Findings Of Fact Respondent is a licensed dentist in the State of Florida, having been issued license number DN 0009725. Respondent's last known address is 1521 Powell Court, Huntington, West Virginia, 25701. The minimum standard of care for treatment of any patient with periodontal disease who anticipates orthodontic treatment requires either that the underlying periodontal disease be resolved prior to orthodontic treatment or that the periodontal disease be controlled through frequent and regular periodontal care administered concurrently with the orthodontic treatment. Orthodontic treatment can exacerbate existing periodontal disease in any patient. Adequate, frequent, and regular periodontal care is especially important for adults who typically have less bone turnover and cell repair than that found in younger patients. Responsibility for monitoring and supervising the periodontal health of a patient is shared by the orthodontist, on the one hand, and either the general dentist or the periodontist, on the other. Respondent provided dental services and treatment to Michael J. Doherty, an adult male, from November 7, 1983, until sometime in June, 1985. The dental services and treatment provided by Respondent consisted of the extraction of 4 bicuspids and the application of an orthodontic appliance. Respondent first saw Mr. Doherty on November 7, 1983, at the Omni Dental Clinic (the "Clinic"). Respondent was not the dentist of record for Mr. Doherty. The dentist of record was a general dentist who was also employed at the Omni Dental Clinic. Mr. Doherty was diagnosed by the dentist of record as having early periodontal disease. The dentist of record prescribed treatment for Mr. Doherty's periodontal disease before Respondent began orthodontic treatment. The treatment for Mr. Doherty's periodontal disease consisted of: a gross scaling of Mr. Doherty's entire mouth on November 30, 1983; a prophylaxis cleaning for approximately one hour on December 14, 1983; and a periodontal scaling of the entire mouth on January 9, 1984. The patient was also instructed to increase the frequency of his brushing and other home health care. The patient was released for orthodontic treatment, and Respondent began such treatment on January 23, 1984. During Respondent's orthodontic treatment, the patient received two more prohylaxis cleanings in August, 1984, and on December 27, 1984. The diagnostic studies and periodontal treatment for Mr. Doherty prior to and during Respondent's orthodontic treatment of the patient were inadequate. Adults with existing periodontal disease should receive adequate periodontal care and monitoring every six weeks. The care required to properly treat the periodontal disease may range from basic scaling all the way to surgical procedures. Mr. Doherty received two prohylaxis cleanings during Respondent's orthodontic treatment. Responsibility for the periodontal health of a patient during orthodontic treatment is shared by the orthodontist. The condition of Mr. Doherty's periodontal disease deteriorated significantly during Respondent's orthodontic treatment. The patient consulted another orthodontis, Dr. David Kornbluth, on December 5, 1985. Dr. Kornbluth was concerned over the fact that the patient's teeth were very loose and that there was considerable pocketing in and around the teeth. Dr. Kornbluth questioned whether continued orthodontic treatment was appropriate and referred Mr. Doherty to a general dentist, Dr. Alan Burch. Dr. Burch examined Mr. Doherty on December 6, 1985, and concluded that the patient needed immediate periodontal and endodontic evaluation. Dr. Burch referred the patient to a periodontist, Dr. Leonard Garfinkel. 3/ Dr. Garfinkel examined Mr. Doherty on December 23, 1985, and diagnosed the patient as having severe periodontal disease with gross soft tissue inflammation and significant osseous loss. 4/ The condition of the patient's lower anterior teeth was poor. He had generalized pockets and excessive mobility in his teeth. The patient was instructed to discontinue orthodontic treatment and was placed on periodontic treatment consisting of three visits of deep scaling and curettage in conjunction with plaque control. The patient was also placed on a Hawley retainer to adjust his bite. 5/ The orthodontic appliance was subsequently removed and periodontic treatment in the form of deep scaling was repeated on March 27 and May 16, 1986. The patient's prognosis improved from poor to guarded. Respondent failed to meet the minimum standards of care in the practice of dentistry by applying orthodontic appliances without an accurate diagnosis of Mr. Doherty's periodontal condition. Respondent failed to meet the minimum standards of care in the practice of dentistry by providing orthodontic treatment without adequate care of the patient's underlying periodontal disease. Respondent was found guilty of negligence in the services provided to Michael J. Doherty. The adjudication of negligence was entered on January 1, 1988, in the Circuit Court of the Eleventh Judicial Circuit in Dade County, Florida. Respondent did not fail to keep adequate medical records. The Omni Dental Clinic was not operated or controlled by Respondent. Respondent was an independent contractor of the clinic. Records for Mr. Doherty were kept by both Respondent and the patient's general dentist and were maintained by the Clinic. The Clinic went out of business and disposed of the records in a manner that made them unavailable to Respondent. Records that otherwise would have been available to the parties in this proceeding were in the possession of counsel for the plaintiffs in the civil negligence action. The records produced in this proceeding did not comprise all of the records of Respondent.
Recommendation Based upon the foregoing facts and conclusions of law, it is recommended that Petitioner enter a final order finding Respondent guilty of violating Section 466.028(1)(y), Florida Statutes, impose a $5,000 administrative fine, and suspend Respondent's license for 3 months. The final order should provide that, upon reinstatement, the Respondent's license shall be placed on probation for a period of 2 years. During the period of probation, Respondent should be required to complete 30 hours of continuing education in diagnosis and treatment planing, 30 hours of continuing education in periodontics, and 18 hours of continuing education in risk management. All continuing education should be in compliance with Florida Administrative Code Rule 21G-12. RECOMMENDED in Tallahassee, Leon County, Florida, this 22nd day of July, 1991. DANIEL MANRY 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 22nd day of July, 1991.
The Issue Should the Board of Medicine (the Board) discipline Respondent's license to practice medicine in Florida, based upon an alleged failure in the level of care and treatment of J.P., his patient?
Findings Of Fact STIPULATED FACTS: Petitioner is the state department charged with regulating the practice of medicine pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes, and Chapter 458, Florida Statutes. The Respondent, whose address of record is 1834 SW 1st Avenue, Ocala, Florida 34474, was issued license number ME 56306. At all times material to this Complaint, the Respondent was a licensed medical physician within the State of Florida. Respondent specializes in pulmonology. Respondent was Patient J.P.'s attending physician. Respondent ordered a bronchoscopy and specimens that revealed possible Mycobacterium Avium-Intracellulare (MAI). The biopsies revealed signs of granulomalous infection as seen in MAI or tuberculosis (TB). During this (his) hospital stay, Patient J.P. was started on the drug ethambutol at 1600 mg daily. It is the manufacturer's recommendation that the dose of ethambutol, if started at 25 mg per kilogram per day, should be reduced to 15 mg per kilogram per day after 60 days. The infections (infectious disease) specialist saw Patient J.P. in his office on or about July 26, and August 8, 2000 and in his August 18, 2000 letter to Respondent, there was no mention or recommendation for a change in Patient J.P.'s dosage after two months on the ethambutol therapy. Patient J.P. was subsequently seen by the Respondent on October 23, and again on December 27, 2000, when Patient J.P. complained of eye problems. At this later visit Respondent immediately discontinued the ethambutol and referred Patient J.P. to an eye specialist. ADDITIONAL FACTS: Patient J.P.: On May 8, 2000, Patient J.P. was seen at Ocala Lung and Critical Care Associates (Ocala Lung and Critical Care) in Ocala, Florida. This practice is Respondent's Professional Association. The patient had been referred by Dr. Dave Metcalf. On that date the patient was seen by Respondent's associate, Poonan Warman, M.D. According to the note in the patient records for that date, the patient reported a complaint of "cough and cold" with no weight loss. (Petitioner's Exhibit No. 1, page 28) On May 23, 2000, the patient returned to Ocala Lung and Critical Care. Again Dr. Warman saw the patient. A note in the patient's chart describes J.P.'s condition on that date. (Petitioner's Exhibit No. 1, page 35) At that time Dr. Warman concluded that the patient had a mass in his left lung with right lung abscess. Dr. Warman scheduled a bronchoscopy and prescribed mediation. On June 13, 2000, Respondent first say Patient J.P. at Ocala Lung and Critical Care. At that time Respondent made notes in the patient's chart concerning the patient's condition. (Petitioner's Exhibit No. 1, page 49) Respondent assessed the condition as a system in the patient's right upper lobe, possible lung abscess. The note refers to the provision of an antibiotic, a CBC differential and CRP that was ordered. This was a follow- up visit for the bronchoscopy that had been performed by Dr. Warman. Cultures in association with the organism found through the bronchoscopy were pending. At that time Respondent's recommendation to the patient was to continue the antibiotic treatment of Augmentin as well as Clindamycin. The patient was to be seen back in a month's time, according to a typed note within the patient's chart bearing Respondent's signature. (Petitioner's Exhibit No. 1, page 48) In that same typed note it was noted that the bronchoscopy and the biopsy that had also been performed did not reveal malignancy but chronic inflammatory cells had developed. The type-written impression entered in the chart was right upper lobe cavitary lesion, most likely lung abscess. On this date Respondent concluded that the patient had bacterial infection in the lung and the lung abscess. Respondent wanted blood work done to monitor the side effects of the antibiotics being given. Respondent discussed the side effects of the medication with the patient as noted in the written entries in the chart. In relation to the antibiotic medications that were provided to Patient J.P., notes were made on June 14 and 20, 2000, in the patient records maintained by Ocala Lung and Critical Care, commenting on the efforts by the practice to assist Patient J.P. in obtaining those medications from that office and other doctors' offices because of his inability to pay for the medicine. (Petitioner's Exhibit No. 1, page 47) On June 27, 2000, Respondent saw Patient J.P. at the Monroe Regional Medical Center (the Medical Center) in Ocala, Florida, for a medical emergency. The Medical Center is a hospital. At that time the patient's chief complaint was a right-side chest pain. The patient was admitted to the Medical Center by Frank E. Reisner, M.D. The patient had called Respondent's office before his admission. Under the circumstances Respondent was concerned that the patient would not receive adequate treatment as an outpatient. It was recommended that the patient be admitted for inpatient hospital treatment of his lung abscess. On June 27, 2000, the emergency department note in the hospital record refers to the admission of Patient J.P. to the service of Dr. Mishra, an internist at the hospital. (Petitioner's Exhibit No. 1, page 354) Dr. Mishra had also spoken to Patient J.P. and told the patient to come to the hospital. Because the Patient J.P. had a lung abscess problem and had been seen by Respondent in the past, Respondent became responsible for the patient in the hospital upon the request of another physician. Respondent's decision to have the patient remain admitted for treatment of the lung abscess was made the same day the patient arrived at the hospital. Under this arrangement Respondent was the attending physician. On June 28, 2000, after receiving the chart for Patient J.P. from Respondent's office, to review the patient history and based upon results at the hospital that revealed the patient had possible MAI present in bronchial washings from a bronchoscopy performed in the hospital, Respondent decided to consult with Lee Prchal, M.D., who specializes in infectious disease and practices in Ocala, Florida. The reason for the consultation was that Respondent does not treat MAI. Decisions about the appropriateness of treatment for MAI, in Respondent's view, would best be made by a physician specializing in infectious diseases. Respondent did not feel comfortable treating MAI, in that he did not have sufficient knowledge about the condition and its treatment. If Dr. Prchal thought that the patient needed to be treated for MAI, Respondent expected that the other physician would be responsible for the care. With this in mind Respondent did not follow the patient as an attending physician would normally during the patient's stay in the hospital. Nonetheless, Respondent was aware that Patient J.P. had been prescribed ethambutol, also referred to as ethambutol hydrochloride or by the generic drug name Myambutol. Respondent understood that the medication had been prescribed initially in a setting in which it was uncertain whether the patient had a problem with MAI or tuberculosis. Dr. Prchal had written the order for ethambutol given to Patient J.P. in the hospital stay. Dr. Prchal intended to address any MAI with the medication. Dr. Prchal did not write orders for ethambutol upon the patient's discharge, although the patient continued to take the medication. Respondent did not order an initial visual acuity test when Patient J.P. was first prescribed ethambutol in the hospital stay. Dr. Prchal did not order visual testing to establish a baseline while the patient was hospitalized. At no point during the time Patient J.P. was treated with ethambutol did Respondent consider himself responsible in addressing MAI. Respondent did not believe that he had the duty to manage the treatment. He believed that Dr. Prchal was responsible while the patient was in the hospital and upon the patient's discharge. On July 19, 2000, following the Patient J.P.'s discharge from the hospital, Respondent saw the patient again in an office visit. Notes concerning that visit were made. (Petitioner's Exhibit No. 1, page 84) The notes reflect that the patient was doing well, and his cough had improved. Respondent's impression was that the patient had atypical TB and COPD. COPD refers to Chronic Obstructive Pulmonary Disease. At the time it was noted that the patient was advised to keep in touch with HRS for atypical TB. HRS refers to Health and Rehabilitative Services. In actuality, the Marion County Health Department was the health organization that Respondent had in mind. The comment on HRS is in association with an adult clinic in Ocala, Florida. According to a note in the patient record made by a member of Respondent's staff, someone previously had spoken to a person from the Health Department, who said that Patient J.P. did not have tuberculosis. This meant that the TB clinic with the Health Department would not follow his case for tuberculosis, but he could be followed in the adult health clinic for the condition he did have and that clinic should be able to help the patient with needed medication. (Petitioner's Exhibit No. 1, page 47) The adult health clinic is a general clinic affiliated with the Department of Health, and if seen in the general clinic Respondent believed that the patient could be provided needed medications. Patient J.P. had experienced difficulties obtaining needed medication in the past. As before, Respondent did not examine Patient J.P. in relation to visual acuity. The patient offered no complaints about his vision at this visit. On the July 19, 2000 visit Respondent did not consider reducing the ethambutol dosage for Patient J.P. The patient was referred to Dr. Prchal for a visit on July 26, 2000, in relation to MAI. Given the referral to Dr. Prchal, Respondent proceeded on the basis that Dr. Prchal was responsible for treating Patient J.P. for MAI. It was intended that the patient return to see the Respondent on October 23, 2000. Patient J.P. saw Dr. Prchal on July 26, 2000. Following that visit Dr. Prchal wrote the Respondent. The letter was dated August 18, 2000. (Petitioner's Exhibit No. 1, pages 87 and 88) In concluding remarks Dr. Prchal stated in the correspondence: Therefore, at this time, I would recommend continued ethambutol and biaxin for treatment of his MAI. The duration of his clindamycin will require your clinical judgment, but in view of his radiographic changes, it may require further prolonged administration. Respondent's reading of the correspondence was that Dr. Prchal would continue to monitor and be responsible for ethambutol therapy while deferring to Respondent to treat the lung abscess with Clindamycin. On October 23, 2000, Respondent saw Patient J.P. in Respondent's office. Handwritten notes were made by the Respondent during the visit, followed by typewritten notes for the patient's record. (Petitioner's Exhibit No. 1, pages 90 and 91) The patient records refer to the Respondent's perception that Dr. Prchal was treating MAI with multiple antibiotics. The note refers to COPD, lung abscess and MAI. Respondent asked the patient to discontinue Clindamycin and to continue Biaxin. Respondent also asked Patient J.P. to continue taking ethambutol. Respondent did not consider himself to be responsible for treating MAI with ethambutol. In the typed document for the patient record pertaining to the October 23, 2000 visit, it is indicated under the section dealing with Respondent's impression that the lung abscess healed resulting from treatment with clindamycin. At the same time the typed notes indicated that MAI would require long-term treatment. Although Respondent contends that Dr. Prchal would follow Patient J.P. routinely for MAI, the typewritten note describes Dr. Prchal's August 18, 2000 correspondence as a "final note." On October 23, 2000, the patient did not complain of any problems with visual acuity and no eye examination was ordered by Respondent. No specific inquiry was made concerning the patient's progress with the MAI. A follow-up appointment was scheduled for December 27, 2000. Patient J.P. kept that appointment. On December 27, 2000, Patient J.P. complained of an eye problem. He told Respondent that he was not able to see and that two weeks before he had seen an eye physician. As the patient record indicates, the patient complained to Respondent whether this problem with his vision was due to medicine. As a record on the patient care states, authored by Respondent, Respondent indicates "In response, [to complaints about the patient's vision] I have stopped his ethambutol." The impression in the patient record that was typed indicates as well "Ethambutol is being stopped today." This patient record is by way of a letter from Respondent to Dr. Prchal. (Petitioner's Exhibit No. 1, page 93) The letter goes on under the portion referred to as "Plan" to say, "I referred him back to you [Dr. Prchal] for evaluation of the disease process and then we will decide how long he will require the Biaxin." The discussion given thus far of the facts, includes the perspective of the Respondent as to his explanation of care for MAI in Patient J.P. The next part of the discussion is in relation to testimony by deposition by Dr. Prchal including his explanation of his care for MAI provided Patient J.P. Dr. Prchal has practiced in Ocala, Florida, since 1987. His primary specialty is infectious disease. His first encounter with Patient J.P. was at the Medical Center when the patient was referred to him by Respondent, the attending physician, to consult as an infectious disease specialist. When Patient J.P. was first seen, the working differential, as Dr. Prchal recalls it, was that the patient had an underlying chronic lung disease with a history of smoking and a family history of lung cancer. The patient had failed outpatient treatment and when seen could have underlying cancer and/or infections in his lung. Following the bronchoscopy performed on the patient in the hospital, Dr. Prchal wrote an order for ethambutol 1600 mg. The order was written on June 28, 2000. He wanted the patient to receive ethambutol because it was an antibiotic that is used for treating MAI. As Dr. Prchal describes, MAI is a germ in the family of tuberculosis. The patient received his first dose of ethambutol on June 29, 2000. The reason for prescribing 1600 mg of ethambutol was in recognition of the patient's weight. The dosage was presented in four tablets of 400 mg. Dr. Prchal's view of the prescription of ethambutol was that he had signed-off on the case before the patient was discharged from the hospital. At the same time, he considered the use of ethambutol to be open-ended and dependent upon the clinical response by Patient J.P. beyond his discharge. The concluding point for using ethambutol was to be decided by Respondent, in Dr. Prchal's perception, in that Respondent was the attending physician and the main person in charge of the case. Dr. Prchal's view of the choice of dosage of milligrams per kilograms of weight ranging from 15 mg to 25 mg per kilogram of weight, depends upon the person's clinical circumstance. The common starting dose is 25 mg per kg, in his view. Dr. Prchal's experience with ethambutol is that he had prescribed ethambutol to more than 50 patients. Dr. Prchal realized that optic neuritis is a potential side effect in the use of ethambutol. Dr. Prchal does not believe that baseline vision testing is necessary before providing ethambutol therapy. Dr. Prchal is familiar with the PDR concerning ethambutol, which he considers to be the manufacturers guidelines for use of that medication. In relation to the PDR reference to monthly testing for visual acuity during the use of ethambutol, particularly in dosages in the amount of 25 mg per kg, Dr. Prchal refers to the difficulty in having an ophthalmologist see patients for screening in the Ocala area and the difference of opinion among members of the medical community concerning screening. He does not believe that there is a specific standard to be followed in the community for screening. When Patient J.P. was in the hospital receiving his first dosage of ethambutol on June 29, 2000, Dr. Prchal indicated that baseline vision testing was not available in that setting and could only be done following the discharge of the patient. The frequency of testing beyond baseline testing would be on a case by case basis. According to Dr. Prchal, visual monitoring is part of the overall monitoring in the use of ethambutol. In Dr. Prchal's physician progress notes for Patient J.P. made on July 1, 2000, at the hospital, pertaining to ethambutol he referred to "appropriate monitoring." He then goes on to say that he "will sign off." He explains the latter reference to indicate that he was signing-off on the case. (Petitioner's Exhibit No. 1, page 121) Dr. Prchal saw Patient J.P. on July 26, 2000. At that time the patient was continuing with ethambutol. Dr. Prchal inquired about any visual symptoms. Patient J.P. responded that he did not have visual symptoms. The patient told Dr. Prchal that he had been referred to the Marion County Health Department. In Dr. Prchal's opinion the patient's medical condition at the time was better and the medicine seemed to be working. This is taken to mean that the ethambutol was working. Dr. Prchal saw Patient J.P. on August 8, 2000. This was their last visit. As with the visit on July 26, 2000, when Dr. Prchal saw Patient J.P. on August 8, 2000, the patient expressed no complaints about his vision. On August 8, 2000, Dr. Prchal had determined that the patient did not have tuberculosis, and medications to treat that disease were not necessary and could be discontinued. The medications for treating tuberculosis were IMH, Tyrazinamide and Rifampin. Dr. Prchal thought that ethambutol for treating MAI was still called for, together with Biaxin. Dr. Prchal did not have in mind a specific dosage of ethambutol. Being persuaded that Respondent was the attending physician overseeing the care, Dr. Prchal made known his views in the correspondence to Respondent on August 18, 2000. (Petitioner's Exhibit No. 1, pages 87 and 88) Dr. Prchal believes that the reason for Patient J.P.'s visits on July 26, 2000, and August 8, 2000, was Respondent's desire to know what medications still needed to be continued in treating the patient. EYE CARE The day before Patient J.P. saw Respondent on December 27, 2000, the patient had been at Ritz Eye Care. The reason for his visit was "check eyes-has trouble seeing." (Petitioner's Exhibit No. 1, page 192). On the visit to Ritz Eye Care he was seen by Daniel L. Ritz, O.D. Dr. Ritz consulted with Robert N. Mames, M.D., specializing in diseases and surgery of the Vitreous and Retina. Dr. Mames performed an ophthalmic examination and diagnosed the Patient J.P.'s condition as (1) decreased visual acuity in both eyes; (2) minimal nuclear sclerosis; and (3) history of lung abscess, Mycobacterium Avium. In his impression Dr. Mames said "etiologies include optic neuropathy secondary to ethambutol versus CAR syndrome (Canon-associated retinopathy), which is unlikely with no history of cancer." These findings were made in the report from Dr. Mames to Dr. Ritz dated January 16, 2001. (Petitioner's Exhibit No. 1, page 199) Patient J.P. was seen at the University of Florida, College of Medicine, Department of Ophthalmology, on March 23, 2001, by M. Tariq Bhatti, M.D., an assistant professor of the Department of Ophthalmology and Neurology. He indicates in correspondence to Mandouh H. Zeini, M.D., practicing in Ocala, Florida, "It appears that Mr. P. has bilateral optic atrophy. As you are aware, ethambutol is a well-known toxin to the optic nerves. However, I think it would be important to rule out other treatable causes of his optic atrophy. Therefore, I have recommended B-12, folate level, sedimentation rate, syphilis serology, ANA and an MRI of the brain and orbits." (Petitioner's Exhibit No. 1, page 224) On April 25, 2001, Dr. Bhatti saw Patient J.P. again. In turn, he corresponded with Dr. Zeini on that date. (Petitioner's Exhibit No. 1, page 227) With the negative work-up on the prior tests given Patient J.P., Dr. Bhatti wrote, "I suspect Mr. P.'s bilateral optic neuropathies are ethambutol- related. He has discontinued the use of ethambutol, therefore this should remain a static process with no visual loss." PHYSICIAN DESK REFERENCE: MYAMBUTOL The PDR in referring to MYAMBUTOL under the heading DESCRIPTION states: MYAMBUTOL ethambutol hydrochloride is an oral chemo-therapeutic agent which is specifically effective against actively growing micro- organisms of the genus mycobacterium, including M. tuberculosis. In the PDR under the heading INDICATIONS it is stated: MYAMBUTOL is indicated for the treatment of pulmonary tuberculosis. The PDR refers to CONTRAINDICATIONS where it states: MYAMBUTOL is contraindicated in patients who are known to be hypersensitive to this drug. It is also contraindicated in patients with known optic neuritis unless clinical judgment determines that it may be used. Under PRECAUTIONS the PDR states: . . . Because the drug may have adverse effects on vision, physical examination should include ophthalmoscopy, finger perimetry and testing of color discrimination. . . . In relation to ADVERSE REACTIONS the PDR states: MYAMBUTOL may produce decreases in visual acuity which appear to be due to optic neuritis and to be related to dose and duration of treatment. . . . Patients should be advised to report promptly to their physician any change of visual acuity. . . . Testing of visual acuity should be performed before beginning MYAMBUTOL therapy and periodically during drug administration, except that it should be done monthly when a patient is on a dosage of more than 15 mg. per kilogram per day. . . . In relation to INITIAL TREATMENT the PDR states: In patients who have not received previous antituberculosis therapy, administer MYAMBUTOL 15 mg. per kilogram. (7 mg. per pound) of body weight, as a single oral dose once every 24 hours. On the related subject of RETREATMENT the PDR states: In patients that have received previous anti- tuberculosis therapy, administer MYAMBUTOL 25 mgs. Per kilogram (11 mg. per pound) of body weight, as a single oral dose every 24 hours. . . . After 60 days of MYAMBUTOL administration, decrease the dose to 15 mg. per kilogram (7 mg. per pound) of body weight, and administer as a single oral dose every 24 hours. During the period when a patient is on a daily dose of 25 mg/kg monthly eye examinations are advised. EXPERT OPINION TESTIMONY: George Andrews Schoonover, M.D. has been licensed to practice in Florida since 1978. He practices pulmonary medicine in Jacksonville, Florida. He is certified in pulmonary medicine as well as internal medicine and has a sub-specialty in critical care medicine. For proposes of this hearing Dr. Schoonover was recognized as an expert in pulmonary diseases. To prepare himself for testimony at hearing he looked at the materials in Petitioner's Exhibit No. 1, which describes the care and treatment received by Patient J.P. during the relevant period. He also looked at the PDR in relation to MYAMBUTOL (ethambutol hydro-chloride). (Petitioner's Exhibit No. 3) His testimony was offered as a consultant for Petitioner. It supports Petitioner's attempt to impose discipline against Respondent's license. In interpreting the physician's progress note entered by Dr. Prchal on July 1, 2000, while Patient J.P. was in the hospital, which states "would sign off," Dr. Schoonover takes this to mean that Dr. Prchal will not be seeing the patient again, either in the hospital or as an outpatient, unless asked to formally consult at a future date. (Petitioner's Exhibit No. 1, page 121) Patient J.P. was discharged from the hospital on July 5, 2000, by Nagesh Kohli, M.D. Dr. Schoonover points out that the discharge summary explained to the patient in the discharge instructions that the patient, if experiencing any recurrence of symptoms, dyspnea, fever or questions or concerns, may call the Respondent. As well, the discharge instructions note that the patient was to follow up with Dr. Mitra in three to four weeks. (Petitioner's Exhibit No. 1, page 77) This instruction tends to coincide with the patient's visit to Respondent on July 19, 2000. Dr. Schoonover commented on the medications that Patient J.P. would continue upon discharge, in particular ethambutol 1600 mg q.d., part of the discharge summary by Dr. Kohli. This is as distinguished from the ethambutol Dr. Prchal had prescribed earlier in the hospital stay. In a patient medication record for Patient J.P. maintained by Respondent's practice, information is contained concerning ethambutol use over time. (Petitioner's Exhibit No. 1, page 9) Dr. Schoonover refers to the dosage of 400 mg four times per day, on July 19, 2000, October 23, 2000, and December 27, 2000, reflected in the patient record. Based upon the record, Dr. Schoonover assumes that Respondent was aware of the dosage of ethambutol for Patient J.P. upon these dates when the patient was seen, indicating a lack of change in the dosage over time. Dr. Schoonover commented upon the correspondence from Dr. Prchal to Dr. Mitra dated August 18, 2000. In his reading, Dr. Schoonover believes that the correspondence points out that Respondent was the physician of record from the standpoint of monitoring Patient J.P., and in treating the patient from the hospital discharge until the patient was seen by Dr. Prchal on July 26, 2000. In this connection notes made by Dr. Prchal concerning Patient J.P. in August 2000 were interpreted by Dr. Schoonover to indicate that the patient was receiving his prescriptions for medication from Respondent. (Petitioner's Exhibit No. 1, page 270) Dr. Schoonover also mentions the August 30, 2000 note in Patient J.P.'s records maintained by Respondent's practice, which describes a call by Dr. Prchal and his office note, taken to mean the correspondence directed to Respondent on August 18, 2000, in which Dr. Prchal requests Respondent to make sure that the patient has plenty of meds (medication) while Dr. Prchal was out of town through September 18, 2000. (Petitioner's Exhibit No. 1, page 89) That note maintained by Respondent in his practice indicates that the request was honored where it states, "Done." Dr. Schoonover assumes that the reference to meds would include ethambutol. Dr. Schoonover commented on the October 23, 2000 visit with Respondent as reflected in the note made on that date by Respondent (Petitioner's Exhibit No. 1, page 90), wherein it indicates that that patient is being continued on ethambutol. Dr. Schoonover believes that Respondent was responsible for monitoring that therapy and potential side effects and drug interactions associated with ethambutol. Dr. Schoonover commented on the December 27, 2000 correspondence from Respondent to Dr. Prchal, in which Respondent describes the complaint by Patient J.P. made December 26, 2000, about some eye problem, and whether the problem was due to medication. As Dr. Schoonover was aware, Respondent responded to those remarks by stopping the ethambutol. Dr. Schoonover was asked about his ability to form an opinion with a reasonable degree of medical certainty, whether the Respondent by his treatment of Patient J.P. practiced medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances. He had an opinion. That opinion was that Respondent deviated from the standard of care, that the Respondent fell below the standard of care. Dr. Schoonover feels that deviation was in two areas. The first was the failure to order eye examinations for Patient J.P. The second reason was that the Respondent did not reduce the dosage of ethambutol after two months of therapy. Dr. Schoonover offered his opinion with the belief that Respondent was the attending physician in the hospital and continued to treat the patient beyond the patient's release from the hospital. Dr. Schoonover indicated that had the Respondent not ordered an initial eye examination be done, then at some subsequent point in the care the examination should have been ordered. Concerning reducing the dosage of ethambutol, Dr. Schoonover further explains his opinion that the dosage should have been reduced by Respondent after 60 days or at least determined why the specialist (Dr. Prchal) had not reduced it after 60 days. Dr. Schoonover concludes that Respondent could have taken steps to prevent the permanent visual impairment of Patient J.P. through an initial eye examination or subsequent follow-up eye examination, finding the problem early enough that this discontinuation of the medication would resolve the problem and promote improvement before permanent damage was done. Dr. Schoonover holds the opinion that Dr. Prchal also deviated from the recognized standard of care in his treatment of Patient J.P. in relation to ethambutol. He believes that both Respondent and Dr. Prchal were in a situation wherein they shared the care and they were both equally responsible and failed to meet the standard of care for the same reasons. In essence Respondent was treating the Patient J.P. for MAI as well as Dr. Prchal. In his testimony Dr. Schoonover is less precise in his opinion concerning the responsibility for a physician to order an initial eye examination for Patient J.P., testifying that it was someone's responsibility. He then goes on to say that it was several persons' responsibility and that Respondent and Dr. Prchal were among those persons. They are the persons discussed as well as Dr. Kohli. Finally, in order to find a deviation from the standard of care by Respondent, Dr. Schoonover believes that it is necessary to show that the patient had diminished visual acuity more probably than not connected to ethambutol. His reading of the April 25, 2001 correspondence from Dr. Bhatti in particular, leads him to believe that there was a connection between the use of ethambutol and bilateral optic neuropathies as described by Dr. Bhatti. (Petitioner's Exhibit No. 1, page 227) Raymond L. Parker, Jr., M.D., has been practicing in Florida since 1976. His current practice is with Pulmonary Physicians of South Florida in South Miami, Florida. He specializes in internal medicine, pulmonary disease and critical care. He is board certified in all specialties. He testified by deposition in behalf of Respondent as an expert, in particular, in relation to his specialty in pulmonary diseases. (Petitioner's Exhibit No. 2) In the deposition the parties stipulated that the witness was an expert in pulmonary diseases. That stipulation is accepted. In preparing to offer his opinion concerning the care provided by Respondent to Patient J.P., Dr. Parker had exposure to the deposition of Respondent, the deposition of Dr. Prchal, the deposition of Dr. Kohli, medical records of Dr. Prchal, Frank's Pharmacy records, medical records of Dr. Leslie Husband, medical records of Beatriz X-Ray and Imaging Center, medical records of Dr. Zeini, medical records of Dr. DiLorenzo, medical records of the Marion County Department of Health, medical records of Express Care of Belleview, and medical records of the Monroe Regional Medical Center. Dr. Parker also had exposure to records related to Patient J.P., part of Respondent's office practice. Dr. Parker comments on the bronchoscopy performed by Respondent on June 29, 2000, while Patient J.P. was in the hospital, in which the bronchoscopic specimen showed no endoscopic evidence of malignancy. Based upon the results of the bronchoscopy in the hospital and an earlier bronchoscopy performed a Dr. Warman on June 7, 2000, Dr. Parker was persuaded that the patient was going to be treated for MAI based upon cultures that grew out from the procedures. Further, Dr. Parker refers to the discharge diagnosis when Patient J.P. left the hospital, where it is stated that the patient had atypical tuberculosis, MAI, in addition to a right-upper lobe abscess and COPD. Dr. Parker's refers to the progress note dated July 1, 2000, when Patient J.P. was in the hospital, made by Dr. Prchal, in which Dr. Prchal recommends 400 mg tablets, four times daily of ethambutol, totaling 1600 mg, as being part of a treatment for TB and MAI pending AFB culture results. Dr. Parker's reading of the note by Dr. Prchal calling for "Appropriate monitoring. Will sign off," in the context of other materials reviewed by Dr. Parker, meant that Patient J.P. was being referred to the tuberculosis health center and those persons in that facility would manage the tuberculosis and MAI issue in the future. Dr. Parker refers to information in the patient records where the wife of Patient J.P. contacted a social worker leading to the patient being informed that the tuberculosis unit did not treat MAI but that an attempt was being made to make an appointment for Patient J.P. to be seen at the adult clinic. Ultimately, Dr. Parker interprets the information he reviewed as indicating that Patient J.P.'s wife decided that an appointment needed to be made with Respondent resulting in the appointment on July 19, 2000, between the patient and Respondent. Between July 1, 2000, when Dr. Prchal wrote his "sign off" note and July 19, 2000, when the patient was seen by Respondent, Dr. Parker expressed the opinion that Respondent and Dr. Kohli were the attending physicians for Patient J.P. The prescription recommendations upon discharge would have been the responsibility of Dr. Kohli because he discharged the patient. According to Dr. Parker this included ethambutol. Dr. Parker is familiar with the PDR. He does not consider it to be an authoritative source for information among doctors. He considers that the information contained in the PDR was written years before. Consequently, it is not authoritative or up to date. Dr. Parker prescribes ethambutol for his patients but rarely. He has a special interest in MAI. He is aware of the recommendations within the PDR pertaining to visual testing and dosage for ethambutol. He considers some of the recommendations for using ethambutol to be controversial. For example, he does not recommend his patients get monthly monitoring for their vision. Instead, he recommends that they watch out for problems. He considers that this approach is the general consensus in the community where he treats patients. Specifically, Dr. Parker does not question the prescription of 25 mg per kg of patient weight for the Patient J.P. when ethambutol was first prescribed. The dosage points to the patient loosing weight, fevers and sweats, not doing well and the need to "jump on him or he would just wither away." Dr. Parker does believe that there should have been an eye test when starting the patient on ethambutol. Dr. Parker in his understanding perceives that when Dr. Kohli discharged the patient from the hospital, Dr. Kohli believed that the patient would be attending the TB Clinic for treatment and monitoring, to include baseline studies for visual acuity. Dr. Parker in his opinion looks upon the suggestion in the PDR that the dosage of ethambutol be changed over time as being a guideline and that the proper treatment is in view of the clinical needs of the patient. If the patient is improving the dosage can be reduced. If he remains very sick, he would not necessarily reduce the dose. Concerning the maintenance of 25 mg per kg over periods of three, four, five, or six months Dr. Parker says that under appropriate circumstances the maintenance of 25 mg per kg of patient weight is acceptable. He does not offer his opinion concerning this case. Concerning the prospect for reducing the dosage, Dr. Parker's review of the records does not lead him to a conclusion one way or the other. When patients are maintained on 25 mg. per kg. of patient weight, Dr. Parker expresses the opinion that more frequent eye testing is in order. If the dosage is less than that amount he would not recommend that a patient have repeat eye testing but that the patient be cautioned to quickly advise the doctor about changes in vision and or visual fields or color vision. From his review of the records Dr. Parker was aware that the patient was maintained on ethambutol 25 mg per kg of weight for approximately six months and no eye tests were provided during that period. Dr. Parker interprets the correspondence from Dr. Prchal to Respondent dated August 18, 2000, as a guiding letter for addressing Patient J.P.'s MAI, leading to the belief by Dr. Parker that Respondent deferred to Dr. Prchal in the treatment of MAI with ethambutol following that correspondence. Overall Dr. Parker does not believe that Respondent was treating Patient J.P. for MAI and had no experience with the drug ethambutol as part of that care. This meant that Dr. Parker does not believe that Respondent was addressing the MAI issue or ethambutol. Dr. Parker interprets the note in Respondent's office practice where on August 30, 2000, the call was received from Dr. Prchal referring to the office note of August 18, 2000, from Dr. Prchal. That request asks that the patient have plenty of meds while Dr. Prchal was out of town until September 18, 2000. This indicates that Dr. Prchal could not write the prescriptions and that he was requesting Respondent's office to handle the writing of prescriptions. This is not seen by Dr. Parker as turning over the management of the patient in reference to the prescriptions. In Dr. Parker's view, when consultants prescribe medication, the attending physician does not have a standard of care obligation to hold the knowledge about these drugs prescribed by the consultant for the patient. The attending physician relies upon the consultant for guidance on the drugs and any questions need to be followed up with the consultant, according to Dr. Parker. In this case he goes on to describe the expectation, upon the discharge from the hospital, that the patient would be seen by a clinic where the attending physician felt there would be necessary expertise. Dr. Parker reached an opinion on standard for care issues concerning Respondent's treatment and care of Patient J.P. His opinion is that Respondent met the standard of care because he was the treating physician limited to the lung abscess and COPD. Dr. Parker interprets the results of the July 19, 2000 visit to Respondent to be one in which Respondent realized that the patient was not going to be seen at a tuberculosis health clinic, resulting in Respondent referring the patient back to Dr. Prchal for management of MAI. Dr. Parker attaches importance to the August 18, 2000 letter from Dr. Prchal to Respondent, in which Dr. Prchal indicates a treatment plan for MAI and Respondent defers to that judgment. At the inception Dr. Parker believes Respondent was acting appropriately to refer Patient J.P. to Dr. Prchal, an infectious disease expert. Concerning the need for a baseline eye examination to be performed when ethambutol is being started, Dr. Parker thinks that is necessary. However, the physician managing the care with respect to the MAI and who ordered the medication is responsible for ordering the initial eye examination. In this case that would have been Dr. Prchal. Any follow-up eye examinations on a periodic basis would be the responsibility of the physician with a special interest in management of atypical mycobacterial disease, with some understanding of the various drugs involved, to include ethambutol. Dr. Parker believes that additional eye examinations are needed when continuing the dosage of 25 mg per kg of patient weight. Given the continuing dosage over time, Dr. Parker believes that Dr. Prchal was responsible for ordering subsequent eye examinations. In relation to the suggestion in the PDR that around 60 days the dosage of ethambutol be reduced, Dr. Parker believes that it is dependent upon the clinical response of the patient. Sometimes the dosage would be reduced earlier, sometimes later. The judgments concerning dosage would be that of the expert familiar with the MAI and drugs used to address it. SUMMARIZING FACTS: Respondent's explanation of the availability of the adult clinic in Ocala, Florida, to address Patient J.P.'s need for medications and other services only establishes that availability. It does not establish what was done at the clinic, if anything, in terms of treatment for MAI through the use of ethambutol and related vision tests. There is no proof that anything transpired at the adult clinic to treat MAI, or test for visual acuity. Whatever may have been offered to the patient in treatment and care by the adult clinic, it does not change the fact that Respondent and Dr. Prchal were involved with the treatment for MAI, to include the need to properly use ethambutol. Having considered the facts found concerning the care provided Patient J.P. by Respondent and Dr. Prchal and the opinions by the parties' experts Dr. Schoonover and Dr. Parker, Respondent has failed to practice medicine with the level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances. Dr. Prchal was responsible for prescribing ethambutol while Patient J.P. was in the hospital. Consequently Dr. Prchal was responsible for testing initial visual acuity for the patient. The initial treatment provided was upon a request to consult made by Respondent. Dr. Prchal was also responsible for establishing the initial dosage for the patient. When the patient was discharged from the hospital, Dr. Prchal was no longer responsible for the treatment from July 5, 2000, the discharge date until July 26, 2000, when called upon again by Respondent to consult. When Dr. Prchal saw Patient J.P. on July 26, 2000, and August 8, 2000, it reestablished his responsibility but only temporarily. The treatment was turned back to Respondent as established in the correspondence following the second consult. That correspondence was dated August 18, 2000, from Dr. Prchal to Respondent involving ethambutol and its use in treating Patient J.P. Respondent had responsibility for Patient J.P. in relation to ethambutol following the patient hospital discharge and upon the visit by Patient J.P. to Respondent's office on July 19, 2000. Respondent briefly deferred to Dr. Prchal as a consultant on July 26, 2000, until he received the correspondence from Dr. Prchal dated August 18, 2000. Beyond that point in time, Respondent was responsible for Patient J.P.'s use of the medication ethambutol. This responsibility was evidenced in the Respondent's transcribed office note dated October 23, 2000, when the Patient J.P. was seen on a follow-up visit. It refers to the final note from Dr. Prchal dated August 18, 2000 and the continuation of ethambutol for the patient. It describes the need for the patient to continue on ethambutol for a year or so. On December 27, 2000, when Patient J.P. was next seen by Respondent in the office, the patient complained of an eye problem. In response Respondent "stopped his ethambutol" as of that day. During the time that Respondent was responsible for Patient J.P., related to the use of ethambutol by that patient, he was expected to make a clinical judgment about the proper dosage, but not necessarily at a two-month interval. There is no indication that he made any judgment. More significantly, given allegations in the Administrative Complaint, Respondent should have arranged periodic testing of visual acuity, while he was responsible for the use of ethambutol in treating Patient J.P., having failed to reduce the dosage from 25 mg per kg of body weight. Respondent's failure to meet the standard of care is not excused by Dr. Prchal's conduct when treating Patient J.P. with ethambutol. Respondent's belief that Dr. Prchal was all together responsible for treating Patient J.P.'s MAI with ethambutol and other medications is not accepted, realizing that to some degree Respondent undertook the treatment whether capable or not. Finally, there was no proof in this record concerning the local Department of Health, adult clinic providing treatment to Patient J.P. for MAI, to include judgment about the dosage of ethambutol and test for visual acuity. Absent such proof the responsibility fell entirely to Respondent and Dr. Prchal at various times. Their stated assumptions concerning the role, if any, played by the Department of Health, adult clinic in treating Patient J.P. without proof are unavailing and create no defense for their conduct. DISCIPLINARY HISTORY In the case of Department of Health, Petitioner vs. Purushottam Mitra, M.D., Respondent, DOH Case No. 1999-58979, a Final Order was entered. This Final Order was based upon a Recommended Order in Department of Health, Board of Medicine, Petitioner vs. Purushottam Mitra, M.D., Respondent, DOAH Case No. 01-2069PL. The Final Order concluded that Respondent had violated Section 458.331(1)(m), Florida Statutes, pertaining to maintenance of patient records justifying a course of treatment for a patient. It imposed an administrative fine amounting to $5,000.00. Respondent was also reprimanded by the Board. (Petitioner's Exhibit No. 4)
Recommendation Upon consideration of the facts found and conclusions of law reached, it is RECOMMENDED: That a final order be entered finding Respondent in violation of Section 458.331(1)(t), Florida Statutes (2000), imposing an administrative fine of $10,000.00, and issuing a written reprimand. DONE AND ENTERED this 25th day of February, 2005, in Tallahassee, Leon County, Florida. S CHARLES C. ADAMS 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 25th day of February, 2005. COPIES FURNISHED: Irving Levine, Esquire Judith Law, Esquire Department of Health 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Michael R. D'Lugo, Esquire Wicker, Smith, O'Hara, McCoy, Graham & Ford, P.A. Bank of America Center, Suite 1000 Post Office Box 2753 Orlando, Florida 32802-2753 Larry McPherson, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701
Findings Of Fact Respondent, Stella Mae Browning Brumley, has been a registered nurse in Florida since 1954 and worked at the Sunland Development Center in Ft. Myers for approximately 10 years before she was dismissed in June, 1975 by the hospital authorities. During the period March-May, 1975 Mrs. Brumley entered on the clinic log that she had administered tannic acid, 20 percent solution, to approximately 14 "clients of the center who had suffered minor cuts, abrasions etc. At the time this medication was administered the standing orders did not provide for use of this medication and there was no doctor's order for this treatment to be given to any of the "clients" so treated. Tannic acid was supplied to the medicine cabinets in each of the cottages where the clients reside and was available for use by the "parents" although all of the Petitioner's witnesses testified that a doctor's order was required before thee use of tannic acid was authorized. Dr. Murray, present Medical Director at Sunland, introduced the use of tannic acid at Sunland but never put it on the standing orders. He considers tannic acid to be an effective medication for minor abrasions. There are standing orders for treating minor skin irritations and rash but there is nothing in the standing orders providing specifically for treatment of abrasions (TR p 44, 47). Webster's New Collegiate Dictionary shows another sense of the word, abrasion, to be irritation. Cottage parents generally considered that medications made available in the medicine cabinets and not kept locked, such as tannic acid, were there for use in first aid treatment, and frequently used same assuming it was authorized by standing orders. On or about February 27, 1975, Manuel Horton, a client at Sunland received ant bites which resulted in his being taken to the clinic. The doctor ordered treatment with furacil and entered same on clinic chart. No copy of the orders or the medication was sent to the cottage. Later that evening Respondent was called to the cottage to administer to Horton. He had scratched himself in several places deeply enough to draw blood. After ascertaining that no record of treatment ordered was in the cottage Mrs. Brumley called the nurse'supervisor on duty in the clinic to discuss treatment but she did not go across the road to the clinic to look at the clinic chart. Mrs. Miller, the supervisor on duty in the clinic, was partially supervisor of the cottage nurses and Mrs. Brumley testified she considered Mrs. Miller to be so because she was a grade higher. Mrs. Miller advised that she had caladryl available if someone could come for it. Mrs. Brumley testified that calomine was received and Horton was treated with calomine. She entered on his chart that he was treated with caladryl. Furasin, which was ordered by the doctor, is an antibiotic while caladryl, a combination of benedryl and calamine, is an antihistimatic. During a period when pin worms were prevalent Povan was ordered administered to all employees as well as the clients. In the initial planning stages Mrs. Brumley was asked to administer the treatment in the cottages in the evening but she demurred. Later it was decided that the treatment would be given only during the day hours. Mrs. Brumley understood the time limitation on treatment during day hours applied only to the children and on the evening of April 15, 16, and 17 she administered Povan to employees in the cottages. On February 14, 1975 Kenneth Skogland and Linda Sallak, clients at Sunland, were administered Visteril by Respondent Brumley. At the time Thorozine was the authorized sedative when a child became unruly. No doctor's orders for substitution of Visteril for Thorozine was entered. Respondent contends that during a conversation with Dr. Murray he suggested the substitution of Visteril for Thorozine and she considered that to be authorization for the substitution. Visteril is both an antihistamine and a sedative. Dr. Miller denied he ever said that Visteril could be substituted for Thorozine. In March, 1972 Respondent entered on the medical records that bread, butter, and cotton was administered to a patient who had swallowed pins. At the hearing Mrs. Brumley acknowledged that she had administered the cotton sandwich but its use had been authorized by a doctor at Sunland who is now deceased. No record of such an order was found. Mrs. Brumley's testimony that she and the prescribing doctor had discussed the cotton sandwich with the Medical Director at the time gas disputed by the Medical Director at the hearing. He had no recollection of such conversation although he recalled the incident where the patient was so treated. No adverse effects resulted from this treatment and the pins were eliminated by the patient without surgery being required.
Findings Of Fact Respondent was licensed as a dentist in Florida at all times pertinent to this proceeding. He specializes in oral surgery and restricts his dental practice to that specialty. Dr. James Spurling, who practices general dentistry, examined Stephen Rice on March 21, 1980. At that time, Rice mentioned an irritation to his lingual frenum (the tissue which connects the front of the tongue to the floor of the mouth). Spurling diagnosed this condition as ankyloglossia (tongue-tie), and advised Rice that he would refer him to Respondent for consultation. Spurling did not contact Respondent directly, but asked his secretary to complete the referral. Spurling's secretary then called Respondent's secretary who noted the referral as "frenectomy" on her records, but did not specify "lingual frenectomy" which is the procedure to correct the tongue-tie condition. On March 26, 1980, Spurling and Respondent along with several other Melbourne area dentists had lunch together. Spurling mentioned the tongue-tie patient to Respondent at that time and they briefly discussed this condition. Respondent saw Rice on April 4, 1980, for the consultation recommended by Spurling, and determined that Rice required a maxillary labial frenectomy. This procedure involves cutting connective tissue between the upper lip and the upper jaw. Respondent noted that Rice did have ankloglossia, but did not consider a lingual frenectomy necessary. Respondent made an appointment for Rice to have the maxillary labial frenectomy on April 11, 1980. Rice kept the appointment and Respondent performed the maxillary labial frenectomy on that date. Respondent introduced ample evidence to establish that the maxillary labial frenectomy he performed on Rice was beneficial to prevent Rice's front teeth from separating. Similarly, Respondent demonstrated that his reservations regarding the lingual frenectomy in Rice's case were reasonable since Rice did not suffer from a speech impediment. Respondent testified credibly that he explained the maxillary labial frenectomy to Rice in lay terminology and offered to answer any questions Rice had. Respondent did not, however, seek Rice's view on this matter or the error would have immediately become apparent. Rice had confidence in Respondent, who had removed his wisdom teeth several years earlier. Thus, he asked no questions in the belief that Respondent would carry out the procedure for which he had been referred by Spurling. Throughout the consultation and the surgery, Rice believed he was receiving the procedure to correct his tongue-tie condition, and did not realize an entirely different procedure had been performed until he left Respondent's office. This lack of awareness established that he avoided focusing his attention on either the discussion of the surgery or the surgery itself. Thus, Rice is partly responsible for the failure of communication. However, this failure of communication became possible initially because Respondent did not know or did not remember that the consultation referral was specifically for a lingual frenectomy and not merely a frenectomy. Because of this, he did not explain to Rice that the lingual frenectomy was, in his view, inappropriate. Rather, he explained the maxillary labial frenectomy which he believed was required, and which Rice erroneously assumed was the tongue-tie surgery he sought.
Recommendation From the foregoing it is RECOMMENDED that Petitioner enter a Final Order finding Respondent guilty of violating Subsection 466.028(1)(p), Florida Statutes (1979), substantially as charged in Count II of the Administrative Complaint. It is further RECOMMENDED that the Petitioner issue a reprimand as provided in Subsection 466.028(2)(d), Florida Statutes (1979). DONE and ENTERED this 23rd day of July, 1982, in Tallahassee, Florida. R. T. CARPENTER, Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 23rd day of July, 1982. COPIES FURNISHED: Benjamin Y. Saxon, Esquire Saxon and Richardson, P.A. 111 South Scott Street Melbourne, Florida 32901 Salvatore A. Carpino, Esquire Assistant General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Fred Varn, Executive Director Board of Dentistry 130 North Monroe Street Tallahassee, Florida 32301 Honorable Samuel R. Shorstein Secretary, Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
The Issue The issues to be resolved in this proceeding concern whether the Petitioner, Philip S. Bennett, Sr., is entitled to reimbursement from the State of Florida Group Health Self Insurance Plan for services rendered him by John S. Dozier, D.M.D., in connection with treatment received by the Petitioner for a "localized mucogingival defect" (abscess and infection) occurring around the first upper molar tooth on the left side of the patient's mouth.
Findings Of Fact The Petitioner is a retired state employee, who is covered for medical benefits under the State of Florida Employees' Group Health Self Insurance Plan. The Petitioner experienced an infection of the gum in the area adjacent to the upper left, first molar, also called a "localized mucogingival defect", which involves a localized, chronic infection of the soft tissue surrounding that tooth and the ligamentous attachment of the tooth. The condition was apparently caused initially by accumulation of food or infectious material beneath the gum line in that area. The Petitioner's general dentist, Dr. Doug Evans, determined that this condition should be treated by a referral of the Petitioner to a periodontal specialist, Dr. John S. Dozier. He was referred to Dr. Dozier sometime in April or May of 1993. He was seen by Dr. Dozier on June 1, 1993. Dr. Dozier diagnosed the condition as is described above. Dr. Dozier determined that there were two courses of therapy available to resolve the infection problem. The first was extraction of the tooth. The second course of therapy involved complete debridement of the infected area, involving thorough cleaning and removal of any necrotic tissue or infectious material, followed by a gingival tissue graft. Since there was a good prognosis for retention of the adjacent tooth, it was determined by the Petitioner and Dr. Dozier to perform the latter procedure, involving the gingival graft, so as to replace, by transplantation, the gum tissue adjacent to the tooth, which would have the effect of filling the void or gap in the gum tissue at the infected area so as to restore the integrity of the gum and gum line and, therefore, prevent further infection in the area. The chronic infection in the area, if left untreated, could have resulted in a bacteremia condition. The gingival graft, which was performed, was thus surgery involving soft tissue and was successfully completed. The postoperative assessment, approximately nine months after the surgery, showed that it was 100 percent successful. The Petitioner has a history of pulmonary disease or condition and a heart problem involving his heart valve. He has been under the care and treatment of Dr. Clifton J. Baily, a pulmonary specialist, for some years. Dr. Baily has, over the years, cautioned the Petitioner that he must be careful to seek prompt and proper treatment for any infection so as to avoid endangering his lungs or heart valve through the systemic effects of any infection. It was especially with this advice in mind that the Petitioner, upon learning that he had the infection in his mouth, sought and obtained the treatment described above. This condition posed significant health risks to the Petitioner, not related to his dental care and treatment. Because of his medical history, the infectious condition placed the Petitioner at risk of infecting his heart valve, the area of previous surgery to his back, and the potential for development of a destructive respiratory infection, given the Petitioner's chronic pulmonary disability and heart valve problem history. It was, therefore, Dr. Baily's reasoned medical conclusion that the grafting of the tissue, by oral surgery performed by Dr. Dozier, was medically necessary to avoid spreading the infection, which would be detrimental to the Petitioner's chronic pulmonary disability and would run the risk of infecting his heart valve, as well. It was thus established that the surgical procedure involved was medically necessary and was not truly a dental treatment or procedure. It involved the surrounding soft tissue adjacent to the tooth in question, which tissue was chronically infected. The tooth itself was not the source of the Petitioner's medical problem. Ultimate tooth loss might have been an incidental result of the deterioration and sloughing away of the infected soft tissue surrounding the tooth, but it was the infection of soft tissue, which had to be surgically repaired, that was the essential problem. The repair was shown to be medically necessary to avoid a deterioration in the Petitioner's pre-existing medical conditions described above.
Recommendation Based on the foregoing Findings of Fact, Conclusions of Law, the evidence of record, the candor and demeanor of the witnesses, and the pleadings and arguments of the parties, it is RECOMMENDED that a Final Order be entered by the Respondent, Department of Management Services, Division of State Employees' Insurance, finding the Petitioner entitled to reimbursement for the charges shown to be medically necessary for the above-described procedure and treatment. DONE AND ENTERED this 10th day of August, 1994, in Tallahassee, Florida. P. MICHAEL RUFF 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 10th day of August, 1994. APPENDIX TO RECOMMENDED ORDER, CASE NO. 93-6939 Petitioner's Proposed Findings of Fact 1-18. Accepted, but subordinate to the Hearing Officer's findings of fact on this subject matter, and rejected to the extent that they may differ from the Hearing Officer's findings of fact. Respondent's Proposed Findings of Fact 1-4. Accepted. Rejected, as subordinate to the Hearing Officer's findings of fact on this subject matter. The preponderant evidence of record reflects that $507.00 was the total fee paid for the services necessitated by the treatment of the infectious condition described in the above Findings of Fact and found to be subject to reimbursement. Rejected, as subordinate to the Hearing Officer's findings of fact on this subject matter, and as not entirely in accord with the preponderant weight of the evidence. Accepted only in the sense that they describe the Respondent's position in this case. COPIES FURNISHED: Brant Hargrove, Esq. 1343 East Tennessee Street Tallahassee, FL 32308 Augustus D. Aikens, Jr., Esq. Benefit Programs and Legal Services Division of State Employees' Insurance 2002 Old St. Augustine Road, B-12 Tallahassee, FL 32301-4876 William H. Lindner, Secretary Department of Management Services Knight Bldg., Ste. 307 Koger Executive Center 2737 Centerview Drive Tallahassee, FL 32399-0950 Paul A. Rowell, Esq. General Counsel Department of Management Services Knight Bldg., Ste. 307 Koger Executive Center 2737 Centerview Drive Tallahassee, FL 32399-0950
The Issue The issue for determination is whether Respondent violated Section 466.028(1)(x), Florida Statutes (2001), by failing to refer patient L.D. to a specialist for evaluation and treatment of numbness of her tongue. (All statutory references are to Florida Statutes (2001) unless otherwise stated.)
Findings Of Fact Petitioner is the state agency responsible for regulating the practice of dentistry in Florida pursuant to Section 20.43 and Chapters 456 and 466. Respondent is licensed as a dentist in Florida pursuant to license number DN9676. Respondent is a general dentist. Respondent practices dentistry in Cape Coral, Florida, and has practiced dentistry for approximately 18 years. Respondent has no prior discipline against his license. The patient at issue is identified in the Administrative Complaint as L.D. The parties stipulated that L.D. is the same person identified in Respondent's medical records as L.V. and in the Transcript as L.W. L.D. is a female who was 19 years old when Respondent removed her four wisdom teeth on February 26, 1998. At the time, Respondent's records correctly identified the patient as L.V. L.V. subsequently married D.D. who was her boyfriend at the time. L.V. is now L.D. L.D. and D.D. were both patients of Respondent. L.D. suffered an injury to her lingual nerve when Respondent extracted her wisdom teeth. Lingual nerve injury is a foreseeable risk of wisdom tooth extraction, and the parties agree that Respondent properly disclosed that risk to L.D. prior to extracting her wisdom teeth. The symptoms of lingual nerve injury include paresthesias, i.e., numbness, of the tongue. The applicable standard of care for lingual nerve injury is observation and, under certain circumstances, referral to an oral and maxillofacial surgeon ("oral surgeon"). Surgery for symptoms of a lingual nerve injury may be exploratory, or it may be undertaken to perform a nerve grafting procedure. One of the risks of such surgery is dyscesthesia, i.e., pain, thereby making the symptoms worse rather than better. Therefore, surgery is not appropriate unless the patient experiences severe or debilitating pain, lip biting and cheek biting, or cannot function. The prudent dentist should observe the patient over time to determine whether the patient is improving and to determine the nature and scope of the patient's symptoms. The Administrative Complaint contains two essential allegations against Respondent. One allegation is that Respondent failed to diagnose the lingual nerve injury. The other allegation is that Respondent failed to refer L.D. to an oral surgeon. Respondent properly diagnosed the lingual nerve injury to L.D. After extracting L.D.'s wisdom teeth on February 26, 1998, Respondent examined L.D. in 1998 on February 27; March 5, 12, and 26; April 30; May 4; and July 8. L.D. did not call or seek an appointment with Respondent between May 4 and July 8, 1998. The first examination on February 27, 1998, was routine. Respondent checked to make sure L.D. had no signs of any complications, gross infection, or pus from the area of the surgery. L.D. had no complaints of numbness. Respondent instructed L.D. to return on March 5, 1998. On March 5, 1998, L.D. complained for the first time of numbness on both sides of her tongue. Respondent properly examined and diagnosed the cause as lingual nerve injury. By using an explorer to identify the areas of paresthesia, or numbness, Respondent determined that the right tip of L.D.'s tongue did not respond to the explorer, the right mid-tongue did respond, the left tip did not respond, and the left mid-tongue did not respond. Respondent also determined that both lingual tissue areas, i.e., the areas toward the tongue, did not respond to the explorer. Respondent properly treated L.D. after diagnosing the lingual nerve injury. Respondent observed L.D. for approximately four months to determine the nature and scope of L.D.'s symptoms. L.D.'s paresthesia of the tongue improved during the four months immediately following the removal of her wisdom teeth. After examining and diagnosing L.D. on March 5, 1998, Respondent explained to L.D. that the numbness may be either transient or permanent and that she was to return in one week for observation. L.D. returned to Respondent's office on March 12, 1998. Respondent stated that the feeling was coming back to her tongue, especially on her left side, and that she felt tingling. L.D. complained only of a tingling sensation on the right side of her tongue. L.D. did not complain that her tongue was numb or that she was biting her tongue. L.D. stated that her tongue was still a little bit numb, and it was tingling a little bit on the right side. A tingling sensation is hyperesthesia or paresthesia. Hyperesthesia can be an indication that the lingual nerve is repairing or healing. It indicates that the nerve is intact, that nerve conduction is occurring, and may indicate a potential for spontaneous self-repair. Respondent instructed L.D. to return for observation in two weeks. L.D. returned to Respondent's office on March 26, 1998. L.D. stated the feeling had returned to the left side of her tongue and that the right side of her tongue was still tingling. Respondent instructed L.D. to return for observation in six weeks. L.D. returned to Respondent's office on April 30, 1998. L.D. stated that she no longer had sensitivity on the right side of her tongue. The comment that she had "no sensitivity" indicated that the patient had none of the tingling sensation that had been her only complaint on March 26, 1998. L.D. returned to Respondent's office on May 4, 1998, for a dental prophylaxis, i.e., cleaning. L.D. did not complain of any numbness or tingling on May 4, 1998. On July 8, 1998, L.D. and D.D. both visited Respondent's office for dental care. D.D.'s visit was routine and not material to this proceeding. L.D. returned to Respondent's office and reported conflicting symptoms. L.D. indicated that she had feeling in her lips, but did not respond to the explorer on the gum in the front or the back of the teeth or in the areas of the tongue in which she had previously indicated that sensation had returned. The symptoms displayed by L.D. on July 8, 1998, included symptoms of buccal nerve damage. The buccal nerve goes to the gum and cheeks and is different from the lingual nerve. Prior to July 8, 1998, L.D. had not previously shown any signs of buccal nerve damage. Because of these conflicting complaints, Respondent referred L.D. to an oral surgeon on July 8, 1998. Respondent referred L.D. to the Southwest Florida Oral Surgery Associates ("Southwest"). Respondent has referred patients exclusively to Southwest for approximately 10 years. Respondent's records for July 8, 1998, do not include an express statement that he was referring L.D. to an oral surgeon. However, the records include a notation, "PTR for records," that indicates L.D. was to return for her records. The notation in the records is consistent with Respondent's longstanding protocol when referring a patient to a specialist. The protocol is to have the patient's records copied and prepared for the patient to pick them up and deliver to the specialist. On July 13, 1998, D.D. obtained copies of the records for L.D. and for D.D. from Respondent's office. The records included a written referral form for L.D. in accordance with Respondent's protocol. Respondent's office staff inadvertently filed Respondent's copy of the written referral form for L.D. in D.D.'s dental records and recovered the form after Respondent was asked to retrieve D.D.'s records during discovery in this proceeding. Respondent informed his office manager on July 8, 1998, that he had referred L.D. to an oral surgeon. Respondent's office manager confirms that Respondent stated to her at the time that he was referring L.D. to an oral surgeon. On March 3, 1999, L.D. saw Dr. Kevin Pollack at Southwest. Dr. Pollack found that L.D. could not perceive touch or pressure on the left side of her tongue. On April 1, 1999, L.D. saw Dr. Timothy Hogan at Southwest. L.D. had improved since she saw Dr. Pollack. Dr. Hogan found that L.D. could perceive light touch and pressure on the left side of her tongue. Petitioner's expert opined that failure to refer L.D. to an oral surgeon failed to comply with the applicable standard of care for lingual nerve injury. However, the issue of whether Respondent referred L.D. to Southwest is an issue of fact for which expert opinion is admissible if: specialized knowledge will assist the trier of fact in understanding the evidence; and the opinion can be applied to evidence at the hearing. Section 90.702. The record does not disclose any specialized knowledge needed to resolve the factual issue of whether Respondent referred L.D. to Southwest. The expert did not testify at the hearing as to why the expert's knowledge, skill, experience, training, or education would assist the trier of fact in making a finding concerning the factual issue of whether Respondent referred L.D. to Southwest. The opinion of Petitioner's expert was not applied to evidence at the hearing. The expert apparently disregarded the entries in Respondent's records that L.D. was to pick up her records, and the expert was not present at the hearing to listen to other evidence and testify as to whether the evidence at hearing altered his opinion. The only other evidence that the expert opinion could be applied to is the testimony by L.D. and D.D. that Respondent did not refer L.D. to Southwest. However, the testimony of L.D. and D.D. is neither credible nor persuasive and is less than clear and convincing. The memories of the two witnesses are not clear and are not without confusion. Most of the facts to which the witnesses testified are not distinctly remembered. The testimony is not precise and explicit. Their testimony lacks certainty and consistency as to specific facts and circumstances and details. Both witnesses testified that they clearly recalled that Respondent did not refer L.D. to Southwest. However, neither witness could recall how L.D. ended up at Southwest. Nor could either witness recall picking up records from Respondent, what was contained in those records, and whether a written referral was included in the records. When asked why L.D. had not returned to Southwest, L.D. refused to answer the question. The testimony of L.D. and D.D. does not produce in the mind of the trier of fact a firm belief or conviction, without hesitancy, as to the truth of the allegation that Respondent failed to refer L.D. to Southwest. The assumption inherent in the testimony of Petitioner's expert that Respondent did not refer L.D. to an oral surgeon is not based on underlying facts or data in evidence and, therefore, is not admissible pursuant to Section 90.705. Even if it were admissible, the underlying facts and data are less than clear and convincing and not persuasive. Petitioner submitted evidence that Respondent failed to meet the applicable standard of care because Respondent did not refer L.D. to an oral surgeon in a timely manner. Without identifying the appropriate time for a referral, Petitioner relies on expert opinion that, "sooner is better than later." The Administrative Complaint does not allege that Respondent failed to meet the applicable standard of care by failing to refer L.D. to an oral surgeon in a timely manner. Rather, the Administrative Complaint alleges that Respondent failed to refer L.D. to an oral surgeon at any time. It would violate fundamental principles of due process to put Respondent on notice in the Administrative Complaint that he must be prepared to defend against the allegations in the Complaint and then prove a different allegation during the administrative hearing. Even if the Administrative Complaint were to allege that Respondent failed to timely refer L.D. to an oral surgeon, the evidence is less than clear and convincing that the referral by Respondent was not timely. Respondent did not refer L.D. to a specialist prior to July 8, 1998, because the numbness in her tongue had been improving. In April of 1999, L.D. had recovered a large percentage of the feeling on the left side of her tongue and was experiencing tingling on her right side. If Respondent had referred L.D. to a specialist during the time that she had been reporting improvement in her parethesias, the referral would have been inappropriate. In the absence of debilitating pain and lip and cheek biting, a dentist need not refer a patient with lingual nerve paresthesia to an oral surgeon. If a patient who experiences lingual nerve parethesias after the removal of wisdom teeth shows signs of improving or if the patient has some feeling in the tongue, the dentist need only observe the patient and need not refer the patient to a specialist.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Petitioner enter a Final Order finding that Respondent is not guilty of violating Section 466.028(1)(x) and dismissing the Administrative Complaint. DONE AND ENTERED on this 17th day of December, 2001, in Tallahassee, Leon County, Florida. DANIEL MANRY 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 17th day of December, 2001. COPIES FURNISHED: Tracy J. Sumner, Esquire Agency for Health Care Administration Post Office Box 14229 Tallahassee, Florida 32317-4229 Jay P. Chimpoulis, Esquire O'Connor & Meyers Post Office Box 149022 Coral Gables, Florida 33114-9022 Frank R. Recker, Esquire Frank R. Recker & Associates Company L.P.A. 267 North Collier Boulevard, Suite 202 Marco Island, Florida 34145 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 William H. Buckhalt, Executive Director Board of Dentistry Department of Health 4052 Bald Cypress Way, Bin C06 Tallahassee, Florida 32399-1701
The Issue By three separate and substantially identical Administrative Complaints each of the Respondents have been charged with violating specified statutory and rule provisions as a result of their having caused to be distributed a certain advertisement for chiropractic services. The Respondents admit that they caused the advertisement to be distributed, but deny that the advertisement constitutes a violation of any statutory or rule provision.
Findings Of Fact Based on the stipulations of the parties, on the admissions of the Respondents, on the testimony of the witnesses at the hearing, and on the exhibits received in evidence at the hearing, I make the following findings of fact. At all times material to this case the Respondent Stephen A. Jacobson was and is a licensed chiropractic physician, having been issued license number CH 0003555. At all times material to this case the Respondent Gary Jacobson was and is a licensed chiropractic physician, having been issued license number CH 0003660. At all times material to this case the Respondent Steven Paul Rosenberg was and is a licensed chiropractic physician, having been issued license number CH 0003784. At all times material to this case the address of each of the three Respondents was and is 9721 South Dixie Highway, Kendall, Florida. The advertisement which is the subject matter of these cases was distributed in Dade County, Florida, as an insert in a publication known as "The Flyer". The subject advertisement was placed by or at the direction of, or was acquiesced in, by all three of the Respondents, Stephen A. Jacobson, Gary Jacobson, and Steven Paul Rosenberg. Stephen A. Jacobson and Gary Jacobson initiated and caused the subject advertisement to be placed and Steven Paul Rosenberg was aware of the contents of the advertisement and acquiesced in its publication. The subject advertisement was an advertisement for chiropractic services, specifically an advertisement for the chiropractic services of the Respondents, each of whom was specifically named in the advertisement. At the time of the distribution of the subject advertisement each of the Respondents practiced at the Sunset Chiropractic Clinic located at 9721 South Dixie, Highway Kendall, Florida. The subject advertisement was distributed approximately two months after an incident in which bottles of Tylenol were found to be contaminated with deadly amounts of cyanide, which contamination resulted in at least one death. The incident involving cyanide contamination was known to all three of the Respondents as well as to the general public. 1/ The subject advertisement contains a prominent picture of a medicine bottle with a skull and crossbones, in conjunction with text urging the reader to try chiropractic and avoid medicine. The predominate theme of the advertisement is that medicine has many dangerous side effects, that one should avoid medicine because it will jeopardize one's health, and that medicine contains cyanide or acid. The subject advertisement contains the following specific statements: "Medicine Has Many Dangerous Side Effects" and "DON'T JEOPARDIZE YOUR HEALTH BY REACHING FOR A BOTTLE." In what turns out to be a statement about chiropractic, the opening text of the advertisement proclaims in large bold letters "IT DOES NOT CONTAIN CYANIDE OR ACID". By the juxtaposition of the picture of a medicine bottle besmirched with the skull and crossbones and the language of the text that follows, the clear import of the advertisement is that medicine is dangerous because it contains cyanide or acid. 2/ The subject advertisement is likely to appeal primarily to a lay person's fears, ignorance or anxieties regarding his state of health or physical well-being. Near the bottom of the subject advertisement are the words "Sunset Chiropractic Clinic." Beneath those words, and in smaller print, are the names of each of the three Respondents. Each name is preceded by the abbreviation "Dr.," but none of the names are followed by the abbreviation "D.C.," or the words "Chiropractor" or "Chiropractic Physician," or by any other designation specifically identifying the Respondents as chiropractors. Thus, the subject advertisement failed to conspicuously identify the Respondents as chiropractors. 3/
Recommendation For all of the reasons set forth above, it is recommended that the Board of Chiropractic Examiners enter a Final Order which would: Find each of the Respondents guilty of all of the violations charged in the Administrative Complaints; Assess a $1,000.00 administrative fine against the Respondent Stephen A. Jacobs, D.C.; Assess a $1,000.00 administrative fine against the Respondent Gary Jacobson, D.C.; and Assess a $1,000.00 administrative fine against the Respondent Steven Paul Rosenberg, D.C. DONE and ORDERED this 29th day of November, 1984, at Tallahassee, Florida. MICHAEL M. PARRISH Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 29th day of November, 1984.
