Findings Of Fact Respondent is a licensed medical doctor, having been issued license number ME004427. Respondent maintains a general practice of medicine in Fort Lauderdale, Broward County, Florida. The parties have stipulated that the following are Schedule II Controlled Substances pursuant to Chapter 893, Florida Statutes: dilaudid; tuinal; percodan; dexedrine; quaalude; and seconal. COUNTS I - III (HILDA BULLARD) In early 1981, Anatole Mizell had been employed as a medical assistant in Respondent's office for approximately two years. In early 1981, she approached Respondent and explained to him that her mother, who was a resident of the Bahamas, had been diagnosed as having terminal cancer. Ms. Mizell explained to Respondent that physicians in the Bahamas had prescribed dilaudid to relieve her mother's pain, but that dilaudid was much more expensive in the Bahamas than in the United States. As a result, Ms. Mizell requested that Respondent write prescriptions for dilaudid in the United States which she could then have filled for use by her mother in the Bahamas. As a result of this conversation, Respondent, without ever having examined either Ms. Mizell's mother, Hilda Bullard, or any medical records concerning Hilda Bullard, began writing prescriptions for dilaudid in March of 1981. From March through October 1981, Respondent wrote prescriptions for Hilda Bullard totaling 1,072 two- milligram dilaudid tablets. According to the information furnished to Respondent by Ms. Mizell, her mother had had exploratory surgery in approximately 1977, at which time she was diagnosed as terminally ill. Ms. Mizell did not approach Respondent to write dilaudid prescriptions for her mother until early 1981. Having written dilaudid prescriptions for Ms. Bullard for March through October, 1981, Respondent began to suspect that perhaps he should examine Ms. Bullard in light of the fact that patients with illnesses of the severity described to him by Ms. Mizell seldom live for as long as Ms. Bullard apparently had. As a result, Ms. Bullard came to the United States and was first examined by Respondent on October 23, 1981. At that time, Respondent discovered that the patient had an enlarged abdominal mass, and sent her for blood samples and a liver scan. As a result of these procedures, Ms. Bullard was diagnosed as having cirrhosis of the liver, rather than terminal cancer. Respondent immediately discontinued prescribing dilaudid for Ms. Bullard. Although the record in this cause establishes that it is not uncommon, and oftentimes is appropriate, for physicians to prescribe a controlled substance for use by patients without first examining them, this procedure is justifiable only when the prescribing physician is prohibited by emergency conditions from personally examining the patient, or is so familiar with the patient's history that an examination might not be necessary. In this instance, Respondent wrote prescriptions for a controlled substance for use by Ms. Bullard for a period of six months without either having reviewed her medical records or personally examining her. There is no evidence, however, from which it could be concluded that Respondent did not act in a good faith effort to assist his employee's mother. Further, it is significant that, upon determining that the patient did not suffer from terminal cancer, Respondent immediately ceased prescribing dilaudid. COUNTS IV-VII (BILL CAUDILL) William Caudill has been a patient of Respondent's since approximately 1957. At the time of final hearing in this cause, Mr. Caudill was 59 years old. For as long as he can remember, Mr. Caudill has suffered from severe headaches of unknown etiology. His headaches are so severe, in fact, that Mr. Caudill has been unable to work, and is presently receiving Social Security disability benefits. Since he became a patient of Respondent, Mr. Caudill has been referred by Respondent to several specialists, including a neurologist, for procedures to determine the cause of his headaches. To date, the cause of Mr. Caudill's headaches remains undetermined, and he still suffers almost constant pain. In approximately 1978, Mr. Caudill ceased visiting Respondent, and instead was treated by a physician in Pompano Beach, Florida. Upon his return as a patient to Respondent in approximately July of 1980, Respondent was taking approximately 800 to 1,000 percodans per month for relief of pain associated with his headaches. The record in this cause is undisputed that percodan was moderately effective in assisting Mr. Caudill with headache pain, and that percodan is, in fact, an appropriate medication for that purpose. Upon his return as a patient, Mr. Caudill was advised by the Respondent that he was taking too many percodans, and that Respondent was instituting a procedure to decrease his habituation to that drug. In fact, during his treatment of Mr. Caudill from July, 1980, until the time of this hearing, Mr. Caudill had reduced his ingestion of percodan from in excess of 800 per month down to approximately 50 per month. During the period July, 1980, through December 1981, Respondent prescribed 2,959 two-milligram percodan tablets and 489 two-milligram tuinals to Mr. Caudill. This procedure of reducing the patient's dependence upon percodan by gradually reducing the dosage over an extended period of time is both medically justifiable and appropriate under the circumstances here present. However, Respondent's patient records on Mr. Caudill for the period July, 1980 through December, 1981, are virtually absent any information other than the identification of medication, and the date and amount of the prescription to justify Respondent's course of treatment for Mr. Caudill. Respondent was, of course, intimately familiar with Mr. Caudill's condition, having treated him since 1957. Respondent did, however, fail to keep records sufficient to justify his course of treatment, document the patient's progress or lack thereof, and any alternative treatment modalities considered or rejected. COUNTS VIII-XII (E. O. WALKER) At the final hearing in this cause, E. O. Walker was 72 years old, and had been a patient of Respondent's for approximately 20 years. Respondent ceased treating Mr. Walker when Mr. Walker moved to California in 1975. Respondent forwarded Mr. Walker's patient records to a physician in California, and did not retain copies of those records in his files. Mr. Walker returned as a patient to Respondent in 1980. At that time, Mr. Walker was suffering almost constant pain as a result of earlier heart surgery, disc disease in his lower back, and arthritis. In addition, Mr. Walker had difficulty sleeping, and was depressed as a result of a recent divorce. Because of the pain associated with the above-described ailments, Mr. Walker is totally disabled. For the period of September, 1980 through December, 1981 Respondent prescribed 650 percodans, 500 quaaludes, 500 dexedrines, and 400 seconals to assist Mr. Walker in coping with the pain, enabling him to sleep, and assisting him with his depression. The record in this cause establishes that, given Mr. Walker's history and his existing condition, the prescription of these controlled substances in two-milligram dosages over the period in question was reasonable, medically justifiable, and not excessive in quantity or dosage. There is no evidence to support a conclusion that Respondent's treatment of Mr. Walker from September, 1980 through December, 1991 in any way departed from medically acceptable levels of care. COUNT XII (SELF PRESERVATION) 10. On July 14, 1980, November 10, 1980, January 20, 1981, August 2, 1981 and December 18, 1981, Respondent prescribed demerol tablets and injectables in the name of "R. S. Faircloth" or "Robert S. Faircloth". These controlled substances were used by Respondent in the treatment of his patients. All such controlled substances received by Respondent as a result of these prescriptions were either administered to Respondent's patients or were accounted for by Respondent at the time of final hearing. Further, the prescription blanks used to obtain these controlled substances had the notation "Office Use" on their face
The Issue The issue in this case is whether the allegations of the Administrative Complaint are correct and, if so, what penalty should be imposed.
Findings Of Fact The Petitioner is the state agency charged by statute with regulating the practice of medicine in Florida. At all times material to this case, the Respondent has been a physician in the state, holding Florida license number ME 0044838. The Respondent's last address of record is 11216 North Dale Mabry, Tampa, Florida, 33168 The Respondent has practiced in Florida since 1984 in Internal Medicine. At all times material to this case, Patient number 1 was a 72 year old male. In early December of 1988 the Respondent performed a physical examination of Patient number 1 on behalf of the American Weight Clinic weight loss program. The records of that examination were forwarded to the clinic. Because the Respondent was not the patient's physician, he did not retain a copy of the exam report. Patient number 1 returned to the Respondent on December 28, 1988 and became his patient. Between December 1988 and May 1989, Patient number 1 was examined and/or treated by the Respondent on approximately ten visits. The Respondent became familiar with Patient number 1 over the course of the six months. Patient number 1 was obese, diabetic, and suffered from chronic obstructive pulmonary disease (COPD), glaucoma and heart disease. COPD can not be cured. Patients with COPD generally deteriorate over time. Treatment of COPD may include medications to open bronchial tubes, but most treatment results in minimal improvement. The overall treatment rendered to the patient by the Respondent included weight loss and "maintenance" of the COPD. The Respondent's treatment of the COPD can essentially be described as the "fine tuning" of medications. Although not codified during the time period relevant to this proceeding, effective professional standards required that physicians make contemporaneous medical records to justify the course of treatment provided to patients. Medical records protect both the patient and the physician. Such records provide an historical record of a patient's physical condition, diagnosis and treatment, and are valuable both to the recording physician and to any subsequent physician who provides treatment to the patient. The Respondent was aware of the purpose of keeping medical records. During the time period relevant to this case, the Respondent's receptionist would greet each patient who entered the Respondent's office. Thereafter, a nurse would guide the patient to an examining room, check the patient's "vital signs" and record the main presenting complaint. After the nurse entered the information on the chart, the Respondent would talk with and examine the patient. Also during this time, the Respondent began utilizing a dictation system to record the results of physical examinations. The Respondent continued to hand write diagnosis and medication information but relied on the dictation for recordation of physical exam findings. The office employee responsible for transcribing the dictation performed inadequately. Examination results were apparently not being entered into the medical records. The Respondent also had problems during this time with the employee responsible for management of his office. The family of Patient number 1, apparently unhappy with the medical care being provided to the patient by the Respondent, began utilizing the services of another physician. The family sought to obtain the patient's medical records from the Respondent. Eventually, Patient number 1's son obtained a copy of his father's records in approximately August of 1989, after making repeated requests to obtain the records. Although the Respondent asserts that he did not review records for completeness until or unless a copy of the record was requested, the records provided to Patient number 1's son in August, 1989 were apparently not reviewed for completeness by the Respondent. The Respondent asserts that he was not made aware by his office manager that such records had been requested. The medical records released to the son in August 1989 fail to document the patient's physical condition for three specific office visits. The record of Patient number 1's office visit on December 28, 1988 sets forth the nurse's documentation of vital signs and medication records. The record does not include a description of physical examination findings made contemporaneously at the time of the examination. Based on the lack of physical examination information, the Respondent's medical record related to and made contemporaneously with Patient number 1's office visit on December 28, 1988 does not justify the course of treatment of the patient as identified in the record. The record of Patient number 1's office visit on February 21, 1989 does not include a description of physical examination findings made contemporaneously at the time of the examination. Based on the lack of physical examination information, the Respondent's medical record related to and made contemporaneously with Patient number 1's office visit on February 21, 1989 does not justify the course of treatment of the patient as identified in the record. The record of Patient number 1's office visit on April 18, 1989 does not include a description of physical examination findings made contemporaneously at the time of the examination. Based on the lack of physical examination information, the Respondent's medical record related to and made contemporaneously with Patient number 1's office visit on April 18, 1989 does not justify the course of treatment of the patient as identified in the record. The Respondent asserted that he dictated the physical examination reports of the patient conducted on December 28, 1988, February 21, 1989 and April 18, 1989. There is no credible evidence to the contrary. After the records were provided to the Patient number 1's son in August, 1989, the Respondent became aware that examination information for December 28, 1988, February 21, 1989 and April 18, 1989 was missing from the medical records. Based on his mental recollection of the Respondent and a review of the existing record, he added physical examination findings to the medical records of Patient number 1 for exams conducted on December 28, 1988, February 21, 1989 and April 18, 1989. Standard practice among physicians is to initial and date any additions or changes made to a patient's medical records. The additions made by the Respondent to Patient number 1's medical records are not initialed or dated. There is no notation made on the records which would indicate that the information was not recorded contemporaneously at the time of the examination. The Respondent testified that at the time of the additions, he had sufficient recollection of Patient number 1 to permit the addition of information related to specific office visits to the medical records. The testimony was not persuasive. The evidence fails to establish that the Respondent's recollections of the patient are of such sufficient reliability to establish that the subsequent additions to the medical records were reliable. At some point in the treatment of the patient, he presented to the Respondent with complaints of hemoptysis. The number of such complaints is indeterminable. Testimony by the patient's family directed to the number of visits and quantities of expelled blood being brought to the office lack sufficient precision to be credible. It appears, based on the medical records, that hemoptysis was reported as early as January, 1989. In any event, the evidence fails to establish that incidents of hemoptysis were reported to and not recorded by the Respondent. There is no credible evidence that the Respondent sought to conceal the fact that information was added to the medical records of Patient number 1. The Respondent's primary medical practice involves a substantial level of managed care. According to the Respondent, the effect of a reprimand or probation will be termination of managed care contracts. The Respondent has not been previously disciplined. The Respondent currently hand writes all medical records because he is not convinced of the reliability of dictation.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED: That the Agency for Health Care Administration enter a Final Order determining that Alexander Sonkin, M. D., has violated Sections 458.331(1)(m), Florida Statutes, and imposing a fine of $1,000. It is also recommended that the Respondent be required to complete such course of education related to appropriate methods of patient care documentation as the Board deems acceptable. DONE and RECOMMENDED this 29th day of November, 1995, in Tallahassee, Florida. WILLIAM F. QUATTLEBAUM 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 29th day of November, 1995. APPENDIX TO RECOMMENDED ORDER, DOAH CASE NO. 95-2535 To comply with the requirements of Section 120.59(2), Florida Statutes, the following constitute rulings on proposed findings of facts submitted by the parties. Petitioner The Petitioner's proposed findings of fact are accepted as modified and incorporated in the Recommended Order except as follows: 2. Rejected, irrelevant. 5-7. Rejected, the dates of reported hemoptysis are not supported by clear and convincing evidence. Respondent The Respondent's proposed findings of fact, set forth at pages 16-22 of the proposed recommended order are accepted as modified and incorporated in the Recommended Order except as follows: 1. Rejected, incorrect license number cited. 4. Rejected, subordinate. 16-18. Rejected, not supported by credible and persuasive evidence. Rejected, subordinate. Rejected, irrelevant. The Respondent is not alleged to have provided inappropriate or unreasonable medical treatment. 24-25. Rejected, cumulative. 29. Rejected, not supported by cited testimony. Dr. Stein did not state that he knew of no standard for making "after the fact" record additions. 30-31. Rejected, irrelevant. 32. Rejected, immaterial. DOAH CASE NO. 95-2535 COPIES FURNISHED: Douglas M. Cook, Director Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Jerome W. Hoffman General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Dr. Marm Harris, Executive Director Board of Medicine Agency for Health Care Administration Northwood Centre 1940 North Monroe Street Tallahassee, Florida 32399-0792 Hugh Brown, Esquire Agency for Health Care Administration 1940 North Monroe Street Tallahassee, Florida 32399-0792 Grover C. Freeman, Esquire 201 East Kennedy Boulevard, Suite 1950 Tampa, Florida 33602
The Issue Whether the Respondent violated Section 458.331(1)(m), Florida Statutes, which requires a physician to keep legible medical records on Patient S.W., during the period August 20, 1992, through November 1992. Whether Respondent violated Section 458.331(1)(t), Florida Statutes, which prohibits gross or 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, where Respondent performed surgery that was not necessary and/or failed to diagnose and treat a postoperative infection that resulted in necrosis of the Patient S.W.'s turbinates.
Findings Of Fact Respondent, Robert Peter Filiberto, is and has been, at all times material hereto, a licensed physician in the State of Florida, having been issued license no. ME 0032703. Respondent maintains offices in Palm Bay and Sebastian, Florida. Respondent is board certified in otolaryngology and head/neck surgery. S.W., a 46 year-old adult female, was referred on March 25, 1991, to Respondent with complaints of "chronic bronchitis." Physical examination revealed the following: Mild polypoid changes of both vocal chords, 2+ rhinitis, with 3+ post nasal drainage. Respondent diagnosed the patient as suffering from allergic rhinitis with a post nasal drainage, which precipitated her chronic cough. S.W. returned to Respondent on August 20, 1992, having fallen and suffered a broken nose. Respondent diagnosed a comminuted (multiple) fracture and septal deformity. Respondent recommended surgical correction. On August 26, 1992, S.W. executed a Surgical Contract for a "septorhinoplasty and bilateral turbs" and also executed a Surgical Consent Form as follows: I consent to the performance of operations and procedures in addition to or different from those now contemplated, whether or not arising from presently unforeseen conditions, which Dr. Filiberto may consider necessary or advisable in the course of the operation. * * * The nature and purpose of the operation, possible alternative methods of treatment, the risks involved, the possible consequences and the possibility of complications have been fully explained to me by Dr. Filiberto or his assistant. These may include infection, loss of function, disability, scar formation, pain, bleeding, and possibility of recurrence. I acknowledge that no guarantee or assurance has been given by anyone as to the results that may be obtained. Dr. Filiberto assured me he would fix my nose and I would be happy. (Final sentence added by S.W.) On or about September 18, 1992, Respondent performed septorhinoplasty (plastic surgery of the nose and septum, the cartilage between the nostrils), with bilateral inferior turbinectomy (removal of the lower moisturizing membranes inside the nose) on S.W. at Humana Hospital - Sebastian. Respondent removed a portion of both inferior turbinates. The right inferior turbinate was manually resected (cut) with superficial electrocauterization used to control bleeding. The left inferior turbinate was fulgurated using an intramural electrocautery technique. The surgery proceeded without complication. Following the operation, the hospital pathology report confirmed Respondent's diagnosis: chronically inflamed hypertrophied nasal turbinates. Respondent's post-operative report indicates he intended to remove only the lower two-thirds of Patient S.W.'s turbinates. Respondent's performance of surgical electocautery is not mentioned in Respondent's medical records until Patient S.W.'s visit on or about November 13, 1992. Between September 21, 1992, through November 20, 1992, Respondent saw Patient S.W. for postoperative follow-up examinations. During her postoperative visits, S.W. complained of pain, a greenish discharge, and a bad smell numerous times. When the symptoms did not cease, Respondent prescribed antibiotics on October 22, 1992, approximately four weeks after surgery. After approximately three weeks on the antibiotics, the pain, discharge, and smell continued. Respondent prescribed more of the same antibiotics. Between on or about September 21, 1992, through on or about November 11, 1992, Respondent's medical records described S.W.'s nose as clear. Between on or about September 21, 1992, through on or about November 11, 1992, Respondent's medical records indicate no postoperative infection. However, the patient had an infection that was impervious to the antibiotics that Respondent had first prescribed. When that became apparent, Respondent failed to order a culture. Patient S.W. subsequently transferred her case to another physician and underwent extensive treatment by other physicians for tissue necrosis and osteonecrosis (infectious destruction of bone), including removal of necrotic tissue and intravenous antibiotics. Patient S.W.'s subsequent treating physicians discovered that her turbinates were completely missing. S.W. now has severely limited senses of smell and taste. She suffers from chronic pain and sinus headaches. She experiences nightly discharges of thick mucous, and numbness of certain parts of her face. Expert witnesses speculated that the turbinates were missing, either because Respondent had removed them entirely, which is not standard practice and is not reflected in his medical notes, or because he allowed the infection to continue so long that necrosis destroyed whatever portion of the turbinates had not been removed. Respondent's medical records do not justify his course of treatment of Patient S.W. Respondent's medical records inadequately document Patient S.W.'s history and physical condition or amounts and frequencies of antibiotics prescribed. The records also do not justify Respondent's delay in diagnosing Patient S.W.'s developing post-operative infection. The evidence is not clear and convincing that Respondent performed inappropriate nasal surgery on Patient S.W. on September 18, 1992. A reasonably prudent similar physician would not have failed to timely diagnose and treat Patient S.W.'s developing postoperative infection.
Recommendation Upon the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the Board of Medicine issue a final order that: Finds the Respondent guilty of failure to keep legible medical records that justified the course of treatment for Patient S.W. during the period August 1992 through November 1992, in violation of Section 458.33(1)(m), Florida Statutes. Finds the Respondent not guilty of gross malpractice or the failure to practice medicine within that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances in regard to the diagnosis and surgery performed on Patient S.W., on September 18, 1992. Finds the Respondent guilty of gross malpractice or the failure to practice medicine within that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances in regard to the treatment of the Patient S.W. for the postoperative infection that resulted in necrosis of the Patient's turbinates in the period September through November 1992, in violation of Section 458.331(1)(t), Florida Statutes. Finds that Respondent has established mitigation as to Count I, in that his current procedures for the generation of medical records are in compliance with statutory and regulatory requirements. Suspends Respondent's license to practice medicine for a period of three months, followed by a period of probation under such terms and conditions as the Board may require; and imposes an administrative fine of $5,000, plus the costs of prosecuting this complaint. DONE AND ENTERED this 26th day of February, 1999, in Tallahassee, Leon County, Florida. COPIES FURNISHED: J. Charles Ingram, Esquire DANIEL M. KILBRIDE 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 26th day of February, 1999. Hannah, Voght, Estes & Ingram, P.A. Post Office Box 4974 Orlando, Florida 32802-4974 John O. Williams, Esquire Maureen L. Holz, Esquire Williams & Holz, P.A. 355 North Monroe Street Tallahassee, Florida 32301 Pete Peterson, General Counsel Department of Health 2020 Capital Circle, Southeast Bin A-02 Tallahassee, Florida 32399-1703 Angela T. Hall, Agency Clerk Department of Health 2020 Capital Circle, Southeast Bin A-02 Tallahassee, Florida 32399-1703
The Issue Did Respondent, James Sotrop, M.D. (Dr. Sotrop), violate section 458.331(1)(t), Florida Statutes (2007),1/ by committing medical malpractice by failing to adequately assess patient P.A.'s complaints and symptoms? Did Dr. Sotrop violate section 458.331(1)(t), Florida Statutes, by committing medical malpractice by failing to order diagnostic imaging studies and laboratory tests for P.A.? Did Dr. Sotrop violate section 458.331(1)(t), Florida Statutes, by committing medical malpractice by failing to document a complete patient history and physical examination? Did Dr. Sotrop violate section 458.331(1)(t), Florida Statutes, by committing medical malpractice by failing to immediately refer P.A. to the emergency department of a hospital on January 14, 2007? Did Dr. Sotrop violate section 458.331(1)(t), Florida Statutes by committing medical malpractice by failing to refer P.A. for specialized consultations? Did Dr. Sotrop violate section 458.331(1)(t), Florida Statutes by committing medical malpractice by making an inappropriate diagnosis of P.A.'s condition? Did the Petitioner, Department of Health (Department), fail to properly notify Dr. Sotrop of its investigation and provide an opportunity to respond to the allegations before determining probable cause? If so, do sections 456.073(1) and 458.331(9), Florida Statutes, require dismissal of the complaint?2/
Findings Of Fact The Department is the state agency charged with the licensing and regulation of medical doctors pursuant to section 20.43, and chapters 456 and 458, Florida Statutes. At all times material to the allegations in the Administrative Complaint, Dr. Sotrop was a licensed medical doctor within the State of Florida, having been issued license number ME 41092. Dr. Sotrop's address of record with the Department of Health is Post Office Box 1628, Lutz, Florida, 33548. He has used this address for mailing purposes for 10 to 15 years. The Department mailed a copy of the complaint against Dr. Sotrop and its investigation in this matter to Post Office Box 1628, Lutz, Florida, 33548. Dr. Sotrop says the he "believes" that he did not receive it. This testimony is not sufficiently persuasive to establish that he did not receive the notice. Dr. Sotrop completed medical school at the Medical School of Wisconsin and started working with his father’s family medical practice in Lutz, Florida. Florida licensed Dr. Sotrop to practice medicine in Florida in 1982. Although Dr. Sotrop intended to attend a residency program after practicing medicine with his father for a short time, he never left his father’s practice and thus never attended a residency program. Dr. Sotrop is not board eligible in family medicine because he never attended a residency program. Dr. Sotrop assumed his father’s practice and operated as a solo practitioner until he sold the practice to a large group. After working for the group practice for several years, Dr. Sotrop left the group in 2006 and started to rebuild his solo practice. While he was rebuilding his practice, Dr. Sotrop worked part-time for a colleague at the New Tampa Urgent Care walk-in clinic. He started working at the walk-in clinic in early January of 2007. Dr. Sotrop eventually rebuilt his medical practice and stopped working at the walk-in clinic. He currently maintains a solo medical practice. New Tampa Urgent Care utilized an electronic medical record keeping system known as Amazing Charts. This was Dr. Sotrop’s first exposure to an electronic medical record keeping system. Dr. Sotrop is a “hunt and peck” or “two-finger” typist. He had previously maintained only hand-written medical records. The Amazing Charts system requires physicians to enter some of the information regarding patient visits into the system by manually typing. Because of his lack of familiarity with the Amazing Charts system and his poor typing skills, Dr. Sotrop limited the information he included in patient records using the Amazing Charts. January 13th Patient Visit Patient P.A. first presented to the walk-in clinic on January 13, 2007, with a chief complaint of right-sided facial pain and weakness of the face. Dr. Sotrop saw her. P.A. reported a history of right-sided facial pain for two to three days, and right-sided facial droop that started that morning. Her right eyelid was swollen. P.A.’s vital signs were: temperature of 101 degrees; blood pressure of 114 over 70 (which was normal); pulse rate of 138; and respiratory rate of 18. Dr. Sotrop examined P.A., following his routine physical-examination process. The process, as Dr. Sotrop generally described during his testimony, consists of observing the patient’s gait as they walk to look for any abnormalities. He then examines both ears and both nostrils. He examines the patient’s mouth in the traditional method, checks the neck for movement, and palpates the neck and upper body for swollen lymph glands. He listens to the patient’s heart and lungs and, if appropriate for the presentation, asks the patient to lie down so he can perform an abdominal examination. While performing the physical examination, he talks to the patient and asks questions so he can verify whether the patient’s mental status is normal. Dr. Sotrop observed P.A.'s gait, examined her eyes (including a fluorescein and fundus examination of the eyes), and examined her face and mouth which included her ability to swallow and move her jaw normally. Dr. Sotrop documented his physical examination findings for P.A. during the January 13th visit as follows: Rt lower facial droop not involving forehead. HEENT neg. ex sl grn d/c nares and eryhema rtconj, fluoro neg. no rash (yet) neck supple Dr. Sotrop interpreted this entry in the patient’s record during his testimony as follows: The patient had a right-lower facial droop not involving her forehead. The head, eyes, ears, nose and throat examination were negative except for a slight green discharge from the right nares (or nasal passage) and there was redness of the right conjunctiva (the white part of the eye) . . . I did a fluorescein examination of the eye which involves putting a drop in the eye and using a special light and looked at the eye and it was normal, negative. There was no rash on the face, and I put in parentheses, “yet” because I expected one… And the neck was supple. Dr. Sotrop explained that he documented “no rash (yet)” because he believed the patient most likely had shingles and would soon develop a rash consistent with this diagnosis. Dr. Sotrop's records document that the patient’s neck was supple to document that her neck was not stiff or painful. Dr. Sotrop found the patient’s mental status normal. As he noted, she was well enough to drive herself to the office. Dr. Sotrop determined that the patient was suffering from either Bell’s palsy or Shingles. In the medical record under A/P (or assessment and plan), he documented “Bell’s Palsy (351.0), Herpes Zoster of Eyelid (053.20).” Dr. Sotrop selected these possible alternative diagnoses from a drop-down menu from the Amazing Charts program. “Herpes Zoster” is another name for shingles. He selected Herpes Zoster of the Eyelid because that was the only Herpes Zoster diagnosis he could find in the Amazing Charts drop down menu at the time. Dr. Sotrop discussed his impressions with the patient. He told her that he was not sure whether she had Bell’s palsy or shingles. Dr. Sotrop told the patient to call him back or go to the emergency room if her symptoms got worse. He documented this advice in the records using the drop-down menu of the Amazing Charts system: “re check 2-3 days sooner, if worse, discussed natural and expected course of this diagnosis, and need to alert me if symptoms do not follow expected course, or if any worse. Re-check or go to ER if symptoms get worse.” Dr. Sotrop prescribed Prednisone, a steroid for treatment of suspected Bell’s palsy, Vicodin for pain, and Acyclovir, an antiviral drug to treat the patient for suspected shingles. The Department did not question Dr. Sotrop’s prescription of these medications. Dr. Sotrop’s records do not indicate that, on January 13, he considered the possibility that the patient had meningitis. During the January 13 visit, P.A. did not present the typical complete constellation of symptoms for meningitis. A stiff or painful neck and confused mental status are two common signs of meningitis. Dr. Sotrop's records do not indicate that he advised P.A. on January 13 to go to an emergency room for additional testing, such as a CT scan or spinal tap, to rule out or confirm more serious conditions like a tumor, meningitis, or other infection. Dr. Sotrop's demeanor during his testimony and inconsistencies in testimony make his claim that he advised P.A. to go to an emergency room or obtain further testing not credible. The testimony is not logically consistent with the fact that Dr. Sotrop entered in the records the much less significant information that he advised the patient to return or visit an emergency room if her symptoms did not improve. And it is not consistent with his stated beliefs about the uses and importance of records for patient care, insurance, and legal concerns. January 14th Patient Visit P.A. called the walk-in clinic the following day, Sunday, January 14th, and told the nurse that she was still having headaches and that the pain medication was not helping. Dr. Sotrop told the nurse that he wanted the patient to return to the office for further evaluation. P.A. drove herself to the walk-in clinic for the return visit. During this visit, she complained of nausea and vomiting and headache. The patient’s vital signs had improved. Her temperature was now normal, 97.8, and her blood pressure was 124/84. P.A.'s pulse rate had come down to 126, and her respiratory rate was slightly higher, at 20. Dr. Sotrop repeated the physical examination he conducted on January 13th. P.A.'s neck was still supple. And her mental status was normal. The patient’s facial symptoms had significantly improved from the January 13th visit. Dr. Sotrop documented “facial symptoms much better” and “exam shows near full return of facial movement and full closure of eye.” Dr. Sotrop also documented that P.A. still had no rash. Dr. Sotrop tapered the prescription for Prednisone and asked P.A. to hold Acyclovir for 12 hours because headaches are a known side effect of these medications. He also gave her an injection of Phenergan during the visit for nausea. Dr. Sotrop’s records do not indicate that on January 14th he considered the possibility that the patient had meningitis. They indicated, as on the 13th he told the patient to return or got to an emergency room if her condition worsen. A stiff or painful neck and confused mental status are two common signs of meningitis. During the January 14th visit, P.A. did not present the typical complete constellation of symptoms for meningitis. Dr. Sotrop's records do not indicate that he advised P.A. on January 14th to go to an emergency room for additional testing such as a CT scan or spinal tap to rule out or confirm more serious conditions like a tumor, meningitis, or other infection. Dr. Sotrop's demeanor during his testimony and inconsistencies with his other testimony make his claim that he advised P.A. to go to an emergency room or obtain further testing is not credible. The testimony is not logically consistent with the fact that Dr. Sotrop entered in the records the much less significant information that he advised the patient to return or visit an emergency room if her symptoms did not improve. And it is not consistent with his stated beliefs about the uses and importance of records for patient care, insurance, and legal concerns. January 15th Hospital Admission On January 15th, P.A.'s daughter found her unresponsive. P.A. was taken to the University Community Hospital by ambulance and placed in the Intensive Care Unit. Dr. Sotrop was not consulted on this hospital admission. But he did visit the patient after he learned of her admission. P.A. was unresponsive when she was admitted to the hospital. Her condition did not improve. A lumbar puncture showed possible bacterial meningitis. P.A. died about 48 hours after her admission to University Community Hospital. The patient’s final diagnoses included acute bacterial meningitis and “possibly shingles.”
Recommendation Upon consideration of the facts found and conclusions of laws reached, it is RECOMMENDED that the Florida Board of Medicine deny the Motion to Dismiss and enter a Final Order dismissing the Administrative Complaint in its entirety. DONE AND ENTERED this 2nd day of July, 2012, in Tallahassee, Leon County, Florida. S JOHN D. C. NEWTON, II 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 2nd day of July, 2012.
The Issue The issue for determination at formal hearings was whether Respondent committed the offenses set forth in the amended administrative complaint, and, if so, what action should be taken.
Findings Of Fact The Agency for Health Care Administration (AHCA) is the state agency charged with regulating the practice of medicine pursuant to Sections 20.165 and 20.42, Florida Statutes, and Chapters 455 and 458, Florida Statutes. At all times material hereto, Alejandro Jose Vilasuso (VILASUSO) has been a physician licensed in the State of Florida, having been issued license number ME 0042999. At all times material hereto, VILASUSO's primary practice was located at 4995 S.W. 82nd Street, Miami, Florida. This address was filed with the Board of Medicine and for the past five years was a part of its records. Also, at all times material hereto, VILASUSO had a satellite office located at 2245 S.W. 27th Street, Miami, Florida. On or about March 11, 1993, Patient J. K. presented to VILASUSO at his satellite office for hypertension. From March through June 1993, she had monthly appointments with him at the satellite office. Patient J. K.'s former husband, Patient C. M., was having a prostate problem. Patient J. K. recommended that he consult with VILASUSO regarding his prostate problem. On or about June 28, 1993, Patient C. M. presented to VILASUSO, at his satellite office, regarding the prostate problem. Patient J. K. accompanied Patient C. M. to VILASUSO's office. Patient C. M.'s blood was drawn for lab tests. He was also provided with a two-week prescription for medication and scheduled for a follow-up appointment on July 8, 1993, at which time VILASUSO would discuss the lab results and his recommendations. Patient C. M. informed Patient J. K. that he had had blood drawn for lab tests, regarding his prostate problem, and that he was returning on July 8, 1993, to discuss the test results with VILASUSO and his (VILASUSO's) recommendations. VILASUSO and his landlord at the satellite office had been having an ongoing rent dispute, concerning an increase in VILASUSO's rent. VILASUSO had refused to sign a long-term lease agreement and, as a result, was on a month-to- month lease. Hoping to force a settlement of the dispute, VILASUSO withheld his rent for June 1993. However, in the last week of June, approximately two days before July 1, 1993, the landlord reacted by threatening to lock VILASUSO out of his office. It was clear to VILASUSO that the dispute could not be resolved and that he had to move on or before July 1, 1993. On or about July 1, 1993, VILASUSO relocated his satellite office. However, he saw all patients scheduled for that day before relocating. He moved about five blocks away. Before leaving his office that day, VILASUSO indicated his new address on a piece of cardboard and posted it on the outside of the office. Telephone service for the satellite office was discontinued between June 28, 1993, and July 8, 1993. Attempting to directly notify his patients of his relocation immediately after the move, VILASUSO directed his office staff to notify all patients by telephone who had an appointment within the following two weeks or who were very ill of the relocation and/or to reschedule their appointments. All other patients were notified of his new location by letter. Patient C. M. had an upcoming appointment within the two-week period. However, for some unknown reason, he was not contacted and VILASUSO did not discover this mistake until sometime after Patient's C. M.'s scheduled appointment on July 8, 1993. On or about July 6, 1993, Patient J. K. went to VILASUSO's former satellite office and found it deserted. She contacted Patient C. M. and told him what she had discovered. On July 8, 1993, Patient C. M. was unable to keep his scheduled follow-up appointment because he was unaware of VILASUSO's new location. On or about July 15, 1993, Patient J. K. discovered the location of VILASUSO's new satellite office and informed Patient C. M. On that same day, Patient J. K. went to VILASUSO's new office and requested a copy of Patient C. M.'s medical records. Believing that Patient J. K. was Patient C. M.'s confidant and that she was requesting the medical records on behalf of Patient C. M., VILASUSO released the records to her. VILASUSO released a copy of Patient C .M.'s records to Patient J. K. without written authorization from Patient C. M. Patient J. K. was neither Patient C. M.'s legal representative nor his other health care provider. On or about July 15, 1993, Patient J. K. notified Patient C. M. by telephone that she had obtained a copy of his medical records and was mailing the copy to him. Patient J. K. mailed the records, and Patient C. M. received them. On June 29, 1993, VILASUSO had only received Patient C. M.'s partial lab results, so the medical file contained only the partial lab results. On July 20, 1993, VILASUSO received the remainder of the lab results, which were normal, and mailed them to Patient C. M. At all times material hereto, VILASUSO did not place an advertisement in the newspaper notifying his patients of the effective date of his relocation and an address at which patients could obtain their records.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order: Dismissing Count One of the Amended Administrative Complaint. Finding a violation of Section 458.331(1)(g), Florida Statutes, as stated in Count Two of the Amended Administrative Complaint. Imposing a reprimand and an administrative fine of $1,500. Imposing a requirement of reading Chapters 455 and 458, Florida Statutes, and submitting an affidavit attesting to such fact. Imposing Continuing Education requirements concerning confidentiality of patient records under terms and conditions determined to be appropriate by the Board of Medicine. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 23rd day of March 1995. ERROL H. POWELL 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 March 1995
