Findings Of Fact Respondent is, and at all material times has been, a licensed physician, having been issued license number ME 0040551, by the State of Florida. Respondent is a 1979 graduate of the University of Juarez. Respondent performed an internship at Mount Sinai Hospital in Chicago, Illinois, from 1979 to 1980. Between 1980 and 1982, Respondent performed a two year internal medicine residency at Grant Hospital in Chicago, Illinois. Respondent is "Board-eligible" in the area of internal medicine. Internal medicine involves a non-surgical approach to evaluating multiple organ systems. It involves understanding diseases at a "higher" level and dealing with multiple illnesses. Respondent once has taken, but did not pass, the examination to become Board certified in internal medicine. Respondent has had no other complaints filed against his license to practice medicine in Florida, other than the one at issue in this case. On or about May 2, 1986, Respondent admitted patient L. S. to Clearwater Community Hospital in Clearwater, Florida, because of a possible cerebral vascular accident which occurred 3 days prior to admission. Patient L. S. was a 76-year old male patient who was a member of the "Gold Plus" IMC Health Maintenance Organization. At or about the time of admission of patient L. S. to Clearwater Community Hospital, Respondent obtained a patient medical history from L. S. and performed a physical examination. As a result of the stroke, patient L. S. had speech difficulties at the time of admission to Clearwater Community Hospital. Respondent's initial patient history for L. S. included the following information: With respect to the cerebral vascular accident, the patient had awakened 3 days prior to the admission and had difficulty with speech and difficulty using his right hand. The patient was able to ambulate without difficulty and had noted no improvement or worsening in symptoms in the three days prior to admission. The patient had had intestinal surgery 50 years previously, which, according to Respondent's documented history, resulted in chronic diarrhea. Additionally, the patient had been hospitalized two years earlier for "dysphagia (a difficulty in swallowing) with a negative work-up." According to the patient, the patient had no coronary artery disease, hypertension, peptic ulcer disease or diabetes. The patient's social history provided the information that the patient smoked tobacco, one-half pack per day, and did not drink alcohol. The patient provided information that he was on the following medication: Lomotil p.r.n. (as needed); Lanoxin 0.125 mg. per day; and Quinaglute 100 mg., dose schedule unknown. Respondent performed an appropriate initial physical examination on patient L. S. Of significance was Respondent's finding with respect to the patient's heart: "Irregular, irregular rhythm with no gallops or murmurs appreciated." After completing the initial history and physical examination, Respondent's impression was: Acute CVA, patient now three days post-insult and appears to be stable. He already has good use of his right upper extremities and his speech is intelligible although slurred History of cardiac arrhythmia History of chronic diarrhea secondary to intestinal surgery 50 years ago. As part of his plan for the patient, formulated after obtaining the initial history and physical, Respondent noted, "Will also consider ECHO cardiogram as the heart irregularity may provide the source of the emboli." While patient L. S. was hospitalized during the May 2, 1986, admission, Respondent ordered the following tests which were performed on the patient: a complete blood count; a prothrombin time test; an activated partial thromboplastin time test; a routine urinalysis; a portable upright chest x-ray; a bilateral duplex carotid ultrasound study; a CT scan of head - stroke routine (non contrast study); a Brain CT Scan Stroke Protocol-Post contrast series only; an electroencephalogram (EEG); a blood chemistry profile; and an electrocardiogram (EKG)(the patient was also placed on a telemetry monitor). On admission, Respondent ordered Lomotil, one tablet to be given as needed for diarrhea, Lanoxin 0.125 mg. to be given four times a day, and Quinaglute 100 mg. to be given twice a day. On the same day of admission, Respondent changed the order for Quinaglute to 325 mg. to be taken by mouth twice a day. On admission and again on May 9, 1986, Respondent ordered blood serum levels of digoxin (Lanoxin is a drug containing digoxin). These blood levels revealed that the digoxin level was low on admission (normal laboratory values were listed as between 0.5 to 2.0 - the actual value was 0.1). The repeat digoxin level reflected that the digoxin was within normal limits on May 9, 1986 (the actual value was 1.1). Quinidine levels were also obtained (to determine the level of the drug Quinaglute in the blood), pursuant to Respondent's request. The quinidine level taken on admission was below normal (normal laboratory values were listed between 2.0 and 5.0 - the actual value was .7). The repeat quinidine level performed on May 9, 1986, reflected that the quinidine levels were within normal limits (2.6). Under the circumstances, the Respondent cannot be severely criticized for the initial history he took from the patient. In ideal circumstances, an internist would attempt to get more detail on the patient's smoking history pertinent to possible chronic obstructive lung disease or possible congestive heart failure, on the patient's chronic diarrhea, and on the patient's drug dosages. But the Respondent was dealing with a 76-year old man who came to see him for symptoms of a stroke three days before. The patient had difficulty making his speech understood and had no family or friends available to help him give his medical history to the Respondent. It was within acceptable standards of care recognized by a reasonably prudent similar physician under similar circumstances for the Respondent to take as much history as the patient was capable of comfortably giving at that time. The Respondent was planning on referring the patient to the hospital's stroke team, which over the course of the hospital stay would completely evaluate the effect of the stroke on the patient. The Respondent planned to have blood serum levels done which would establish proper drug dosages. The Respondent's primary concerns were the possibility of an evolving stroke and the possibility of malignant cardiac arrhythmias. Since there were no complaints or symptoms of chronic obstructive pulmonary disease or congestive heart failure, it was not necessary to pursue the smoking details on the initial history on this admission. As for the diarrhea, the Respondent was dealing with a 76-year old man who reported chronic diarrhea for 50 years. It may have resulted from intestinal surgery 50 years ago, and it may have been exacerbated by the Quinaglute the patient had been prescribed for his heart arrhythmias. Severe malabsorption problems would show up on the blood screen and the complete blood count the Respondent was planning to have the patient undergo. Otherwise, it was acceptable under the circumstances of this case to concentrate on the two primary concerns and treat the diarrhea symptomatically with Lomotil as needed for the time being. The Respondent should have followed up on obtaining available previous hospital records, especially the local admission for dysphagia two years prior, but that information would not appear in the initial history. While L. S. was in the hospital, the Respondent appropriately and adequately evaluated the patient's heart as a possible cause of the stroke. The evidence suggests that it is fairly debatable among physicians whether to order a $500-$600 echocardiogram in a case such as this; it is not necessary to meet the standard of care. When the Respondent initially examined the patient and heard irregularly irregular heart rhythms, he initially considered an echocardiogram. Irregularly irregular heart rhythms suggest atrial fibrillation which can predispose a patient to heart clots (emboli) which can break off, travel through the circulatory system and cause a stroke. But the results of the CAT Scan indicated that the stroke was not caused by a heart embolus but by a constriction of smaller blood vessels. In addition, the results of the EKG and telemetry monitoring revealed that the patient did not have atrial fibrillation but had significant and possibly malignant premature ventricular contractions (PVCs). While this particular heart beat irregularity is serious and can be fatal, it does not predispose a patient to heart emboli and resulting strokes. With this information, the echocardiogram was no longer necessary. While L. S. was in the hospital, the Respondent appropriately and adequately evaluated his lung function. The chest x-ray and EKG which the Respondent had done for the patient enabled the Respondent to diagnose obstructive pulminary disease (C.O.P.D.) if the patient had it. Milder cases of C.O.P.D. would have required with a pulmonary function test or a blood gas level. The evidence suggests that it is fairly debatable among physicians whether to have done one of those tests in this case; it was not necessary to meet acceptable standards of care recognized by a reasonably prudent similar physician under similar circumstances. The patient had no complaint of shortness of breath with exertion that would suggest emphysema. To the contrary, he progressed well in physical therapy during the 10-day hospitalization with no indication of this symptom. Nor did the patient have cyanosis or clubbing that would be symptomatic of chronic bronchitis. Those are the two kinds of C.O.P.D. about which a physician evaluating L. S. would be concerned. Regarding the patient's chronic diarrhea, the Respondent performed some general screening tests which, while non-specific in nature, had potential to provide some information about the patient's nutritional status. The complete blood count (C.B.C.) may provide information about some deficiencies. Generally, in an isolated deficiency of vitamin B12 or folic acid, one would expect to find an elevated M.C.V. (mean corpuscular volume), which would show up on a C.B.C. In this case, however, the C.B.C. provided no real information about the nutritional status of patient L. S. The M.C.V. was only slightly elevated. A prothrombin time test can be done to evaluate vitamin K deficiencies and was done in this case. Additionally, the blood levels of several substances can provide information about malnutrition. In this case, the chemistry profile revealed malnutrition. The blood chemistry profile revealed low albumin levels, low globulin levels and low total protein levels. The possibility exists that patient L. S. suffered from diarrhea which was caused or aggravated by the Quinaglute that the patient was also taking. Quinaglute can cause diarrhea. This was not evaluated by the Respondent. It could not be evaluated by the medication history the patient was able to give (i.e., by determining how long the patient had been taking Quinaglute in relation to the period of time the patient had had diarrhea.) Besides, the Respondent made the decision to stabilize the patient's potentially life- threatening heart arrhythmias using the Quinaglute instead of withdrawing the Quinaglute in an attempt to cure the diarrhea problems with which the patient had lived for 50 years. The Respondent cannot be severely criticized for this decision. On this admission, it was acceptable to treat the patient's diarrhea symptomatically for the time being and further evaluate and treat it after the Respondent dealt with the more serious matters of the C.V.A. and the heart arrhythmias. On or about May 12, 1986, Respondent transferred patient L. S. to Druid Hills Skilled Nursing Center from Clearwater Community Hospital. As reflected in Respondent's discharge summary for patient L. S., Respondent was not able to determine the precise cause of the stroke which patient L. S. suffered prior to discharging the patient from the hospital. The discharge diagnoses reflect: (1) acute cerebral vascular accident; and (2) cardiac arrhythmias with frequent P.V.C.'s. The Respondent kept patient L. S. in Clearwater Community Hospital for ten days, from May 2 until May 12, 1986. Although the evaluation and tests were completed within five days, the Respondent did not want to discharge the patient to his home where he would be by himself, but rather to a nursing home. While waiting for a nursing home bed to become available, the Respondent used the resulting extended hospital stay to continue physical therapy. At the time of transfer from the hospital to Druid Hills, patient L. S. was frail. He was 76 years old, five feet ten inches tall and weighted only 113 pounds. Having just had a stroke, he was far from the picture of health, and this was noted by some of the nursing staff upon transfer to Druid Hills Skilled Nursing Center. He looked and was ill, but he was stable. At the time of admission to Druid Hills, patient L. S. was in essentially the same condition as when admitted to Clearwater Community Hospital, ten days earlier. The patient still suffered from slurred speech and had problems with his right arm. But he was stable and anxious to begin speech and physical therapy. On May 12, 1986, at about 2:00 p.m., Judith Salyer, L.P.N., attempted to contact Respondent in order to confirm routine house orders by "beeping" Respondent. Respondent called the nursing home at 4:30 p.m. on the same day to provide the following admission orders: Lanoxin 0.125 mg. by mouth four times a day ASA by mouth four times a day Persantine 75 mg. by mouth two times a day Quinaglute 325 mg. by mouth every eight hours Lomotil by mouth three time a day for diarrhea Tylenol by mouth four times a day Restoril 15 mg. by mouth at night for sleep as needed Physical Therapy Speech Therapy In addition to slurred speech, on May 14, 1986 (two days after admission to Druid Hills), patient L. S. began to have problems with his eye which was red and draining yellow matter (inaccurately described as "pus" in the nursing notes.) When asked by nursing staff if his eye hurt, L. S. advised them that it did. In all other respects, patient L. S.'s condition seemed essentially unchanged. Respondent was not advised of the change in the patient's eye. On the following date, patient L. S. developed additional symptoms. These included coughing and a runny nose with white mucous. The patient's eyes continued to be pink tinged with a moderate amount of yellow drainage from the eye noted. At 2:20 p.m. on May 15, 1986, Judith Salyer, L.P.N., spoke with Respondent and received the routine house orders which Salyer had called about on May 12, 1986. Salyer did not advise Respondent of the minor cold symptoms. Later on the evening of May 15, 1986, it was noted that patient L. S.'s appetite was poor. On May 16, 1986, at 2:00 p.m., it was noted that L. S. was refusing to eat meals and had a inoderately unsteady gait. On May 17, 1986, it was noted that L. S. informed the nurse on duty that he had had loose stools five times. Additionally, it was noted that the patient was refusing to eat meals. At 9:00 p.m. on May 17, 1986, patient L. S. was noted to be "out of bed." No complaints of diarrhea were noted. Additionally the patient ate 80% of his meal and requested ice cream. In the early part of the day on May 18, 1986, patient L. S. was noted to have "chronic diarrhea" by nursing staff. (Throughout his nursing home stay, the patient was given Lomotil, an anti-diarrheal agent, in an effort to treat the diarrhea.) Between at least 9:30 p.m. on May 18, 1986, and the evening of May 19, 1986, patient L. S. appeared to be doing reasonably well. The patient's appetite was good. There were no complaints of diarrhea. The runny nose, coughing and eye drainage were not noted after May IS, 1986. At 2:00 p.m. on May 20, 1986, Nurse Salyer noted that patient L. S. appeared slightly confused at intervals. The patient had mild congestion and a productive cough. The patient's gait was noted to be unsteady at times. At that time, Salyer "beeped" Respondent in an attempt to advise Respondent of the patient's change in condition. Respondent did not call back on May 20, 1986. A productive cough is a cough which produces "gobs" of mucous. Such a cough can be indicative of a lower (as opposed to upper) respiratory infection or congestion in the chest. The presence of a productive cough is a cause for concern. In a later entry made on May 20, 1986, a Nurse Rooker noted that the patient had remained in bed during the shift. His appetite was 40%. It was noted that L. S. was congested, coughing up large amounts of whitish mucous. On May 21, 1986, at some time before 2:00 p.m., Respondent was notified by telephone of patient L. S.'s stable vital signs, "cold symptoms," that the patient appeared slightly confused at intervals, was refusing to eat, was mildly congested with a productive cough and had an unsteady gait at times. Given this information, Respondent determined that the patient had a "cold" or upper respiratory infection. New orders were received and transcribed. On May 21, 1986, Respondent ordered Ampicillin 250 mg. to be taken every four hours for eight days. Respondent also ordered Actifed to be taken three times a day as needed for "sinus congestion." Respondent gave patient L. S. Ampicillin, which is an antibiotic, for his symptoms as a precautionary or prophylactic measure. Antibiotics should not, as a general rule, be ordered without having a well-grounded understanding why the patient is ill. The cause of the infection should be determined. The most basic reason for not giving an antibiotic without first evaluating the source of the infection is that the antibiotic then can serve to simply hide the symptoms. The antibiotic will cause some improvement, making it appear that the patient is not quite as ill, when in fact the infection persists. Additionally, there is a theory in medicine that the antibiotic can serve to cause a resistant strain of infection. Respondent assumed that, like most other nursing home patients, patient L. S. was suffering from a cold. Respondent ordered no further tests to evaluate the patient and Respondent declined to see the patient on May 21, 1986. Under the facts and circumstances of this case, it was inappropriate for Respondent to prescribe Ampicillin, an antibiotic, without first evaluating the source of the infection. Assuming that L. S. had a "cold" or upper respiratory infection, it was appropriate for Respondent to order Actifed, an antihistamine, for L. S. on May 21, 1986. However, given the presence of a productive cough, chest congestion could have been present. With chest congestion, an antihistamine like Actifed would have been inappropriate. Actifed will dry up the chest. Mucous in the chest which needs to be expectorated, and brought up and out, will remain in the chest. A mucolytic expectorant, not an antihistamine, should be ordered when the chest is congested. Given the facts that patient L. S. was recuperating from a recent CVA, had difficulty in swallowing, and had multiple medical problems, the Respondent could have been more aggressive in either examining this patient, who had a productive cough, or ordering appropriate testing. A reasonably prudent physician, under similar conditions and circumstances, could have personally examined the patient L. S. on May 21, 1986, or soon thereafter. Alternatively, a reasonably prudent physician could have ordered a C.B.C. and a chest x-ray or some other ancillary diagnostic modalities. A C.B.C. is a method by which one can obtain a count of blood cells, particularly white blood cells, in a patient in order to determine whether there is an ongoing infection. The type of white blood cells present (lymphatic cell or a leukocytic cell) can assist in the determination of whether the infection is bacterial or viral in nature. A chest x-ray is necessary to diagnose pneumonia or obstruction in the lungs. Given the history of patient L. S.'s difficulty in swallowing, it is entirely possible that the patient aspirated food or mucous. When such a foreign substance is inhaled into the lungs, it blocks off the bronchials (the airways into the lungs) and causes an obstruction which will lead to pneumonia. Given this patient's condition and history, Respondent could have used a chest x-ray to evaluate the patient to rule out the possibility of aspiration. But it was not necessary for the Respondent to have arranged to personally examine the patient or order tests at this stage. It would be appropriate to monitor a patient with a viral infection (or "cold") or to prescribe antibiotic such as Ampicillin for a bacterial infection. On May 21, 1986, the antibiotic Ampicillin was given to patient L. S. by nursing staff at Druid Hills. This antibiotic was administered as ordered until May 29, 1986, when it was discontinued on the eighth day. On May 22, 1986, Nurse Salyer noted that patient L. S. had diarrhea. Patient L. S. told Nurse Salyer that in the past the patient had taken Ampicillin and that the Ampicillin had caused diarrhea. Salyer further noted on that date that L. S. was coughing up large amounts of yellowish phlegm. On May 22, 1986, at some time prior to 3:00 p.m., Salyer "beeped" Respondent in an attempt to advise Respondent of L. S.'s statement that the antibiotic was causing diarrhea. Respondent did not call Salyer back by the end of her shift on May 22, 1986. On the 3:00 p.m. to 11:00 p.m. shift at Druid Hills, on May 22, 1986, Kathy Rooker, L.P.N., was involved in the care of patient L. S. At 4:50 p.m., Rooker noted that Respondent had not returned the earlier telephone call. Therefore, Rooker called the answering service for Respondent again and asked the answering service to "beep" Respondent again. The Respondent did not call Rooker back. On May 23, 1986, Nurse Salyer notified Respondent of L. S.'s statement that the antibiotic that patient L. S. was taking (Ampicillin) had previously caused the patient to have diarrhea. Respondent decided not to change the antibiotic order for patient L. S. Ampicillin is known to cause diarrhea in some individuals. But so do many other antibiotics. A reasonably prudent physician, after having been advised that the patient had diarrhea and that the patient previously had had diarrhea while on the same antibiotic, could either change the antibiotic therapy or wait and see if the diarrhea continued or became a problem. On May 23, 1986, at 2:00 p.m., Salyer noted that patient L. S. continued to experience congestion and a productive cough, and continued to have a poor appetite. The same information was noted on the evening shift on May 23, 1986. This condition persisted on May 24, 1986. Additionally, the patient's temperature was 100 degrees on May 24, 1986. Previously, the patient had had an essentially normal temperature. On May 25, 1986, it was noted that patient L. S. was still congested with a productive cough. Additionally, the patient's temperature continued to be elevated. On May 26, 1986, no entry was made in the nurses' notes as to the status of the patient's congestion and cough. It was noted that the patient's friend, "John," came to request permission to take L. S. out for the day. However, L. S. indicated that he felt too weak to go. Both L. S. and his friend asked that Respondent be called for a leave of absence order in the future. It was further noted that the patient continued to have a poor appetite. In the morning on May 27, 1986, Nurse Salyer "beeped" Respondent for the leave of absence order. Respondent did not return that call during Salyer's shift on May 27, 1986. In the 2:00 p.m. entry for May 27, 1986, Salyer noted that patient L. S.: had bed rest during the shift; suffered from chronic diarrhea with mucous in the stool; was refusing to eat with poor fluid intake; had yellow mucous draining from his eyes; and had continued congestion with a productive cough. At 9:00 p.m. on May 27, 1986, it was noted that the patient's condition as described above had persisted. Additionally, it was noted that Respondent had not returned the telephone call made by Salyer that morning. In fact, it does not appear that Respondent ever returned Salyer's call made on May 27, 1986. On May 28, 1986, it appeared that patient L. S. was improving some in comparison to the patient's condition on previous dates. It was noted that the patient's respirations were "easy." However, it was also noted that the patient still had periods of confusion, still had poor appetite, still was congested and had yellowish drainage from the right eye. On May 29, 1986, the patient's condition further deteriorated. On this date, in the morning, it was noted that the patient remained congested. In the afternoon, a friend of L. S. named Sigfred Ivanicki, came to see L. S. Ivanicki had visited L. S. in Druid Hills twice a week (on Sundays and Thursdays) while L. S. was in the nursing home. When Ivanicki saw L. S. on Thursday, May 29, 1986, in the afternoon (Ivanicki usually visited between 4:00 p.m. and 6:00 p.m.), Ivanicki was very concerned about the deterioration he saw in L. S.'s condition and believed at that point that L. S. was dying. Ivanicki had had an opportunity to see patient L. S. several times before May 29, 1986. Initially, when Ivanicki saw patient L. S. shortly after the admission of the patient to Druid Hills, patient L. S. appeared cheerful and on the road to recovery. Ivanicki would, on each visit, perform tasks of a personal nature for L. S. Thereafter, the patient developed bad congestion with a productive cough and had diarrhea. None of these symptoms appeared too serious to Ivanicki. However, on May 29, 1986, Ivanicki became truly concerned about L. S. After seeing patient L. S. on May 29, 1986, Ivanicki went to see the head nurse at Druid Hills and asked that Respondent be called to come see the patient and transfer the patient to the hospital. At that time, Ivanicki was told that Respondent was very hard to reach. At 6:00 p.m. on May 29, 1986, a nurse Febbo assessed patient L. S.'s condition. Nurse Febbo noted that the patient refused to eat, complained of shortness of breath and had a flushed face. The patient's skin was warm and dry. The patient's vital signs were as follows: pulse 102 beats per minute, temperature 99.8, blood pressure 120/60 and respiration rate 28 per minute. The patient's lungs were clear with decreased breath sounds. The patient was congested and was expectorating thick clear mucous. The patient was incontinent of bowel. On May 29, 1986, at 6:00 p.m., Nurse Febbo noted that she attempted to contact Respondent at 546-5702 unsuccessfully, and had notified Respondent's answering service that she was attempting to contact Respondent. Respondent returned Nurse Febbo's call at 8:00 p.m., on May 29, 1986. The nursing staff advised the Respondent of patient L. S.'s condition as reflected in Finding 52, above. In response, the Respondent provided the following telephone order for the patient: Lomotil three times a day, discontinue betadine to the little finger, and obtain a splint for right hand. Respondent did not order a C.B.C. or a chest x-ray at that point, even though both tests would have been appropriate. Additionally, Respondent did not go see the patient when advised of the patient's condition. Regardless whether the nursing staff had placed a "STAT" call, a reasonably prudent physician, after being advised of the condition of patient L. S., would have either gone in to see the patient or promptly ordered a C.B.C. and a chest x-ray. The vital signs and physical examination results reflect a very sick individual. The decreased breath sounds indicated that pneumonia or a pneumonic process had begun in the patient's lungs. Additionally, the diarrhea had advanced to the stage where the patient was incontinent. Respondent should have either seen the patient (something he had decided not to do up to this date) or should have ordered a chest x-ray and C.B.C. The nurses' notes for 8:00 p.m. on May 29, 1986, reflect that the patient L. S. was given Actifed by mouth for congestion, consistent with Dr. Hayward's orders given on May 21, 1986, and not changed. Given the presence of a pneumonic process in L. S.'s lungs, Actifed was inappropriate. See Finding 36, above. On May 30, 1986, it was noted prior to 9:30 a.m. that the patient L. S. was growing increasingly weak and was coughing up a greenish yellow mucous. The patient's lungs were noisy and appeared to be filled with fluid. The nursing staff had begun attempts to contact Respondent, probably beginning as early as 7:30 a.m. At 9:30 a.m., the nurses' notes reflect that the nursing staff had attempted to call Respondent several times and had paged Respondent at the hospital but had received no return telephone call. At 10:00 a.m., Gold Plus called the nursing staff at Druid Hills. Mr. Ivanicki had contacted Gold Plus to complain about Respondent's failure to transfer L. S. to the hospital for treatment. Gold Plus, after talking to the nursing staff, was also to attempt to contact Respondent. At 10:15 a.m., on May 30, 1986, over two hours after the first telephone calls, Respondent finally called Druid Hills and ordered that the patient be sent to the emergency room at Clearwater Community Hospital. Confusion occurred over the transfer of the patient to the hospital, due to no fault of Respondent. As a result of this delay, the patient was not transported to Clearwater Community Hospital until about 11:45 a.m., on May 30, 1986. However, before the actual transport could occur, the patient partially "coded" or had a cardiopulmonary arrest. At the time of the arrival of patient L. S. at Clearwater Community Hospital, the patient had a cardiopulmonary arrest and resuscitation techniques were successfully used. A chest x-ray performed showed haziness in the lungs which was suspicious for aspiration pneumonia. On June 14, 1986, patient L. S. died at Clearwater Community Hospital. The patient had been in a coma since arrival at the hospital. The immediate cause of death was listed as cardiogenic shock. Respondent's final diagnoses were: (1) cardiopulmonary arrest; (2) aspiration pneumonitis; (3) possible acute myocardial infarction; (4) thrombocytopenia; (5) cardiac arrhythmia with frequent PVCs; (6) hyperkalemia; (7) status post-recent CVA; and (8) severe post-anoxic encephalopathy. It was the practice of nursing personnel at Druid Hills to identify calls to physicians as "STAT" calls when an emergency or critical situation existed. With a STAT call, an immediate response was necessary. Nursing staff at Druid Hills did not consider patient L. S.'s condition to be an emergency or critical until May 30, 1986. The calls to Respondent were not identified as "STAT" calls. It would have been inappropriate for the Respondent to delay his response to telephone calls made by Druid Hills nursing staff pertaining to patient L. S. on May 29 and 30, 1986. A reasonably prudent physician, acting under similar conditions and circumstances, would have returned such telephone calls within an hour unless other emergencies existed. But it was not proved that the Respondent received and delayed his response. The Respondent generally was good about returning telephone calls and was experiencing difficulty both with the Gold Plus switchboard and with his answering service. The Respondent's response to those calls may well have been reasonable under the circumstances. In contrast, the calls on May 20, 22 and 27 were not of any emergency nature and did not require priority response. It was not proved that the Respondent's response to' those calls were delayed unreasonably. (Gold Plus had a policy of not permitting a leave of absence, the subject of the May 27, 1986, call.) Except to the extent that the Respondent's course of treatment was inappropriate, as noted above, the Respondent's records (including the hospital and nursing home records) justify his course of treatment of L. S. Respondent, in his treatment of patient L. S., failed to practice medicine with the level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as acceptable under similar conditions and circumstances, as a result of the deficiencies and omissions noted above.
Recommendation Based on the foregoing Findings Of Fact and Conclusions Of Law, it is recommended that the Board of Medicine: (1) hold the Respondent, Edward C. Hayward, M.D., guilty of violating Section 458.331(t), Florida Statutes (1985)(Count One of the Administrative Complaint); (2) dismiss the charges in Count Two of the Administrative Complaint (alleged failure to maintain adequate medical records); (3) place the Respondent on probation for two years under such terms as the Board of Medicine deems appropriate; and (4) fine the Respondent $1,000.00. RECOMMENDED this 13th day of April, 1988, in Tallahassee, Florida. J. LAWRENCE JOHNSTON Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 13th day of April, 1988. APPENDIX TO RECOMMENDED ORDER, CASE NO. 87-2568 To comply with Section 120.59(2), Florida Statutes (1987), the following rulings are made on the parties' proposed findings of fact: Petitioner's Proposed Findings Of Fact. 1.-11. Accepted and incorporated. Proposed findings regarding the milk of magnesia order, rejected. It was part of routine orders. The patient never developed constipation so it never was administered. The proposed finding is irrelevant and unnecessary. Otherwise, accepted and incorporated. Accepted and incorporated. 14.-17. Rejected as contrary to facts found. The paragraphs reciting the tests the Respondent had done are accepted and incorporated; the rest is rejected as contrary to facts found. First three sentences, accepted and incorporated; the rest is rejected as contrary to facts found. Accepted and incorporated. Rejected as contrary to facts found. Nurse's description of the patient as "acutely ill" is subordinate to facts found. It is not a diagnosis. Otherwise, accepted and incorporated. 23.-25. Accepted and incorporated. 26. Except that the use of the word "pus" is rejected as inaccurate, accepted and incorporated. 27.-36. Accepted and incorporated to the extent necessary and not subordinate. Accepted but subordinate to facts found. Accepted and incorporated to the extent necessary and not subordinate. Rejected that the Respondent made no attempt to determine the cause of the patient's illness as contrary to facts found; the rest is accepted and incorporated. Rejected, as contrary to facts found, that Actifed was "inappropriate." What was inappropriate was the failure to properly evaluate whether the patient had chest congestion. 41.-44. Accepted and incorporated to the extent necessary and not cumulative. 45. Rejected as contrary to facts found. 46.-57. Accepted and incorporated. Accepted and, to the extent not subordinate, incorporated. Accepted and incorporated. Accepted and, to the extent not subordinate, incorporated. 61.-68. Accepted and incorporated. Rejected as contrary to facts found. Accepted but subordinate to facts found. Rejected as contrary to facts found. Accepted and incorporated. Respondent's Proposed Findings Of Fact. 1.-7. Accepted and, to the extent necessary, incorporated. Penultimate sentence rejected as contrary to the greater weight of the evidence; the rest is accepted and incorporated. Accepted, as far as it goes, and incorporated. However, the proposed findings ignore the productive cough that was observed throughout the period May 20-29, 1986, and which was reported to the Respondent on May 21 and 29, 1986. Third sentence, to the extent it implies it states all the symptoms, rejected as contrary to facts found. Fourth sentence rejected as contrary to facts found--temperature was somewhat elevated and both pulse and respirations were up for a patient in bed rest. Sixth sentence rejected as contrary to facts found--the patient was awake at intervals during the night. Rest is accepted and incorporated with some additional facts. First sentence rejected as contrary to facts found--the patient's condition began to worsen seriously on May 29, 1986, and continued to worsen through the night. The nurses were alarmed at his condition on the morning of May 30, 1986, and began trying to call the Respondent at approximately 7:30 a.m. Third sentence, rejected as not proven when the Respondent received the message that the nursing staff was trying to contact him. The rest is accepted and incorporated. COPIES FURNISHED: Stephanie A. Daniel, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Richard W. Payant, Esquire 2349 Sunset Point Road Clearwater, Florida 34625 Dorothy Faircloth Executive Director Board of Medicine Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 William O'Neil General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
Findings Of Fact At all material times, Respondent has been currently licensed as a physician in Florida, holding license ME 0033496. Patient 1 was a 32 year old female who was admitted to Lykes Memorial Hospital on March 24, 1988, due to upper and lower abdominal pain, vomiting, and early signs of dehydration. Respondent placed Patient 1 on intravenous fluids and administered medications to control the vomiting. Patient 1 underwent diagnostic studies, including an upper gastrointestinal series, and received medication for the abdominal pain. After five days of hospitalization and tests, the source of the pain had not yet been identified. However, the lower abdominal pain had ceased, and the upper abdominal pain had lessened considerably. In general, the patient had improved during the hospitalization. At this point, Respondent discharged Patient 1 from the hospital with a final diagnosis of acute gastroenteritis. Respondent directed Patient 1 to return to his office for a follow-up visit. Five or six days after discharge, Patient 1 called Respondent and told him that her symptoms, which she now linked with taking birth control pills, had disappeared. Respondent advised her not to resume taking the pills, but to return to her gynecologist. With respect to Patient 1, Respondent practiced medicine with that level of care, skill, and treatment that is recognized by a reasonably prudent similar physician as being unacceptable under similar circumstances. Patient 2 was a 37 year old male who was admitted to Lykes Memorial Hospital on May 9, 1988, after having been found by a relative in a state of semi-consciousness. The admitting diagnosis was a probable overdose of lithium and possibly Thorazine. Respondent treated the drug toxicity during Patient 2's three-day hospitalization. Respondent became increasingly lucid during his hospitalization, and Respondent successfully managed the event of drug toxicity. Respondent tried to elicit from Patient 2 a medical and psychiatric history, but Patient 2 would or could not cooperate. Respondent was unable to identify any relatives or friends of Patient 2, including the person who brought him to the hospital. Respondent could not even find out where Patient 2 obtained the lithium and Thorazine that he was taking. Respondent treated the altered mental status that Patient 2 presented. There was no need during the short period of hospitalization to obtain a psychiatric consultation. Resumption of psychotropic medication so soon after the drug intoxication would have been imprudent. Consistent with the policy of Lykes Memorial Hospital, which has no psychiatrists on staff, Respondent referred Patient 2 to the Hernando County Mental Health Center. He directed Patient 2 not to take lithium or Thorazine until instructed to do so by a psychiatrist or other physician at the mental health center. Respondent and the hospital ensured that Patient 2 got to the mental health center following discharge. With respect to Patient 2, Respondent practiced medicine with that level of care, skill, and treatment that is recognized by a reasonably prudent similar physician as being unacceptable under similar circumstances. Patient 3 was a 49 year old male who was admitted to Lykes Memorial Hospital on or about February 5, 1988, with complaints of difficulty breathing. At the time, Patient 3 had been diagnosed with lung cancer that had metastasized to the spine and had undergone maximum radiation therapy. He was paralyzed from the waist down and in the last year of his life. He steadfastly refused all diagnosis or treatment involving radiation. By his own request, Patient 3's standing medical orders were "Do Not Resuscitate." He only wanted to be made comfortable. The acute illness resulting in Patient 3's admission was pulmonary congestion. There is some likelihood that the symptoms of infectious bronchitis with which he presented at time of admission were exacerbated by his chronic obstructive pulmonary disease. There is a possibility that some of Patient 3's discomfort was caused by mucous plugs in the lungs, whose capacity had already been diminished by the other diseases. However, mucous plugs were not affecting Patient 3 at the time of discharge. Respondent discussed with Patient 3 the possibility of cleaning out his lungs with a bronchoscope, but Patient 3 refused. Respondent treated Patient 3's discomfort with oxygen, diuretics, and increased steroids. Patient 3 had been receiving steroids due to a spinal disorder resulting from the cancer. Patient 3 was already receiving bronchodilators at the time of his admission. There is also a possibility that Patient 3 suffered from superior vena cava syndrome in which one or more tumors would block veins of the thorax. However, diagnosis of the condition would have been invasive, and Patient 3 refused such interventions. Treatment of such a condition would likely have required radiation, and Patient 3 would not tolerate additional radiation treatment. Respondent discussed with Patient 3 the possibility of superior vena cava syndrome and the possible treatment, but Patient 3 declined this intervention. Patient 3 received no EKG while in the hospital. The emergency medical services team transporting Patient 3 to the hospital performed a rhythm strip, which provides information about limited cardiac functions. Although Patient 3's potassium levels were slightly below normal at discharge, they had improved during hospitalization. With respect to Patient 3, Respondent practiced medicine with that level of care, skill, and treatment that is recognized by a reasonably prudent similar physician as being unacceptable under similar circumstances. Respondent's medical records represent the bare minimum required by law to justify the course of treatment. Matters discussed with Patient 3 were not always recorded. Patient 3's decisions concerning diagnosis and treatment were likewise not always recorded. But, on balance, the medical records adequately documented the course of treatment of Patient 3 while under Respondent's care at the hospital. Patient 4 was a 68 year old male who was admitted to Lykes Memorial Hospital on or about February 14, 1988, with complaints of a persistent cough and some gastric upset. He was suffering from exacerbation of chronic obstructive pulmonary disease. Respondent appropriately treated Patient 4's conditions. Patient 4 experienced problems with certain medications, which interfered with his progress, but he was drinking and eating without difficulty prior to his discharge. X-rays taken at admission and discharge revealed no significant change in Patient 4's condition during his eight-day hospitalization. At discharge, Respondent ordered Patient 4 to return for an office visit in two weeks. Patient 4's condition continued to improve following discharge. With respect to Patient 4, Respondent practiced medicine with that level of care, skill, and treatment that is recognized by a reasonably prudent similar physician as being unacceptable under similar circumstances.
Recommendation Based on the foregoing, it is hereby RECOMMENDED that the Department of Business and Professional Regulation enter a final order dismissing the administrative complaint. ENTERED on October 11, 1993, in Tallahassee, Florida. ROBERT E. MEALE 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 on October 11, 1993. APPENDIX Treatment Accorded Proposed Findings of Petitioner 1-5: adopted or adopted in substance. 6: rejected as unsupported by the appropriate weight of the evidence. 7-12: adopted or adopted in substance. 13: rejected as unsupported by the appropriate weight of the evidence. The pain or discomfort had lessened considerably. 14: adopted. 15: rejected as unsupported by the appropriate weight of the evidence. 16-17: rejected as irrelevant and unnecessary. 18: rejected as unsupported by the appropriate weight of the evidence. and 21-23: adopted or adopted in substance. and 24: rejected as unsupported by the appropriate weight of the evidence. 25: adopted except that Respondent and the hospital ensured that the patient was referred to a mental health treatment center as soon as his condition was sufficiently stabilized to allow discharge from the hospital. 26: rejected as unsupported by the appropriate weight of the evidence. 27: adopted or adopted in substance. 28: rejected as unsupported by the appropriate weight of the evidence. The record does not suggest how a psychiatrist would obtain a history from an unwilling patient. 29: adopted with respect to the period of the hospitalization through the point at which the patient could recommence active psychiatric treatment. 30: rejected as unsupported by the appropriate weight of the evidence. Respondent duly referred the patient to an appropriate facility for the treatment of the patient's underlying mental health problems. 31: rejected as recitation of evidence and subordinate. 32: rejected as legal argument and unsupported by the appropriate weight of the evidence. 33-36: adopted or adopted in substance. 37-38: rejected as unsupported by the appropriate weight of the evidence. 39: rejected as subordinate. 40: rejected as unsupported by the appropriate weight of the evidence. 41-43 (through third sentence): adopted or adopted in substance. 43 (fourth sentence): rejected as unsupported by the appropriate weight of the evidence with respect to this patient. 44-48 (first sentence): adopted or adopted in substance. 48 (except first sentence)-50: rejected as irrelevant and subordinate. 51-52 and 54: adopted or adopted in substance. 53: rejected as unsupported by the appropriate weight of the evidence. 55-56: adopted or adopted in substance. 57-59: rejected as unsupported by the appropriate weight of the evidence. Treatment Accorded Proposed Findings of Respondent 1-6: adopted or adopted in substance. 7: rejected as legal argument. 8: rejected as recitation of evidence. 9: rejected as legal argument and recitation of evidence. 10: adopted or adopted in substance. 11: rejected as recitation of evidence. 12: rejected as recitation of evidence and subordinate. 15: adopted or adopted in substance. 16 (first sentence): rejected as legal argument. 16 (second and third sentences): adopted or adopted in substance. (fourth sentence): rejected as recitation of evidence. (first sentence): rejected as legal argument. 17 (second sentence): adopted or adopted in substance. 17 (third sentence)-19 (first sentence): rejected as recitation of evidence. 19 (second sentence): adopted or adopted in substance. 20: rejected as recitation of evidence. 21: rejected as legal argument and recitation of evidence. 22: rejected as legal argument and recitation of evidence. 23: rejected as subordinate. 24: rejected as recitation of evidence. 27: adopted or adopted in substance. 28-31 (second sentence): rejected as legal argument and recitation of evidence. 31 (third sentence): adopted or adopted in substance. 32-34: rejected as legal argument and recitation of evidence. 38: adopted or adopted in substance. 39-43: rejected as legal argument, recitation of evidence, and subordinate. COPIES FURNISHED: Dorothy Faircloth Executive Director Board of Medicine 1940 North Monroe Street Tallahassee, FL 32399-0792 Jack McRay, General Counsel Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Barbara Whalin Makant, Staff Attorney Department of Business and Professional Regulation Northwood Center, Suite 60 1940 N. Monroe St. Tallahassee, FL 32399-0972 William B. Taylor, IV Macfarlane Ferguson P.O. Box 1531 Tampa, FL 33618
The Issue Whether the Respondent committed the violations alleged in the Administrative Complaint December 19, 2005, and, if so, the penalty that should be imposed.
Findings Of Fact Based on the oral and documentary evidence presented at the final hearing and on the entire record of this proceeding, the following findings of fact are made: The Department is the state agency responsible for the investigation and prosecution of complaints involving physicians licensed to practice medicine in Florida. See § 455.225, Fla. Stat. (2009). The Board is the entity responsible for regulating the practice of medicine in Florida and for imposing penalties on physicians found to have violated the provisions of Section 458.331(1), Florida Statutes. See § 458.331(2), Fla. Stat. (2009). At the times pertinent to this proceeding, Dr. Achong was a physician licensed by the State of Florida, having been issued license number ME38304, and his medical office was located at 690 East 49th Street, Hialeah, Florida. Dr. Achong specialized in obstetrics and gynecology, although he was not board-certified in these areas of practice. Dr. Achong has not previously been the subject of disciplinary action by the Board of Medicine, and he is not currently practicing medicine, having retired with a disability in 2006. At the times pertinent to this proceeding, Dr. Achong had hospital privileges at Hialeah Hospital and at North Shore Medical Center ("Medical Center"). Both facilities had his home telephone number and his beeper number. It was his practice to keep his beeper close to him at all times. When he was in the delivery room, it was his practice to give his beeper to the circulating nurse, who would be responsible for alerting him whenever someone tried to reach him on his beeper. The beeper he used in 2004 gave only the telephone number of the person trying to reach him, but he was able to recognize the number of Hialeah Hospital and the Medical Center. On February 12, 2004, Patient L.H. went to her gynecologist, Ramon Hechavarria, M.D., for a routine examination. Patient L.H. was, at the time, a 27-year-old who was 32 weeks' pregnant, and she had previously had one live birth. Dr. Hechavarria's examination revealed that Patient L.H.'s blood pressure was elevated, and Dr. Hechavarria admitted her to Medical Center for 24 hours for observation. On February 12, 2004, Dr. Hechavarria ordered blood and laboratory tests done in the Medical Center. The blood tests included a Disseminated Intravascular Coagulopathy ("DIC") profile and a Fibrinogen Degradation Profile ("FDP"); the results of these blood tests were normal. Patient L.H.'s hemoglobin and her platelet count were normal, and, although there was a slight trace of protein in her urine, that is considered normal. On February 13, 2004, Dr. Hechavarria discharged Patient L.H. with a diagnosis of chronic hypertension and a prescription for 250 milligram tablets of Aldomet, to be taken three times per day. Aldomet is a medication that treats hypertension by lowering the blood pressure. Patient L.H. was in good, stable condition when she was discharged on February 13, 2004. Readings from a fetal heart monitor taken during the time Patient L.H. was in the Medical Center indicated that the fetus was alive. Dr. Hechavarria considered Patient L.H.'s to be a high risk pregnancy in part because of her hypertension but also because she came in late for prenatal care, missed two appointments, and was overweight. Dr. Hechavarria left town for a vacation on February 13, 2004, and Dr. Achong was to cover his patients during his absence under an arrangement whereby Dr. Hechavarria and Dr. Achong provided coverage for each other when one or the other was out of town or otherwise unavailable to see patients. Under the arrangement, Dr. Achong was expected to go to the hospital if one of Dr. Hechavarria's patients were in labor or if a patient were to go to the emergency room complaining of vaginal bleeding or any other obstetrical or gynecological condition. Whenever coverage of patients was passing from one physician to the other, Dr. Hechavarria and Dr. Achong advised each other of any patient that was in the hospital for gynecological, obstetrical, or any other medical reason. They did not advise each other of patients that had recently been discharged from the hospital, and, therefore, Dr. Hechavarria did not discuss Patient L.H. with Dr. Achong because she had been discharged from the Medical Center before Dr. Achong began covering Dr. Hechavarria's patients. Patient L.H. presented at the Medical Center at approximately 2:00 a.m. on February 15, 2004, complaining of abdominal pains. She was seen by labor and delivery nurse Jennifer Williams, a registered nurse with 20 years' nursing experience, with 13 years' experience in the Medical Center's labor room, and with training as a mid-wife. Nurse Williams had worked with Dr. Achong at the Medical Center since 1991. Subsequent to Patient L.H.'s arrival at the Medical Center, Nurse Williams interviewed her, took her medical history, examined her, and entered the pertinent information on the Medical Center's Admission Assessment. The Admission Assessment form was dated February 15, 2004, and the time was noted as 2:45 a.m. The time written by Nurse Williams' signature on the Admission Assessment form was 3:00 a.m., and it appears that the information was obtained and entered on the form between 2:00 a.m. and 3:00 a.m. Pertinent to this matter, Nurse Williams maintained several other documents recording Patient L.H.'s condition and observations and actions taken by Nurse Williams relating to Patient L.H. Nurse Williams began maintaining a Labor Flow Record at 2:07 a.m. and she made periodic entries on the Labor Flow Record related to, among other things, Patient L.H.'s vital signs, the results of vaginal examinations and fetal monitoring, uterine activity, and pain intensity at different times during the night and morning. In addition, Nurse Williams entered on the Labor Flow Record the time and content of her communications with Dr. Achong; the first recorded contact between Dr. Achong and Nurse Williams was recorded on the Labor Flow Record as 2:30 a.m. Nurse Williams also maintained Progress Notes in which she recorded her observations of Patient L.H. and her conversations with Patient L.H. The first entry in the Progress Notes was at 2:35 a.m.2 Nurse Williams' Progress Notes reflect that, at 2:35 a.m., Patient L.H. advised Nurse Williams that she had contractions and believed she had been in labor since 6:00 p.m. the previous evening but had waited to come to the Medical Center until she was certain she was in labor. Patient L.H. also reported abdominal pain in her upper abdomen that did "not go away," and Nurse Williams observed that Patient L.H. was distressed by the pain in her abdomen. Patient L.H. also told Nurse Williams that she had no ruptured membranes or vaginal bleeding. Nurse Williams noted that she examined Patient L.H. and felt contractions but was unable to detect a fetal heart tone. Nurse Williams reported in the Admission Assessment form that Patient L.H. was having uterine contractions of moderate intensity and 60 seconds' duration, that her cervix was dilated 1-to-2 centimeters, that she had vaginal bleeding that was bright red, that her blood pressure was 159/118, which she described as "elevated," and that Patient L.H.'s abdominal pain was the "worse" pain on a pain scale ranging from 1 to 10; there is, however, no indication on the Admission Assessment form that the pain was constant. Nurse Williams also noted on the Admission Assessment form that she heard no fetal heart rate. Although the time noted on the Admission Assessment form was 2:45 a.m., it is apparent from a review of the relevant records that the information included on the Admission Assessment form was obtained by Nurse Williams over a period of time extending from the time Patient L.H. presented to her until 3:00 a.m., the time on the Admission Assessment form beside Nurse Williams' signature. Nurse Williams reported in the "Physician /CNM in/Called Report" section of the Labor Flow Record that she contacted Dr. Achong at 2:30 a.m. and conveyed to him the following information: "[P]atient arrived in ER c/o contractions since 6 pm last night & observation that no FHT [fetal heart tone] and contractions palpated." Nurse Williams telephoned Dr. Achong using his home telephone, even though his beeper number was also on file at the Medical Center. There is nothing in the report Nurse Williams gave to Dr. Achong at 2:30 a.m. that would require that he proceed to the Medical Center and examine Patient L.H., and he did not violate the standard of care by failing to do so. Because Dr. Achong did not know Patient L.H., Nurse Williams' normal procedure would have been to advise Dr. Achong of Patient L.H.'s history, including the medications she was taking, and her vital signs, including her blood pressure. No notation appears in the Labor Flow Record to confirm that she gave Dr. Achong this information during her conversation with him at 2:30 a.m., nor is there a notation in the 2:30 a.m. entry in the Labor Flow Record that Nurse Williams told Dr. Achong about the results of her examination of Patient L.H.'s cervix, Patient L.H.'s complaint of abdominal pain, or the presence of vaginal bleeding of bright red blood.3 Nurse Williams indicated in her entry in the "Physician/CNM in/Called Report" section of the Labor Flow Record that Dr. Achong ordered a "stat," or expedited, obstetrical sonogram during the 2:30 a.m. contact with Nurse Williams. The purpose of the obstetrical sonogram was to determine if the fetus was alive. Although not noted in the Labor Flow Record, the Labor and Delivery Orders form completed by Nurse Williams indicates that, at 2:30 a.m., Dr. Achong ordered a complete blood count, which is routine with a patient in labor; a DIC profile; and a Comprehensive Metabolic Panel ("CMP"). The Labor and Delivery Orders form contains standard orders for a woman in labor, but the DIC profile and the CMP tests were not included on the form but were ordered specifically by Dr. Achong. A DIC profile is used to determine if a patient has a problem with blood clotting. The DIC includes an assessment of prothrombin time and partial thromboplastin time, both of which indicate different levels at which a patient's blood is able to clot. It is important to know whether a woman in labor and delivery has a clotting problem, or coagulopathy, because of the danger of bleeding, and the classic situation in which DIC profiles are ordered is when there is fetal demise. Because Patient L.H. had the high risk factors of overweight and hypertension and because Nurse Williams could detect no fetal heart tone, Dr. Achong's order for the DIC profile was appropriate and met the standard of care. It is also appropriate to order a DIC profile when there is a concern about placental abruption, which is the separation of the placenta from the walls of the vagina. A placental abruption causes a great deal of bleeding, and can cause death when not treated, because the fetus is still in the womb and the uterus is not able to contract and constrict the large blood vessels that attach to the placenta. Although hypertension is one risk factor for placental abruption, the symptoms of placental abruption also include fetal demise, bleeding, constant pain, a decrease in hematocrit, and a number of other conditions. There is no indication in Patient L.H.'s medical records that Dr. Achong had sufficient information at 2:30 a.m. that would indicate that Patient L.H. had a possible placental abruption, and he ordered the DIC profile because of the lack of fetal heart tones.4 The CMP includes tests for kidney and liver function and for uric acid. It is used to determine if a woman has pre-eclampsia, or pregnancy-induced hypertension. Given Patient L.H.'s history of hypertension and the level of her blood pressure as reflected in the Admission Assessment form, Dr. Achong's order for the CMP was appropriate and met the standard of care in ordering the CMP. All orders for blood tests for women in labor and delivery are treated as "stat" orders and are processed ahead of all other test orders except those from the emergency room. When the situation warrants, a physician may order that the tests be performed more quickly than the usual "stat" order would require, and it would be possible to obtain blood-test results within 45 minutes. There is, however, no indication in Patient L.H.'s medical records that Dr. Achong had any information at 2:30 a.m. that might indicate that he should further expedite Patient L.H.'s blood tests. Nurse Williams reported in her Progress Notes that, at 2:40 a.m., Patient L.H. reported a "gush of something down there," and Nurse Williams noted that she observed a large amount of blood; there is, however, no notation in the Progress Notes regarding the color of the blood. Nurse Williams also included a notation in the Progress Notes that Patient L.H.'s cervix was "3cm dilated, 50% effaced, -3 station" to describe the progress of Patient L.H.'s labor. Nurse Williams reported in the Labor Flow Record that she contacted Dr. Achong at 2:45 a.m. and conveyed to him the following information: "Dr. Achong notified of gush of vaginal bleeding. VE [vaginal examination] 2-3, 50% effaced, -3 station and that we are awaiting sonogram." The results of Nurse Williams' vaginal examination of Patient L.H. showed that Patient L.H. was in active labor. The information that Patient L.H. experienced a "gush of vaginal bleeding" did not indicate to Dr. Achong that there was anything more than one episode of bleeding, which he attributed to an especially heavy "bloody show," which is the bleeding that occurs when the cervix is dilating. The notation indicates that Dr. Achong told Nurse Williams to call him if Patient L.H. went to delivery. The information conveyed to Dr. Achong at 2:45 a.m., as reflected in the notation in the Labor Flow Record, was not sufficient to indicate that Patient L.H. was not proceeding through labor normally to a vaginal delivery of the dead fetus, which is preferred over delivery by a Cesarean Section. Nurse Williams did not include in her records a notation that she advised Dr. Achong that the "gush of vaginal bleeding" consisted of a large amount of bright red blood, which would have been an indication of a possible placental abruption. Some bleeding is normal during labor, but it is usually a dark color from having been in the uterus and in a small amount or tickle, although there could be a "gush of blood" during normal labor. When Dr. Achong was advised by Nurse Williams that Patient L.H. had a "gush of blood," however, it was his responsibility to inquire into the amount of blood, the color of the blood, and the persistency of the bleeding to determine if Patient L.H. was proceeding with normal labor or if she was experiencing a hemorrhage or other abnormal condition. Nurse Williams made no entries in the Progress Notes for Patient L.H. between 2:40 a.m. and 3:40 a.m., when she reported that the ultrasound had been completed. She further noted in her Progress Notes: "Report of no fetal heart tones to Dr. Achong. Orders given." Nurse Williams additionally made a notation in the Labor Flow Record that, at 3:40 a.m., she contacted Dr. Achong and reported to him the following: "Ultrasound report No FHT's given to Dr. Achong. Orders received." Nurse Williams did not, however, indicate in her notations what orders were given. Nurse Williams contacted Dr. Achong through his home telephone number, which was normal procedure during the nighttime hours. When the sonographer, that is, the person performing the sonogram, entered Patient L.H.'s room to perform the sonogram, he noted that Patient L.H. was sitting upright in bed, was combative, and was in a lot of pain. He also noted that there was a fair amount of blood on the bed sheets. The sonographer was able to get Patient L.H. to lie on the bed, and he performed "a very short ultrasound,"5 and pulled the machine out of the room and into the hall. He powered the machine back up and read the numbers off the worksheet on the machine. He confirmed that the fetus was dead and that the placenta appeared to be balled up rather than lying smoothly against the uterine wall, as is normal. While he was writing down the information from the worksheet on the machine, Nurse Williams approached him and told him that she had Dr. Achong on the telephone. He told her that he had "a placental abruption and fetal demise."6 He then wrote up his report, left a copy for Nurse Williams, and went downstairs to process the sonogram images.7 The results of the sonogram were reported on a form headed "Obstetrical Preliminary Report," which was completed by the sonographer. A radiologist is usually present at the Medical Center during daytime hours to read sonograms, but on the off-hours, it is the practice of the sonographer to present a sonographer's impression of what was seen during the sonogram. The sonographer who performed the sonogram on Patient L.H. noted on the report that her history included obesity, hypertension, heavy vaginal bleeding, and contractions. He included the following comments in the report: "Ant/Rt [unintelligible] placenta appears to be 'balled up[.]' Suggestion of placental abruption," and, on a separate line, "NO FETAL HEART MOTION SEEN PT IS COMBATIVE." Finally, at the bottom of the report, the sonographer noted that a copy of the report was given to Nurse Williams. There was no notation as to the time the sonographer gave the report to Nurse Williams, but, even if she had the report, she did not read it to Dr. Achong; rather, she put the copy of the report in Patient L.H.'s chart for Dr. Achong to review when he came to the hospital and gave him only a verbal report. Nurse Williams did not tell Dr. Achong during the 3:40 a.m. telephone conversation that the sonographer had reported a possible placental abruption.8 Dr. Achong was familiar with and had treated placental abruptions prior to February 15, 2004, and he always treated patients with placental abruptions on an emergency basis because both the mother and the baby could die if treatment was not received as soon as possible. Had Nurse Williams advised Dr. Achong that the sonographer had told her that he found a placental abruption or that the sonogram report included a reference to a possible placental abruption, he would have gone to the Medical Center immediately. At 3:45 a.m., Nurse Williams noted in her Progress Notes that she gave Patient L.H. Nubain and Phenergan for her painful contractions. There is no mention of continued vaginal bleeding in this entry in the Progress Notes. At 4:15 a.m., Nurse Williams noted in her progress notes that Patient L.H. was sleeping quietly and was relaxed and that Pitocin had been administered in accordance with Dr. Achong's orders. Pitocin is used to induce labor, augment labor, or to stop bleeding. In this case, Dr. Achong ordered the Pitocin to regulate Patient L.H.'s contractions. There is no mention in the 4:15 a.m. entry in the Progress Notes of continued vaginal bleeding. The next entry in Nurse Williams' Progress Notes was made at 5:15 a.m., when Nurse Williams reported that she had observed vaginal bleeding, that a vaginal examination showed dilation of four centimeters, and that Patient L.H. was very restless and moving around the bed. Nurse Williams received the laboratory report showing the results of the blood tests ordered by Dr. Achong at or around 5:00 a.m. According to the laboratory report, the blood for these tests was drawn at or about 3:20 a.m.; the report did not show any critical values in the blood sample. Nurse Williams attempted to contact Dr. Achong to convey these results to him. She noted on the Labor Flow Record that, at 5:15 a.m. "Dr. Achong beeped re lab results. Phone message left on home phone to call LR [Labor Room]." Nurse Williams made another entry on the Labor Flow Record that, at 6:55 a.m., she left a "message to Dr. Achong answering machine at home re labor progress update and labs." Dr. Achong was not, however, at home to receive the telephone calls or the messages. At or about 5:00 a.m. on February 15, 2004, Dr. Achong received a telephone call on his home telephone from Hialeah Hospital advising him that one of his patients or one of Dr. Hechavarria's patients was in active labor and about to deliver. Shortly after receiving the telephone call, Dr. Achong left his home to travel to Hialeah Hospital. He carried his beeper with him, but he did not receive any calls on the beeper. When he arrived at Hialeah Hospital and prepared to go into the delivery room, he gave it to the circulating nurse in case he should receive a beeper call while he was in the delivery room. Nurse Hayes, who had replaced Nurse Williams when Nurse Williams' shift had ended at 7:00 a.m., made a notation on the Labor Flow Record that, at 7:15 a.m., she called Dr. Achong and left a message. At 7:25 a.m., while he was in the delivery room, Nurse Hayes called his beeper. The circulating nurse had his beeper, and she notified him that he had received a call and told him the number. He recognized the number of the Medical Center, and he told the nurse to call the Medical Center and let them know that he was in the delivery room at Hialeah Hospital. Nurse Hayes asked that he call back as soon as possible. Blood for additional blood tests was drawn at or about 7:30 a.m., and the results, which were available within 15 minutes, showed several critical values that indicated that Patient L.H. was entering coagulopathy. At 7:38 a.m., as soon as he finished the delivery, he called the Medical Center and spoke with Nurse Hayes, who gave him a report on the status of Patient L.H. She told him that Patient L.H. had heavy bleeding and that the vaginal examination showed no change in the cervix. Dr. Achong ordered the Pitocin turned off. When Dr. Achong arrived at the Medical Center at 7:56 a.m., he found Patient L.H. very combative, bleeding, and with very bad vital signs. He ordered a "stat" Cesarean Section and ordered a blood transfusion. Patient L.H. died at 8:38 a.m., before any of the measures ordered by Dr. Achong could be implemented. The cause of death was recorded as placental abruption. Summary In summary, the evidence presented by the Department is not of sufficient weight to establish that Nurse Williams conveyed to Dr. Achong the information necessary for him to conclude that he should personally conduct a clinical evaluation of Patient L.H.; that he should consider the possibility that Patient L.H. had placental abruption; or that he should have provided medical assistance to Patient L.H. prior to his contact with Nurse Hayes at 7:38 a.m. Nurse Williams' Progress Notes report only two remarkable items: There were no fetal heart tones detected by physical examination or by sonogram; and, at 2:40 a.m., Patient L.H. reported a "gush of something" and Nurse Williams observed a large amount of blood. Neither Nurse Williams' entries in the Labor Flow Record regarding her contacts with Dr. Achong nor her testimony, to the extent that it has been found persuasive, is sufficient to establish that she advised Dr. Achong that she had observed a large amount of red blood at 2:40 a.m. or that the sonographer detected a possible placental abruption in the sonogram. Finally, Nurse Williams did not follow the protocol that required her to contact Dr. Achong through his beeper when she did not get an answer on his home telephone; she tried his beeper only once, at 5:15 a.m., and when she failed to reach him, left three messages on his home telephone. The Department presented no evidence to establish that Nurse Williams attempted to reach Dr. Achong by beeper between 5:15 a.m. and 7:55 a.m., the time of her last call to Dr. Achong's home telephone. Furthermore, the Department did not present evidence of sufficient weight to establish that Dr. Achong failed to initiate the appropriate procedures after he arrived at the Medical Center and examined Patient L.H. at or around 8:00 a.m. The evidence presented by the Department is, however, of sufficient weight to establish that Dr. Achong should have questioned Nurse Williams further when she advised him at 2:45 a.m. that she had observed a "gush" of vaginal bleeding. Even though vaginal bleeding may not be not unusual during labor, a report of a "gush" of blood should have alerted Dr. Achong to a potential problem. Although a physician practicing obstetrics is meeting the standard of care when relying on labor room nurses to advise him or her of the clinical status of labor and delivery patients and of any unusual symptoms exhibited by the patients, it is also incumbent on the physician to inquire further if a patient is presenting unusual symptoms. The persuasive evidence establishes that Dr. Achong violated the standard of care when he failed to ask Nurse Williams for additional information on Patient L.H.'s status during their 2:45 a.m. telephone conversation. Had he inquired further, Dr. Achong would have been alerted to the possibility that Patient L.H. had a placental abruption and would have gone to the hospital to provide appropriate care for Patient L.H.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health, Board of Medicine, enter a final order finding that Dr. Achong violated Section 458.331(1)(t), Florida Statutes, by failing to elicit further information from Nurse Williams regarding the gush of blood she observed in Patient L.H and imposing the following penalties: Issuance of a letter of reprimand; Imposition of administrative fine in the amount of $2,500.00; and Six months' probation under such conditions as the Board of Medicine determines appropriate, should Dr. Achong ever resume the practice of medicine. DONE AND ENTERED this 4th day of January, 2010, in Tallahassee, Leon County, Florida. PATRICIA M. HART 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 January, 2010.
