The Issue Whether the Petitioner is entitled to a medical license in the State of Florida by examination?
Findings Of Fact The Petitioner is a graduate of a foreign medical school. She graduated from the University of Ceylon, Colombo, Sri Lanka. The Petitioner was licensed in Sri Lanka on March 8, 1976. From March 8, 1976, through May, 1979, the Petitioner was employed as a physician at a government hospital located in Galle, Sri Lanka. From May, 1979, until January 24, 1981, the Petitioner was employed as a physician at a government hospital located in Colombo, Sri Lanka. While employed at the government hospitals in Galle and Colombo, Sri Lanka, the Petitioner earned 21 days of vacation time and 24 days of "casual" leave a year. Upon the termination of her employment at the government hospital in Colombo, Sri Lanka, the Petitioner was paid for 21 days of her accrued vacation and casual leave. If the 21 days for which the Petitioner was paid for upon her departure from the government hospital at Colombo, Sri Lanka are counted as time during which the Petitioner worked as a licensed physician, the Petitioner's employment during this period of time would run from March 8, 1976, to February 14, 1981. This is a total of 4 years and 343 days. If the 21 days are not counted, the Petitioner's employment would run from March 8, 1976, to January 24, 1981. This is a total of 4 years and 322 days. On January 24, 1981, the Petitioner traveled from Sri Lanka to the United Kingdom to be with her husband. Therefore, the Petitioner did not practice medicine as a physician after January 23, 1981. The Petitioner remained in the United Kingdom from January 24, 1981, to July 11, 1982. The Petitioner was issued a Certificate of Limited Registration as a Medical Practitioner by the General Medical Council in the United Kingdom which authorized her to practice medicine. The Certificate limited the Petitioner's "employment" as a physician to the following: Any supervised employment in hospitals within the National Health Service excluding employment in casualty or in accident and emergency departments except to give a second opinion with a view to management or to assist a casualty officer in treatment or to administer anesthetics. The Certificate also provided the following "period of limited registration": 9 Oct. 981 to 8 Oct. 1982. In substance the Petitioner's practice as a physician in the United Kingdom was limited only as to where she could work (National Health Service hospitals) and the period during which she could practice (9 Oct. 1981 to 8 Oct. 1982). The requirement that her employment be supervised was consistent with the manner in which all physicians in the hospitals of the National Health Service are treated; "consultants" supervise all other physicians. The exclusion of the Petitioner's employment in casualty or in accident and emergency departments was included on the certificate only because the Petitioner did not choose to pay an additional 15 Pounds Sterling. While in the United Kingdom, the Petitioner worked as a physician from October 1, 1981 until July 10, 1982, a total of 283 days. On July 11, 1982, the Petitioner returned to Sri Lanka to visit with her son and her family before joining her husband in the United States. The Petitioner remained in Sri Lanka from approximately July 11, 1982, until October 30, 1982. In August of 1982 the Petitioner took over the practice of Dr. S. H. M. Kaleel, on 7 intermittent days. Dr. Kaleel's practice consisted of a general-family practice. Dr. Kaleel was in the United Kingdom from September 1, 1982, to October 7, 1982. This was a period of 37 days. During this period the Petitioner operated Dr. Kaleel's office for him. On October 30, 1982, the Petitioner left Sri Lanka to join her husband in the United States. She arrived in New York, New York, on October 31, 1982. The Petitioner and her husband initially lived in Athens, Georgia, where her husband attended the University of Georgia. The Petitioner and her husband subsequently moved to Gainesville, Florida. The Petitioner still resides in Gainesville. The Petitioner has more than 5 years of licensed practice if her employment with the government hospitals in Sri Lanka (March 8, 1976 to February 14, 1981), her employment in the United Kingdom (October 1, 1981 to July 10, 1982), and her employment by Dr. Kaleel (7 days in August, 1982, and from September 1, 1982 to October 7, 1982) are counted. If the period from January 24, 1981 to February 14, 1981, and the Petitioner's employment in the United Kingdom are not counted, the Petitioner still has more than 5 years of licensed practice. If the period from January 24, 1981 to February 14, 1981, the Petitioner's employment in the United Kingdom and her employment by Dr. Kaleel are not counted the Petitioner has less than 5 years of licensed practice. The Petitioner filed an Application for licensure by examination which was received by the Respondent on February 13, 1985 (hereinafter referred to as the "First Application"). In the First Application the Petitioner listed her current address as Gainesville, Florida. On the second page of the First Application, when requested to list "all places of residence since initiation of medical training," the Petitioner failed to list her residence in Athens, Georgia or Gainesville, Florida. The Petitioner also did not indicate that she had been in Sri Lanka from July 11, 1982, until October 30, 1982. Finally, the Petitioner indicated that she had resided in Sri Lanka until February, 1981. In completing this portion of the First Application the Petitioner did not list her residences. Instead, the Petitioner listed places of employment. Her failure to list all of her residences was caused by sloppiness and carelessness. The Petitioner was also requested to list her places of employment on the First Application. In doing so, the Petitioner indicated that she had been employed in Sri Lanka until February of 1981. This was consistent with the position she has taken in this proceeding. The Petitioner also failed to list her employment in Sri Lanka after leaving the United Kingdom in July of 1982. She failed to list this employment because she forgot about this period of employment. The Petitioner also filed a Professional Biodata dated February 9, 1985. Again she indicated that she worked in Sri Lanka until February, 1981, that she left for the United Kingdom in February, 1981, and failed to indicate that she had worked in Sri Lanka during 1982. Two routine certifications of personal knowledge of the Petitioner's practice were filed with the Respondent by a Dr. Yogasakaran and a Dr. de Lanerllore. By letter dated August 23, 1985, the Respondent informed the Petitioner that the affidavits submitted by Drs. Yogasakaran and de Lanerllore contain erroneous information about her Sri Lanka practice. The affidavits refer to her practice being from February 15, 1976 through February 14, 1981. The letter states that the Petitioner had stated in her letter to the Board that she was in the United Kingdom from February through October, 1981. The letter further advises that the practice in the United Kingdom is unacceptable toward the 5 years of licensed practice, because it was under a limited license. In a letter dated October 2, 1985, the Petitioner informed the Respondent for the first time that she had worked as a physician from September 1, 1982 to October 7, 1982, at Dr. Kaleel's clinic. She enclosed affidavits from Drs. Devacaanthan and Yogasarkara indicating that she had practiced as a physician from March 8, 1976, to February 14, 1981 and from September 1, 1982 to October 7, 19.82. She also enclosed a letter from Dr. Kaleel indicating that she had practiced from September 1, 1982 to October 7, 1982. In September, 1986, the Petitioner filed a second application for licensure by examination (hereinafter referred to as the "Second Application") pursuant to Section 458.311, Florida Statutes (1985), seeking a license based upon taking the FLEX examination and completing 5 years of licensed practice. In the Second Application the Petitioner again listed her current residence as Gainesville, Florida. She left off her residence in Athens, Georgia, and Gainesville on the second page of the Second Application, however, and again indicated that she had resided in Sri Lanka until February, 1981. Again the Petitioner listed her places of employment instead of her residence on the Second Application. Her failure to properly list her residences was caused by her sloppiness and carelessness. The Petitioner also listed her places of employment on the Second Application. Although the Petitioner had informed the Respondent about her employment in Sri Lanka during 1982, the Petitioner again failed to list this employment. By Order filed June 19, 1987, the Respondent denied the Petitioner's Second Application. The Petitioner incorrectly answered the question, "[h]ave you ever had to discontinue practice for any reason for a period of one month or longer," on the First and Second Applications. She did so because she was sloppy and careless in completing these Applications. Since at least 1978 the Respondent has interpreted Section 458.311(1)(c), Florida Statutes, to exclude practice by a physician pursuant to a limited or restricted license issued by a foreign jurisdiction for purposes of determining whether a physician has 5 years of licensed practice. Therefore, the Respondent did not accept the period during which the Petitioner practiced in the United Kingdom. The position of the Respondent set out in Finding of Fact 34 has not been adopted as a rule. It has been consistently applied by the Respondent. The Respondent has taken this position because it believes that it is unable to determine what actual restrictions apply to a limited or restricted license issued by a foreign jurisdiction. The evidence in this proceeding proved, however, that the actual restrictions which apply to a limited or restricted license can be determined and are a matter of proof. The Petitioner's testimony concerning the affidavits submitted by various physicians in support of the Petitioner's applications was not credible. The Petitioner testified that the dates of employment included by physicians who submitted affidavits were not provided to those physicians by the Petitioner and that she did not know where they got the dates. This testimony defies logic. Only one of those physicians, Dr. Kaleel, had any personal knowledge of the exact dates that the Petitioner engaged in the licensed practice of medicine. One of the physicians, Dr. Yogasakaran filed one affidavit with dates consistent with those supplied by the Petitioner. When the Respondent questioned those dates, Dr. Yogasakaran submitted a second affidavit with the new dates supplied by the Petitioner. The Petitioner's testimony on other matters was credible and her position that she has completed 5 years of licensed practice was substantiated by other credible evidence.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be issued GRANTING the Petitioner's application for licensure by examination. DONE and ENTERED this 3rd day of February, 1988, in Tallahassee, Florida. LARRY J. SARTIN 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 3rd day of February, 1988. APPENDIX TO RECOMMENDED ORDER, CASE NO. 87-3004 The parties have submitted proposed findings of fact. It has been noted below which proposed findings of fact have been generally accepted and the paragraph number(s) in the Recommended Order where they have been accepted, if any. Those proposed findings of fact which have been rejected and the reason for their rejection have also been noted. The Petitioner's Proposed Findings of Fact Proposed Finding Paragraph Number in Recommended Order of Fact Number of Acceptance or Reason for Rejection 1-9 These proposed findings of fact were stipulated to by the parties. They are hereby accepted. 10 3, 4 and 21. The first sentence is accepted in paragraph 5. The rest of these proposed findings of fact are rejected as irrelevant. 5-8. The Petitioner did not resign from her employment effective February 14, 1981. Although the last sentence is true, it is not relevant to these proceedings. 13 8, 9, 14 and 16-18. 14 18. 15 These proposed findings of fact are summaries of testimony. See 34. The Respondent's Proposed Findings of Fact 1 1 and 22. 2 29. 3 24 and 31. 4 21 and 24. 5 25. 6-7 28. 8-16 and 18 These proposed findings of fact are generally correct. They have been taken into account in weighing all of the evidence in this case. See 26-28. 17 2-4 and 8. 19 9-10 and 13. 20 34. See 34 and 35. Irrelevant. 23 10. 24 1. 25-26 Not supported by the weight of the evidence. 27-28 33. COPIES FURNISHED: Paul Watson Lambert, Esquire Taylor, Brion, Buker & Greene Post Office Box 11189 Tallahassee, Florida 32302 Allen R. Grossman, Esquire Assistant Attorney General Department of Legal Affairs Suite 1601, The Capitol Tallahassee, Florida 32399-1050 Ms. Dorothy Faircloth, Director 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
The Issue Whether Respondent, a licensed physician, committed the offenses set forth in the Administrative Complaint and the penalties, if any, that should be imposed.
Findings Of Fact Petitioner is the agency of the State of Florida charged with regulating the practice of medicine in the State. At all times pertinent to this proceeding, Respondent was licensed as a physician in the State of Florida and practiced in the specialty of ophthalmology. Respondent's license, number ME 0022716, expired while this matter was pending. On May 25, 1993, Petitioner filed an Administrative Complaint against Respondent who thereafter timely requested a formal hearing. The matter was referred to the Division of Administrative Hearings, and this proceeding followed. Shortly after filing the request for hearing Respondent's whereabouts became unknown to Petitioner. Despite diligent search and inquiry, Petitioner was unable to locate Respondent. Notices mailed by the Division of Administrative Hearings to his last known address were returned. Constructive notice of the hearing in this matter was given to Respondent by publication. In May 1991, Respondent worked at Lucy Optical Store in the Little Havana section of Miami, Florida. On May 13, 1991, Augustin Garcia, an investigator employed by Petitioner appeared at Lucy Optical Store in an undercover capacity. Mr. Garcia posed as a patient who complained that he was having difficulty seeing at night and that lights were causing him to have headaches. Mr. Garcia requested an eye examination. After discussing his complaints, Respondent led Mr. Garcia from the waiting room to an examining room. On May 13, 1991, Myriam Garcia Lacayo was working at Lucy Optical Store as Respondent's medical assistant. Ms. Lacayo is not licensed by the Petitioner in any capacity. While Respondent was present in the examining room, Ms. Lacayo performed a refraction test on Mr. Garcia's eyes. Upon completing the refraction test, Ms. Lacayo told Mr. Garcia that he did not need glasses and instructed Mr. Garcia to return within nine months to a year for a follow-up examination. Ms. Lacayo further advised Mr. Garcia that he should wear non- prescription eyeglasses with a light tint for night driving. Mr. Garcia was not told by anyone that he had not been given a complete eye examination. After the examination was completed, Mr. Garcia revealed his true identity and requested the medical records that had been taken, including a prescription that Mr. Garcia had seen Respondent write. Respondent became very upset upon learning Mr. Garcia's true identity and refused to give him the prescription. The manager of Lucy Optical Store gave Mr. Garcia the medical record, consisting of a one page document, that had been generated as a result of his visit. Respondent failed to administer to Mr. Garcia appropriate tests for glaucoma or for cataracts. The standard of care requires that a patient such as Mr. Garcia be evaluated for glaucoma and cataracts when the patient requests a complete eye examination. Failure to perform these tests may falsely reassure the patient that his eyes have been fully examined and found to be healthy. If these tests are not performed, the ophthalmologist should explain to the patient that he had only had a refraction test and not a complete eye examination. Respondent practiced below the standard of care in failing to test Mr. Garcia's eyes for glaucoma and cataracts. Respondent's medical records fail to document any reason why appropriate tests for glaucoma and cataracts were not performed.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Petitioner enter a final order that adopts the findings of facts and conclusions of law contained herein. IT IS FURTHER RECOMMENDED that Petitioner assess an administrative fine in the amount of $5,000.00 against Respondent and require that Respondent demonstrate that he has the present ability to practice medicine with the requisite degree of skill and safety prior to the renewal of his license to practice medicine in the State of Florida. IT IS FURTHER RECOMMENDED that his licensure be placed on probation for a period of two years if it is renewed. DONE AND ENTERED this 3rd day of January, 1995, in Tallahassee, Leon County, Florida. CLAUDE B. ARRINGTON 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 3rd day of January 1995.
The Issue The issue in this case is whether Respondent is guilty, with respect to two patients, of exercising influence within a patient-physician relationship for the purpose of engaging a patient in sexual activity, engaging in sexual misconduct in the practice of medicine, failing to practice medicine with the minimum standard of care by engaging the patients in sexual activity and performing inappropriate thermography, and failing to keep written medical records justifying the course of treatment of the patients. If Respondent is guilty of any of these allegations, another issue is what penalty should be imposed.
Findings Of Fact At all material times, Respondent has been a licensed physician in the State of Florida, holding license number ME 0044547. Respondent is a neurologist, who operates the Headache & Neurology Clinic of S.W. Florida. Patient 1 is D. Q. She was injured in an automobile accident about four years ago. While at the hospital, she learned of Respondent, so she set up an appointment. In her initial office visit on November 3, 1989, Patient 1 was taken to an examination room where she sat on the examination table and gave Respondent a history. She and Respondent were alone in the examination room. Patient 1 complained of pain in her neck, back, shoulders, and left arm, as well as headaches. She explained that she had initially injured her back and neck in an accident in 1988, and had reinjured these areas in a car accident in late October, 1989. While still alone with Respondent in the examination room, Patient 1 removed her shirt at Respondent's request. Still sitting on the table, but now wearing only a bra above the waist, Respondent was not given a gown. Respondent examined Patient 1, touching her left and right shoulder blades, neck, and lower back. He eventually stopped and began writing notes, without telling Patient 1 to put her shirt back on or giving her a gown. Becoming uncomfortable, Patient 1 decided to put on her shirt. At the conclusion of the examination, which lasted about 30-45 minutes, Respondent suggested that Patient 1 wear a cervical collar and heat pad for her neck. He then had Patient 1 return to the receptionist to arrange for a follow- up appointment. Patient 1's next appointment was on November 7, 1989. During this appointment, Respondent performed a thermogram. A thermogram is a heat-sensing device that is designed to detect and photograph areas of pain resulting from conditions not disclosed by x-rays or MRIs. Respondent's thermogram is a contact thermogram, rather than an electronic thermogram. A contact thermogram requires that a portion of the machine touch the patient's body. Again without other persons in the room, Respondent directed Patient 1 to remove all of her clothes from the waist up. He then conducted thermography of her left and right shoulders, both from the front and the back. When he finished, he told her she could get dressed. He recommended that she get an MRI. Patient 1's third and last office visit with Respondent took place on November 10, 1989. When she arrived at the office at the time set for her appointment, it was lunchtime and a sign on the door stated that the office was closed. She entered the office and saw the receptionist, who assured her that Respondent would see her. Patient 1 was shown to an examination room. Respondent entered, saying that he had the results of the thermogram. He again recommended an MRI. He then explained how biofeedback worked and said that he would give her a session that day. The biofeedback device includes sensors attached to the patient's body. The sensors monitor indicators of stress. A video monitor in front of the patient displays the stress output, and the patient learns to regulate her stress by watching the monitor display various biological reactions to various calming strategies. After attaching the sensors to Patient 1, Respondent left the room. Patient 1 became more relaxed as a result of the session, which last about half an hour. When the session concluded, Respondent returned and Patient 1 got up, complaining of knots in her back. Respondent offered Patient 1 a massage, and she agreed. He told her to take off her shirt and climb onto the examination table. As before, no one else was in the room with them and no one gave Patient 1 a gown. As instructed, Patient 1 lay face down on the table. After a few moments, Respondent excused himself to get some lotion to assist in the massage. When he returned, he massaged her back with the lotion and asked her to turn over. After Patient 1 turned over, Respondent unclasped her bra, which fastened in the front. He then started to massage her breasts. Patient 1 pushed him away. Respondent said that she was a "pretty girl," he was a man, and these things sometimes happen. He said he hoped that she could forgive him. Patient 1 evidently did because she continued to lie face up on the table with her breasts exposed. Respondent asked Patient 1 to remove her jeans. After she had done so, while her eyes were closed and the room darkened, Respondent began to massage her feet, working up her legs. Patient 1 felt his warm breath on her thighs and then felt him kiss her inner thigh. But, explaining at the hearing that she knew he was a doctor, she remained lying still on the table. She then felt his finger slide her underpants to the side and penetrate her vagina. Respondent was not wearing gloves. Some discrepancies in Patient 1's story arise at this point. She gave the sheriff's office a statement under oath that her underpants were off and that Respondent said he was checking her vagina for nerve damage. Patient 1 is maintaining a civil action against Respondent for damages arising from the above- described incidents. At this point, Patient 1 terminated the massage and office visit. She jumped off the table, put her clothes back on, and proceeded toward the front door of the office. Finding it locked, she momentarily struggled with the door handle before it opened. Approaching her from behind, Respondent suggested that she and he go for a drink to discuss the incident. She declined, explaining that she was on medication and could not drink alcoholic beverages. Patient 1 did not return to Respondent's office. She instead filed a complaint on November 11, 1989, with the local hospital from which she had gotten Respondent's name. After making her complaint, Patient 1 was called by Respondent, who said that he was in a lot of trouble and hoped that she would tell the medical society that it was all a misunderstanding. He then sent her a plant. Later, Respondent sent Patient 1 an Easter card in April, 1990. The card, quoting a person named Rebecca Shaw, states: AN EASTER WISH FOR SOMEONE WONDERFUL Some people, like flowers, give pleasure just by being. The inside of the card, which bears illustrations of a butterfly and many flowers, states: Remembering you at Easter For the thoughtfulness you've shown, The kindness you have given In a way that's all your own-- Remembering you at Easter And fondly hoping, too, That all the happiness you've brought Will be returned to you. HAVE A BEAUTIFUL EASTER SEASON The card is signed, "B. K. Nair, MD." Respondent did not send Easter cards to all of his patients. Inside the card was a typewritten note on Respondent's office stationery and signed by Respondent in the same way that he signed the card. The note states in its entirety: Hope your neck is better. If I can be any help please do not hesitate to call. I have sent all records to your attorney. The insurance company also wanted your records. We have a therapist in the clinic who is very experienced. I am not doing it myself anymore. I also have an extra nurse who is with me when I examine patients. Nothing is more rewarding to a doctor than good patient doctor relationship. Misunderstandings and miscommunications can occur [a]t times however. Once again I thank you for giving me an opportunity to talk to you to dispel the cloud. Patient 1 had not agreed to discontinue pursuing her complaint against Respondent. When she received the Easter card, she contacted the sheriff's office and asked for them to investigate Respondent. Patient 2 is D. D., who began seeing Respondent in late 1987. She was complaining about problems with her back and neck. These injuries evidently were sustained in connection with an incident at work in which Patient 2 lifted a heavy case of motor oil. In May, 1989, Patient 2 had surgery performed by another physician. The surgery resulted in a lateral incision at the top of her pubic area. On the day she had the staples removed, Patient 2 had a scheduled office visit with Respondent, who was to recheck her neck and back. When Patient 2 arrived at Respondent's office, she was led to an examination room. Respondent entered, and, alone with Patient 2, he raised her blouse to check her back, then lowered her pants and underpants to examine her lower back. Patient 2 was standing during the examination. No one offered Patient 2 a gown. During the course of the examination, Respondent unfastened Patient 2's bra. He then asked her to walk a short distance across the room and get on the examination table. With her shorts down around her knees and confining her steps, Patient 2 made her way to the table with shortened steps. After she lay down on her back on the table, Respondent conducted a breast examination of Patient 2, which he did during each of her monthly office visits. In each case, he never recorded the fact or findings of the breast examination in Patient 2' records. Checking the incision, Respondent's hands went down to Patient 2's pubic area and vagina. She explained that she had just come from a visit to her gynecologist and Respondent should not be checking her vaginal area. Respondent had no gloves on at the time. Respondent answered that he was her doctor, not her lover, and she had nothing to worry about. He continued to touch Patient 2 in a manner she found offensive, so she got up. Dressing, she tried the door, found it locked, opened it, and left the office. Notwithstanding this experience with Respondent, as well as his continual inquiries into her sex life and whether her husband was out of town, Patient 2 continued to see Respondent for several more office visits over several more months, although she also failed to show up for some appointments. Patient 2 also made conflicting statements under oath to the effect that, at first, she did not think anything about the incident and allowed the examination to proceed until Respondent was finished. Patient 2 is also prosecuting a civil action against Respondent for damages arising from the above-described incidents. Respondent sent Patient 2 a bill in November, 1989, for about $3200, which Patient 2 has not paid. After some delay, Patient 2 filed a complaint with Petitioner. Respondent called her to ask why she had done so and told her exactly what to write to Petitioner in order to withdraw the complaint. In April, 1990, Patient 2 received the same Easter card from Respondent that Patient 1 did. The only differences are that Patient 2's card was signed "from your doctor" with Respondent's name and his post office box in Pt. Charlotte. Patient 2's card was also personalized at the top with, "To [D.D.]" and a handwritten note on the bottom, "Hope you are better. If I can be of any help let me know." Enclosed with Patient 2's card was a handwritten note written on a blank prescription form initialled or signed by Respondent. The note reads: Debbi I would appreciate much if you could mail me a copy of note asking them to withdraw the letter of complaint. Thanks.
Recommendation Based on the foregoing, it is hereby RECOMMENDED that the Board of Medicine enter a final order finding Respondent guilty of two separate violations of Section 458.331(1)(j), Florida Statutes, and imposing an administrative fine of $10,000 ($5000 per separate offense), requiring Respondent to refund to Patient 1 and Patient 2 (or the appropriate third-party payors) all fees billed and collected and refrain from attempting to collect any outstanding balances, and concerning Patient 1--suspending Respondent's license for two years; provided, however, the two- year suspension shall be reduced to the longer of six months or the point (but not more than two years) at which Respondent successfully completes such educational and ethical coursework and psychological and psychiatric counseling and treatment as the Board requires and obtains a certificate from a suitable professional that he is safe to return to the practice of medicine. Following the expiration of the suspension, Respondent's license shall be restricted, for such term as the Board requires, so that Respondent must always have an employee present when he examines, diagnoses, treats, or otherwise meets with a female patient. ENTERED on January 10, 1994, 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 January 10, 1994. APPENDIX Rulings on Petitioner's Proposed Findings 1-15: adopted or adopted in substance. 16-24: rejected as unnecessary and subordinate. 25: adopted. 26-28: rejected as subordinate. 29-33: adopted. 34-35: rejected as legal argument. 36-49: adopted or adopted in substance. 50 (first sentence): rejected as unsupported by the appropriate weight of the evidence. 50 (second sentence)-56: adopted or adopted in substance. 57-60: rejected as subordinate. 61-64: adopted or adopted in substance. 65-69: rejected as subordinate and unnecessary. 70-71: adopted. 72-73: rejected as legal argument. 74-79: rejected as recitation of evidence. Rulings on Respondent's Proposed Findings 1 (first and last sentences): adopted or adopted in substance. 1 (remainder): rejected as irrelevant. 2-4: adopted or adopted in substance except that, at Tr-107, "backend" is "back." 5-7: adopted or adopted in substance. 8-11: adopted or adopted in substance. 12-18: rejected as recitation of evidence, subordinate, and irrelevant. 19-24 (first sentence): adopted or adopted in substance. 24 (second sentence): rejected as subordinate. 25-26: rejected as recitation of evidence. 27: adopted or adopted in substance. 28: rejected as subordinate. COPIES FURNISHED: Francesca Plendl, Senior Attorney Department of Business and Professional Regulation 1940 North Monroe Street, Ste. 60 Tallahassee, FL 32399-0792 Michael D. Dutko Bogenschutz & Dutko, P.A. Jefferson Bank Bldg., Ste. 500 600 South Andrews Ave. Ft. Lauderdale, FL 33301 Jack McRay, General Counsel Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Dorothy Faircloth Executive Director Board of Medicine 1940 North Monroe Street Tallahassee, FL 32399-0792
Findings Of Fact At all times pertinent to the allegations contained herein, Respondent was licensed as a naturopath in Florida under license number NA0000530, issued by the State of Florida, and maintained an office for his practice at 7202 East Broadway, Tampa, Florida. The Petitioner, Board of Medicine, is the state agency charged with regulating the practice of naturopathy in Florida. Pursuant to an ongoing investigation, on September 24, 1987, Detective Robert S. DuBose, acting in an undercover capacity in the name of Robert Adams, went to the Respondent's office to try to buy a controlled drug. He was accompanied by several other police officers and Mr. Fierman-Rentas, a DEA agent, all of whom remained outside in a car across the street, attempting to record the transmission from the body brig Mr. DuBose was wearing. On entering the Respondent's office, Mr. DuBose introduced himself to the doctor and told him he had been cut off from his prior source of Valium pills formerly supplied by an unstated friend. When the Respondent asked DuBose why he wanted the Valium, DuBose replied that nothing was wrong with him but that the Valium just made him feel good. Dr. Helland took DuBose's temperature, blood pressure, and pulse rate, stating at the time that he had to have some support for the prescription but that he knew nothing was wrong with DuBose. As a matter of fact, at that time, DuBose was under the care of another physician for a stomach condition not treated by Valium, but did not advise Respondent of this. DuBose's actual condition had no bearing on his relationship with the Respondent. During their conversation, Respondent asked DuBose how long he had been taking Valium and DuBose replied that though he had been taking it for 6 months, he was not sick but just wanted it because of how it made him feel. Respondent indicated he knew DuBose had nothing wrong with him but he had to put something down in his records. As a result, DuBose laughingly stated he was nervous. After filling out a small card on which he wrote some of the information given him by DuBose, Respondent then wrote out a prescription for Robert Adams for 30 tablets of 10 mg Valium for which DuBose paid him $30.00. At no time did Respondent take a proper medical history from DuBose or ask him if he was under the care of another physician. Valium is the commercial brand name of Diazepam, a Schedule IV controlled substance. On October 1, 1987, DuBose returned to Respondent's office, again accompanied by the other officers who waited in cars across the street. DuBose asked for a refill of his prescription and after Respondent asked DuBose what his name was and looked at his patient card, he indicated that DuBose was three days early for a refill. Thirty pills, prescribed for use at the rate of three a day, would not be used up for 10 days. When Respondent pointed this out, DuBose indicated he had given some to his girlfriend. Dr. Helland responded that he didn't care what DuBose did with them, but that he should come for a refill only every 10 days. However, Respondent stated that since he had obviously not explained that fully on the prior visit, he would write another prescription for 30 Valium tablets which he did after giving DuBose a cursory examination. When DuBose asked if an exam would be necessary each visit, Respondent stated that it would. Respondent seemed concerned that DuBose not suffer any side effects from the Valium and counselled him to stop taking them. Nonetheless, he wrote out the prescription which he gave to DuBose upon payment of a $30.00 fee. Again, DuBose indicated no medical support for a prescription for Valium. DuBose went back to Respondent's office on October 27, 1987, this time in the company of Detective Sinclair, also under cover as Donald Simpson, a construction worker. Sinclair waited in the waiting room while DuBose saw Respondent who took his pulse and blood pressure and listened to his heart and lungs. When DuBose asked why they had to go through that each time, Respondent replied that he had to make sure DuBose was all right. After receiving his third prescription for 30 Valium tablets from the Respondent, DuBose asked him if he could see his friend. Respondent asked what was wrong with the friend and DuBose stated he didn't think anything was wrong. Respondent stated then that he'd have to have some reason to prescribe for Sinclair. DuBose then got Sinclair, introduced him to the doctor, and left them alone. Sinclair had a brief introductory conversation with the Respondent during which Respondent asked what he wanted. Sinclair indicated he wanted Percodan, a Schedule II drug, because it made him feel good. Respondent would not prescribe Percodan for Sinclair stating he needed something more to justify any prescription. Respondent asked if Sinclair were nervous or needed something to help him sleep, which Sinclair denied. Respondent then said he had to have some "damned" thing to justify a prescription. Sinclair continued to decline to say more than it made him feel better. Respondent ultimately indicated that Sinclair must be nervous and needed a tranquilizer and Sinclair finally agreed. Respondent then took some personal information from him, took his blood pressure, temperature, and pulse, and listened to his heart and lungs. He then wrote out a prescription for 30 Valium tablets, whereupon Sinclair paid him $30.00 and left. At no time did Respondent take any medical tests or ask if Sinclair was under the care of another physician. When DuBose again went to Respondent's office, on November 19, 1987, he had Detective Stanbro with him posing as his girlfriend. As previously done, Respondent took his blood pressure and did a cursory examination during which DuBose said he felt good. Respondent wrote out a prescription for 30 Valium and DuBose asked if the doctor would prescribe Percodan as well. Respondent refused to do so. DuBose then asked Respondent to see his "girlfriend", introduced her, and left after paying for his own visit and prescription. At no time did DuBose ever indicate to the Respondent he had any ailment. In fact, he always said he felt good. When Respondent indicated he needed some medical justification to prescribe Valium, DuBose told him to put down that he was nervous and could not sleep. Respondent never tried to find a legitimate cause for that condition but instead merely conducted a cursory examination. He never asked if DuBose was under the care of another physician or if he was taking any medication. The first visit lasted about 15 minutes and the others were shorter. It is clear, therefore, that the "examinations" conducted by the Respondent of DuBose and Sinclair were no more than shadow exercises to justify writing a prescription and had no basis in actual medical diagnosis or treatment. When Ms. Stanbro saw the Respondent on November 19, 1987, he immediately saw there was nothing wrong with her and refused to give her a prescription for anything other than aspirin. He denied her request for Percodan and Valium even though he did no examination of any sort. Stanbro was with the doctor for only about a minute and a half. When he turned her down for both drugs, she left. At all times in his relationship with Ms. Stanbro, Respondent acted in a professional manner.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore: RECOMMENDED that Respondent's license as a naturopathic physician in Florida be revoked. RECOMMENDED this 8th day of August, 1988, at Tallahassee, Florida. ARNOLD H. POLLOCK, 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 8th day of August, 1988. APPENDIX TO RECOMMENDED ORDER, CASE NO. 88-1318 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties to this case. For the Petitioner: DPR 1 - 2. Accepted and incorporated in Findings of Fact 1. 3. Accepted and incorporated in Findings of Fact 6. 4 - 8. Accepted and incorporated in Findings of Fact 2-5. 9 -10. Accepted and incorporated in Findings of Fact 7. 11 - 19. Accepted and incorporated in Findings of Fact 8-9. For the Respondent: Dr. Helland 1 - 3. Accepted and incorporated in Findings of Fact 1. 4 - 5. Accepted. 6. Accepted and incorporated in Findings of Fact 6. 7. Accepted. 8 - 12. Accepted and incorporated in Findings of Fact 2-5. 13 - 16. Accepted and incorporated in Findings of Fact 7. 17 - 20. Accepted and incorporated in Findings of Fact 8-9. 21 - 23. Accepted and incorporated in Findings of Fact 10-11. 24. Accepted as a restatement of testimony and not a Finding of Fact. 25 - 26. Accepted and incorporated in Finding of Fact 9. Accepted as a restatement of testimony and not a Finding of Fact. Accepted and incorporated in Finding of Fact 12. Rejected as a comment in the evidence and not a Finding of Fact. COPIES FURNISHED: John R. Alexander, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 John M. Fitzgibbons, Esquire Suite 1550 600 North Florida Avenue Tampa, Florida 33602-4505 Dorothy Faircloth, Executive Director DPR, Board of Medicine 130 North Monroe Street Tallahassee, Florida 32399-0750
The Issue Should Respondent's license to practice podiatric medicine be disciplined for failure to keep required written medical records, for prescribing or dispensing legend drugs other than in the course of his professional podiatric practice, for failing to practice as a reasonably prudent podiatric physician, and for practicing beyond the scope of his license?
Findings Of Fact Petitioner is the state agency charged with regulating the practice of podiatric medicine pursuant to Section 20.43, Florida Statutes, and Chapters 456 and 461, Florida Statutes. Dr. McNally has been licensed without interruption to practice podiatry in the State of Florida since October 22, 1996. He has not been the subject of disciplinary action by the Board of Podiatry. Dr. McNally was licensed as a podiatrist in the State of Florida by the Agency for Health Care Administration (AHCA) in October 1996. He was born on June 19, 1969. Ms. Sara Helen Lowe, a pharmacist, is an inspector for AHCA. She conducted a survey of pharmacies in the vicinity of Destin and Ft. Walton area and discovered that Respondent had written multiple prescriptions for legend drugs which were in the name of Patient B.R. She also determined from her survey that Respondent had prescribed the legend drug Phentermine for six of his patients. A legend drug is a drug for which a prescription is required and includes Schedule II controlled substances under Chapter 893, Florida Statutes. A Schedule II controlled substance is a pharmaceutical which has medical uses and also has a potential for being abused. Mrs. B.R. is the wife of Patient B.R. She was aware that her husband received numerous prescriptions from Dr. McNally for multiple drugs including oxycodone and methadone in 1998 and 1999. Mrs. B.R. was aware that her husband had an open wound on his foot for several years. She was also aware that he suffered chronic and severe pain from this condition. Mrs. B.R. was concerned about the amount of drugs being consumed by Patient B.R. and discussed this matter with Dr. McNally. During this conversation, Dr. McNally told her that, "B.R. was in chronic pain, and that the amount of medication that B.R. took was basically B.R.'s problem." Mrs. B.R. was angry with regard to the amount and type of drugs which were prescribed by Dr. McNally. However, she thought that during this time his foot wound was improving. Mrs. B.R. was aware that Dr. McNally brought drugs to patient B.R.'s hospital room when patient B.R. was hospitalized in November of 1998. Mrs. B.R. was aware that her husband was hospitalized on an emergency basis for an overdose of Tegrital, a drug designed to combat seizures. This drug was not prescribed by Dr. McNally. It was prescribed by another doctor. The pain that patient B.R. suffered caused a hardship in Mrs. B.R.'s home but she preferred that he take the pain medication rather than see him suffer. Patient B.R. lives in Destin with his wife. He is receiving disability payments due to a hip replacement, a knee replacement, and an ulcer on his right foot. In an effort to relieve the pain in B.R.'s foot Respondent prescribed Oxycodone, Endodan, Endocet, Methadone, Roxicet, Roxiprin, Percocet, Oxycontin, Morphine Sulfate Er, MS Contin, Oramorph SR, and Roxicodone. All of these are forms of oxycodone, methadone, or morphine, alone, or in combinations with acetaminophen. Dr. McNally prescribed approximately 8,705 units of oxycodone, 250 units of methadone, and 510 units of morphine for patient B.R. during the eighteen-month period he treated him. These drugs were prescribed to him subsequent to his first visit to Dr. McNally in 1997. All of the foregoing drugs are Schedule II controlled substances pursuant to Chapter 893, Florida Statutes. Patient B.R. obtained prescriptions during office visits and by telephoning Dr. McNally. When B.R. called Dr. McNally the doctor would ask him what drugs he wished to have and B.R. would tell him. Dr. McNally would then provide the prescription to a pharmacy telephonically. On at least one occasion the prescription was left inside the screen door of Dr. McNally's dwelling for Patient B.R. to pick up. Office visits were on some occasions made at the offices of Dr. Haire from which Dr. McNally occasionally practiced. During office visits Dr. McNally would sometimes take B.R.'s temperature. He checked B.R.'s vital signs approximately every six months. Patient B.R. got prescriptions from Dr. McNally when Dr. McNally was on an extended trip to Europe in early 1998 or 1999. While Patient B.R. was a patient in the local hospital, Dr. McNally brought him drugs because the pain medication provided by the hospital was inadequate. Dr. McNally brought the drugs to his hospital room four or five times. He bought these drugs with patient B.R.'s credit cards. Patient B.R. was in the hospital November 9 through 17, 1998. Dr. McNally submitted insurance claims for patient B.R. for a portion of the time he was treating patient B.R. but eventually stopped. Patient B.R. stopped seeing Dr. McNally. Subsequently, a therapist, Sherry Levitis, recommended that patient B.R. attend a pain management center in New Orleans. As a result of his attendence there he experienced a decrease in needle-like pains. The pain management succeeded in getting B.R. to gradually reduce the amount of pain-killing drugs that he was ingesting. Patient B.R. never received any drug rehabilitation. The pain management clinic taught him that he could get by without the aid of drugs. Patient B.R. went to different pharmacies to have his prescriptions filled because he thought they would question the amount if he received too many drugs from the same business. He was advised by Dr. McNally to avoid making frequent visits to the same pharmacy. Patient B.R. never shared the drugs he obtained with others. The use of these drugs changed patient B.R.'s personality and caused domestic difficulties. He became dependent on the drugs. Buying the drugs was a financial strain. At the time of the hearing patient B.R. still was suffering from the ulcer on his right foot. Though he has had surgery on the ulcer three times, it has not healed. Patient B.R. believes his emergency trip to the hospital was the result of his taking Tegrital which is an anti- seizure medicine. He believes he should have coordinated the taking of this medicine with Dr. McNally and that his failure to do so was the cause of the medical event which resulted in emergency hospitalization. The medical doctor who prescribed the Tegrital never asked him if he was taking other medications. Numerous efforts were made by Dr. McNally to address patient B.R.'s foot condition and the resultant pain, including surgery, orthotics, and pain management efforts. The drugs prescribed by Dr. McNally enabled patient B.R. to get off of his couch and live a more normal life. Patient B.R. had better results in addressing his pain and treating his ulcer with Dr. McNally than with any other doctor. At the insistence of Petitioner, Dr. McNally supplied to Petitioner what he claimed to be patient records in the case of B.R. Petitioner believed these records to be phony. Dr. McNally prescribed Phentermine to patients and asserted that he believed it would enhance circulation in the lower extremities. Dr. McNally has been out of the country often and has prescribed drugs for patients in the United States while he was physically located in Italy. Dr. McNally prescribed drugs for patient B.R. while in Europe. He provided patient B.R. with numerous prescriptions for limited amounts because he did not want him to have too many drugs in his possession at once. Dr. McNally, at the time of the hearing, was not accepting new patients but was continuing to treat some old ones. He no longer carries malpractice insurance. Dr. McNally claimed that the medical records in the case of patient B.R., records which he supplied to ACHA at ACHA's request, were prepared by him either at the time of patient B.R.'s visits, a few days after a visit, or several days after a visit. Dr. McNally used the word "analgesic" when preparing records on patient B.R. He did not enter the actual names of the drugs. "Analgesic" could encompass all drugs which relieve pain. Dr. McNally turned to pharmaceuticals in B.R.'s case because he had tried all available alternative treatments without success. Dr. McNally prescribed drugs for the benefit of patient B.R. in the belief that he was doing what was best for his patient. Barry C. Blass, D.P.M., testified. He is an expert in the field of podiatry. Dr. Blass reviewed the evidence with regard to Dr. McNally and his treatment of patient B.R. and with regard to Dr. McNally's prescriptions of Phentermine for six patients. The pain-relieving drugs prescribed by Dr. McNally for B.R. were far in excess of an amount which would be appropriate. The amounts of legend drugs prescribed were about double that permitted by the instructions contained on the container. Dr. Blass reviewed 229 pages of office notes addressing the treatment of patient B.R. which purported to encompass the period January 2, 1998 through September 29, 1999. Almost all of the notes were identical with the exception of the dates. For the notes to be legitimate, patient B.R. would have had to visit Dr. McNally every day during October 1998 and almost everyday on several other months. It is a deficiency for a physician to fail to note on office notes that a patient has been prescribed legend drugs. The standard of care requires a physician to sign office notes. Respondent did not sign his notes. Additionally, the office notes were inconsistent with the hospital records of B.R., in that they indicated treatment in Dr. McNally's office when in fact B.R. was on those dates resident in a hospital. The office notes provided by the Respondent were manufactured, are not authentic, were not prepared at or near a time of an actual office visit, if there was an office visit, and are not, therefore, actual medical records addressing the treatment of patient B.R. It is inappropriate for a physician to bring drugs into a hospital for the use of a hospitalized patient. Phentermine is a diet drug which has no podiatric uses and therefore should not be prescribed by a podiatrist. Phentermine is usually prescribed as a remedy for exogenous obesity. Thomas L. Hicks, M.D., is an expert in the field of medicine. His testimony was provided by deposition. Dr. Hicks reviewed the medical records supplied by Dr. McNally, and provided expert opinions based on that review. It is inappropriate for a podiatrist to prescribe Phentermine. Respondent's prescriptions for Phentermine were unsafe and in excess of the customary dosages recommended by the manufacturer. By writing these prescriptions, Dr. McNally practiced outside of the scope of his license. The amount of Schedule II drugs prescribed for patient B.R. was inappropriate, dangerous, and not justified by the medical records. Dr. McNally wrote the prescriptions for patient B.R. at very frequent intervals which, while peculiar, did not violate the Practice Act. Usually when writing prescriptions for chronic pain a physician prescribes for a longer period of time. Richard D.Roth, D.P.M., testified. He is an expert in the field of podiatric medicine. Dr. Roth reviewed the medical records supplied by Dr. McNally. The prescribing of Phentermine by Dr. McNally was outside of the scope of his license and was potentially dangerous. Dr. McNally's treatment notes were inadequate in that, for example, they do not describe the exact location, size, or depth of an ulcer, among other things. Neither do they describe the types of analgesics prescribed even though massive doses of narcotic analgesics were prescribed. Dr. McNally's records in the case of patient B.R. are grotesquely incomplete. Most of the notes provided by Dr. McNally were canned notes generated by a computer.
Recommendation Based upon the findings of fact and conclusions of law, it is RECOMMENDED: That the Board of Podiatric Medicine enter a final order finding that the Respondent, George C. P. McNally, failed to keep required medical records during the period January 2, 1998 through September 29, 1999, in violation of Section 461.013(1)(l), Florida Statutes; that the Respondent prescribed legend drugs other than in the course of his professional podiatric practice during the period January 1988 through August 1999, in violation of Section 461.013(1)(o), Florida Statutes; that Respondent failed to practice as a reasonably prudent podiatric physician during the period January 2, 1998 through September 29, 1999, in violation of Section 461.013(1)(s), Florida Statutes; and that Respondent practiced beyond the scope of his license during the period January 1988 through August 1999, in violation of Section 461.013(1)(u), Florida Statutes. It is recommended that Respondent's license to practice podiatric medicine be suspended for a period of six months, that he pay a $2,000 fine, and that he pay for the cost of the investigation and prosecution. The cost of investigation and prosecution shall be assessed at the time the matter is presented to the Board of Podiatric medicine. DONE AND ENTERED this 9th day of November, 2000, in Tallahassee, Leon County, Florida HARRY L. HOOPER 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 9th day of November, 2000. COPIES FURNISHED: Wings S. Benton, Esquire Agency for Health Care Administration Post Office Box 14229 Tallahassee, Florida 32317-4229 George C. P. McNally Post Office Box 5585 Destin, Florida 32540 Joe Baker, Jr., Executive Director Board of Podiatric Medicine Department of Health 4052 Bald Cypress Way, Bin C07 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 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.
