evidence was not clear and convincing that Respondent failed to take adequate diagnostic imaging prior to placing an implant to replace Patient J.A.D.’s tooth 8. Respondent placed an implant into the socket left from tooth 8. The implant was in the buckle cortex, a “notoriously thin” bone feature at the anterior maxilla. The fact that it is thin does not make it pathological, and placement of an implant near a thin layer of bone is not a violation of the standard of performance as long as the implant is, in fact, in the bone. The implant used by Respondent was shorter than the length of tooth 8 and the tooth 8 socket, and did not have a full taper, being more truncated. The evidence of record, including the testimony of Dr. Kinzler, indicates that the length of the implant, though shorter than the tooth it was to replace, was not inappropriate. The evidence of record, including pre-extraction and post-implantation scaled radiographs offered as a demonstrative exhibit, was insufficient to support a finding that the implant diameter was too great for the available socket. Patient J.A.D. felt like the implant was too close to the front of his maxillary bone because it felt like a little bump on the front of his gums. That perception is insufficient to support a finding that the placement of the implant violated a standard of performance. Subsequent x-rays indicated that there was bone surrounding the implant. Clinical observations by Respondent after placement of the implant noted bone on all four walls of the implant. Her testimony is credited. The evidence that the tooth 8 implant was not placed in bone, i.e., that at the time the implant was placed, the implant penetrated the buccal plate and was not supported by bone on all four sides, was not clear and convincing. Respondent’s records document the dimensions and manufacturer of the implant. Implants are delivered with a sticker containing all of the relevant information, including model and serial number, that are routinely affixed to a patient’s dental records. It is important to document the model and serial number of implants. Every implant is different, and having that information can be vital in the case of a recall. Patient J.A.D.’s printed dental records received by the Department from Respondent have the implant size (5.1 x 13 mm) and manufacturer (Implant Direct) noted. The records introduced in evidence by the Department include a page with a sticker affixed, identified by a handwritten notation as being for a “5.1 x 13mm - Implant Direct.” (Pet. Ex. 11, pg. 43 of 83). The accompanying sticker includes information consistent with that required. Dr. Fish testified to seeing a sticker that appears to be the same sticker (“The implant label of 141, it just has the handwritten on there that it should be added.”), though it is described with a deposition exhibit number (page 141 of a CD) that is different from the hearing exhibit number. Dr. Fish indicated the sticker adequately documented the implant information. The evidence was not clear and convincing that the sticker was not in Patient J.A.D.’s records, or that Respondent failed to document the model or serial number of the implant she placed. Later in the day on March 3, 2016, Patient J.A.D. was fitted for a temporary crown, which was placed on the implant and the adjacent two teeth, and Patient J.A.D. was scheduled for a post-operative check. Patient J.A.D. appeared for his post-operative visit on March 10, 2016. He testified that he was having difficulty keeping the temporaries on, and was getting “cut up” because the two outer teeth were sharp and rubbed against his lip and tongue. Respondent noticed that Patient J.A.D. was already wearing a hole in the temporary. Since Patient J.A.D. was missing quite a few of his back teeth, much of his chewing was being done using his front teeth. His temporaries were adjusted and reseated. On March 17, 2016, Patient J.A.D. was seen by Respondent for a post-operative check of the tooth 8 extraction and implant placement. The notes indicated that Patient J.A.D. had broken his arm several days earlier, though the significance of that fact was not explained. He was charted as doing well, and using Fixodent to maintain the temporary in place. The records again noted that Patient J.A.D. had worn a hole in the back of the tooth 9 temporary crown. A follow up was scheduled for final impressions for the permanent crowns. On March 10 and March 17, 2016, Patient J.A.D. complained of a large blister or “zit” that formed over the area above the end of the implant. Patient J.A.D. had no recollection of whether Respondent told him he had an infection. He was prescribed antibiotics. The evidence was not clear and convincing that the “zit” was causally related to the placement of the implant. Patient J.A.D. also testified that the skin above tooth 9 was discolored, and he thought he could almost see metal through the skin above his front teeth. Patient J.A.D. next appeared at Respondent’s office on June 2, 2016, for final impressions. Respondent concluded that the site had not healed enough for the final impression. She made and cemented a new temporary, and set an appointment for the following month for the final impression. Patient J.A.D. did not return to Respondent. On September 28, 2016, Patient J.A.D. presented to the office of Dr. Harold R. Arthur for further treatment. The records for that date indicate that he appeared without his temporary restoration for teeth 7 through 9, stating that he had several at home, but they would not stay on. Dr. Arthur probed a “[s]mall (1.0 x 1.0 mm) red spot in facial keratinized gingiva communicating with implant.” After probing the opening in the gingiva and the “shadow” in the gingiva, he believed it was at the center of the implant body and healing screw. Dr. Arthur’s dental records for Patient J.A.D. over the course of the following year indicate that Dr. Arthur made, remade, and re-cemented temporary crowns for teeth 7, 8, and 9 on a number of occasions, noting at least once that Patient J.A.D. “broke temps” that had been prepared and seated by Dr. Arthur. On December 1, 2016, Patient J.A.D. was reevaluated by Dr. Arthur. He noted the facial soft tissue at the implant was red, with an apparent fistula. A periapical radiograph was “unremarkable.” The temporary crowns, which were loose, were removed, air abraded to remove the cement, and re-cemented in place. Patient J.A.D. was prescribed an antibiotic. He was again seen by Dr. Arthur on December 13, 2016. The temporary on tooth 9 was broken, which was then remade and re-cemented. The fistula was smaller but still present. Patient J.A.D. was seen by Dr. Arthur on February 2, 2017, with the tooth 9 temporary crown fractured again. The fistula was still present. Patient J.A.D. advised that “the bone feels like it’s caving in around where she put that implant.” That statement is accepted not for the truth of the matter asserted, but as evidence that the complaint was first voiced in February 2017. On April 4, 2017, more than a year after the placement of the implant, Patient J.A.D was seen by Dr. Arthur. Dr. Arthur determined that the implant for tooth 8 was “stable and restorable in current position.” The fistula was still present and, after anesthesia, a probe was placed in the fistula where it contacted the implant cover screw. Although Dr. Arthur replaced the implant abutment, he ultimately placed the final crown on the implant placed by Respondent, where it remained at the time of the final hearing. The fact that incidents of Patient J.A.D. breaking and loosening the temporary crowns that occurred with Respondent continued with Dr. Arthur supports a finding that the problems were, more likely than not, the result of stress and overuse of Patient J.A.D.’s front teeth. On October 24, 2016, a series of CBCT radiographs was taken of the implant and its proximity to tooth 7. Dr. Kinzler testified that, in his opinion, the implant was of an appropriate length, but was too large for the socket. Much of his testimony was based on the October 24 radiograph and his examination of the resulting October 29, 2016, report. Although the report indicated that there was minimal bone between the implant and the root of tooth 7, and that the buccal cortex appeared thinned or eroded, those observations are of limited persuasive value as to whether the standard of performance was met almost eight months prior. Patient J.A.D. obviously worked, and overworked, his dental appliances. Without more, the evidence is not clear and convincing that his subsequent and repeated problems, including “thinned or eroded” bone in the buccal cortex, were the result of a violation of the standard of performance in the sizing and placement of the tooth 8 implant by Respondent.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health, Board of Dentistry, enter a Final Order: Dismissing the Administrative Complaint in Case No. 19-2898PL and the Amended Administrative Complaint in Case No. 19-2902PL; With regard to Case No. 19-2899PL: 1) dismissing Count I of the Administrative Complaint; 2) determining that Respondent failed to comply with the applicable standard of performance in the care and treatment of Patient S.S. by: failing to adequately diagnose the condition of the roots of tooth 30; failing to adequately obturate the canals of tooth 30 during root canal treatment; failing to adequately obturate the canals of tooth 31 during root canal treatment; failing to take a new crown impression of tooth 31 following changes to the tooth’s margins; and failing to adequately assess and correct the crown on tooth 31 when the fit was compromised, as alleged in Count II of the Administrative Complaint; and 3) determining that Respondent did not fail to comply with the applicable standard of performance in the care and treatment of Patient S.S. by failing to adequately diagnose decay in tooth 30, as alleged in Count II of the Administrative Complaint; With regard to Case No. 19-2900PL, determining that Respondent failed to comply with the applicable standard of performance in the care and treatment of Patient G.H. by seating a crown containing an open margin on tooth 13 and failing to adequately diagnose issues with the crown on tooth 13, and by failing to perform appropriate corrective treatment after having sufficient evidence of the deficiencies, as alleged in the Administrative Complaint; With regard to Case No. 19-2901PL: 1) determining that Respondent failed to comply with the applicable standard of performance in the care and treatment of Patient J.D. by: failing to lift, or refer for lifting of, Patient J.D.’s sinus before placing an implant in the area of tooth 14; failing to appropriately place the implant by attempting to place it into a curved root which could not accommodate the implant; failing to react appropriately to the sinking implant by trying to twist off the carrier instead of following the technique outlined in the implant’s manual; and paying, or having paid on her behalf, an indemnity in the amount of $75,000 as a result of negligent conduct in her treatment of Patient J.D., as alleged in the Amended Administrative Complaint; and 2) determining that Respondent did not fail to comply with the applicable standard of performance in the care and treatment of Patient J.D. by failing to obtain sufficient radiographic imaging showing Patient J.D.’s sinus anatomy, extent of available bone support, and/or root locations; Suspending Respondent’s license in accordance with rule 64B5-13.005(1)(x) and rule 64B5-13.005(3)(e), to be followed by a period of probation, with appropriate terms of probation to include remedial education in addition to such other terms that the Board believes necessary to ensure Respondent’s practical ability to perform dentistry as authorized by rule 64B5- 13.005(3)(d)2.; Imposing an administrative fine of $10,000; and Requiring reimbursement of costs. DONE AND ENTERED this 31st day of January, 2020, in Tallahassee, Leon County, Florida. S E. GARY EARLY 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 31st day of January, 2020. COPIES FURNISHED: George Kellen Brew, Esquire Law Office of George K. Brew Suite 1804 6817 Southpoint Parkway Jacksonville, Florida 32216 (eServed) Kelly Fox, Esquire Department of Health 2585 Merchant’s Row Tallahassee, Florida 32311 (eServed) Octavio Simoes-Ponce, Esquire Prosecution Services Unit Department of Health Bin C-65 4052 Bald Cypress Way Tallahassee, Florida 32399 (eServed) Chad Wayne Dunn, Esquire Prosecution Services Unit Department of Health Bin C-65 4052 Bald Cypress Way Tallahassee, Florida 32399 (eServed) Jennifer Wenhold, Interim Executive Director Board of Dentistry Department of Health Bin C-08 4052 Bald Cypress Way Tallahassee, Florida 32399-3258 (eServed) Louise Wilhite-St. Laurent, General Counsel Department of Health Bin C-65 4052 Bald Cypress Way Tallahassee, Florida 32399 (eServed)
