Conclusions Having reviewed the Administrative Complaint and Amended Administrative Complaint, and all other matters of record, the Agency for Health Care Administration finds and concludes as follows: 1. The Agency has jurisdiction over the above-named Respondent pursuant to Chapter 408, Part II, Florida Statutes, and the applicable authorizing statutes and administrative code provisions. 2. The Agency issued the attached Administrative Complaint and Election of Rights form to the Respondent. (Ex. 1) The Election of Rights forms advised of the right to an administrative hearing. 3. The parties entered into the attached Settlement Agreement. (Ex. 2) Based upon the foregoing, it is ORDERED: 1. The Settlement Agreement is adopted and incorporated by reference into this Final Order. The parties shall comply with the terms of the Settlement Agreement. 2. The Respondent shall pay the Agency $3,000.00. If full payment has been made, the cancelled check acts as receipt of payment and no further payment is required. If full payment has not been made, payment is due within 30 days of the Final Order. Overdue amounts are subject to statutory interest and may be referred to collections. Any check made payable to the “Agency for Health Care Administration” and containing the AHCA ten-digit case number should be sent to: Office of Finance and Accounting Revenue Management Unit Agency for Health Care Administration 2727 Mahan Drive, MS 14 Tallahassee, FL 32308 Filed March 26, 2015 11:09 AM Division of Administrative Hearings ORDERED at Tallahassee, Florida, on this 2U day of Maca , 2015, aw, Elizdyeth’Dudgk{ Secretary y for H€ Care Administration
Other Judicial Opinions A party who is adversely affected by this Final Order is entitled to judicial review, which shall be instituted by filing one copy of a notice of appeal with the Agency Clerk of AHCA, and a second copy, along with filing fee as prescribed by law, with the District Court of Appeal in the appellate district where the Agency maintains its headquarters or where a party resides. Review of proceedings shall be conducted in accordance with the Florida appellate rules. The Notice of Appeal must be filed within 30 days of rendition of the order to be reviewed. CERTIFICATE OF SERVICE I CERTIFY that a true and correct of this Final Order, was served on the below-named persons by the method designated on this Debit Aer Cc ZL. , 2015. Richard Shoop, Agency Cler Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, Mail Stop #3 Tallahassee, FL 32308-5403 Telephone: (850) 412-3630 Facilities Intake Unit Finance & Accounting (Electronic Mail) Revenue Management Unit (Electronic Mail) David Selby, Assistant General Counsel Louis F. Gerrard, President Office of the General Counsel Grace Manor at Lake Morton, LLC Agency for Health Care Administration c/o Mainstay Financial Services (Electronic Mail) 5578 Commercial Blvd. NW Winter Haven, FL 33880 (U.S. Mail) J. Davis Connor, Esq. Peterson & Myers, P.A. 225 East Lemon Street Lakeland, FL 33802-4628 (U.S. Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION Petitioner, . . CASE NO. 2013013450 vw a 2014002084 GRACE MANOR AT LAKE MORTON, LLC, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint : against the Respondent, Grace Manor at Lake Morton, LLC (“Respondent”), pursuant to Sections 120,569 and 120.87, Fla. Stat. (2013), and alleges: ‘This is an action against an assisted living facility (“ALF”) to impose a $2,000 fine for one State Class Il violation (Count 1) and a $ 1,000 fine for an uncorrected State Class TI violation (Count I). SS “JURISDICTIONAND VENUE ss— 1. The Agency has jurisdiction pursuant to Sections 20.42, 120.60, and Chapters 408, Part II, and 429, Part I, Fla. Stat. (2013). 2, Venue lies pursuant to Florida Administrative Code (“F.A.C.”) Rule 28-106.207. 1 EXHIBIT - 1 a oemec eae rena nipnpintetineccpinat: tty uinepiman menttinie manent pasa pammemnat ety arr sec nmmpematest ean neem at tt CT BE PARTIES 3. The Agency is the regulatory authority responsible for licensure of ALFs and enforcement of all applicable State statutes and rules governing ALFs pursuant to Chapters 408, Part IL, and 429, Part ], Fla, Stat., and Chapter 58A-5, F.A.C., respectively. 4,, Respondent operates a 50 bed ALF at 610 East Lime St, Lakeland, FL 33801, Standard license #5217. 5, Respondent was at all times material hereto.a licensed facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes, COUNT I - $2,000 CLASS I FINE (Case No. 2013013450; State Tag A0030: Resident Care - Rights & Facility Procedures) 6 The Agency re-alleges and incorporates paragraphs 1-5 asif fully set forth herein. 7. The Agency’s surveyor conducted an unannounced complaint investigation (CCR 2013008974) on 8 October, 2013, 8. The surveyor learned this information during the survey: _-a,-Based_on interviews and-a-record-reviews, the facility failed-to ensure that Resident #1,-an-85-—— Sanne year old man, with received appropriate medical care in a timely manner which led to delayed medical care and extreme continual pain. b. Phone interview with Staff ‘A’, a former med tech/caregiver, on 10/9/13 at about 4:40 pm. She stated that the last night that Resident #1 was sent to the hospital, Staff “B’ (another - ‘categiver) and she were working, They did their final rounds. Resident #1 came.out about 10:30 - i 11:30 pm and complained about a burning, like a hot rod was in his eye. She called the resident care coordinator (RCC) and told her what was going on. She asked the RCC if she could give him a i brand name medication for Acetaminophen that he had scheduled for later in the moming. The RCC said Staff “A? wasn't supposed to but she could just this one time. Staff ‘A stated Resident #1 was hurting. She could tell he was in pain by his demeanor, About 11:30 to 12:30 am he started vomiting when he was in the recliner. He. was in the recliner so they could keep an eye on him. She called the RCC again and she said just keep an eye on him and she would deal with him in the morning. The RCC told Staff ‘A’ that she knew the family would be upset if they sent him out because he had done this thing before. At 12:30 to 1:30 am it got worse and his breathing got worse, He was breathing funny. His vitals were going crazy. His blood pressure was 200 and something over 100 and something. His pulse was fast and oxygen saturation was low. His breathing was irregular. She called the RCC again and she said to call the home health company. The guy she spoke to at home health asked why did he need to come and she explained the situation and the vitals. He stated based on Resident #1's vitals he should be sent out to the hospital. She called the RCC again and told her what home health said and the RCC said "no " , to not send him out and she would deal with him in the morning. At 1:30 to 2:30 am he was panic screaming (like yelling). He said now I know what it feels like to die alone. He already had problems:with his left eye and it was white and lie could not see out of it but he.could see out of his tight eye. However, then he complained that he could not see ~ ~ them and they were Fight in front of him. She called the RCC again and she responded again that she - would deal with him in the moming. At 3:30 am he was puking but she could hear it gurgling back in his hings. He was.aspirating. She called the RCC and told her that she was sending this man out even if she had to be written up. He was throwing up and now he‘is aspirating. She stated OK do started to move him onto the stretcher. He couldn't stand. He had a stroke. Emergency medical services (EMS) and the emergency room doctor asked her why the resident was not sent to the hospital earlier, A friend who worked at the facility told her the next day that Resident #1 died at 6:45 am. c Phone interview with Staff ‘B’,a med tech/caregiver, on 10/9/13 at approximately 5:40 “am. She reported that on the night of the incident at 11:00 pm, Resident #1 complained that his eye hurt and he had a bad headache, Staff ‘A’ called the RCC and she said to go ahead and give the brand name medication for Acetaminophen he had scheduled at.some point during the next morning, In an hour he stated it was getting worse. Staff ‘A’ called the RCC and she stated he did this before and to keep an eye on him, They sat with Resident #1 throughout the night in the living room in front. Resident #1 would freak out if he could not see them. He stated he could not see them and they were right in front of his face. He said to please not leave him because he did not want to die alone. Staff ‘A’ called again and finally got permission to call 911 from the RCC about 2:00 to 3:00 am. Paramedics asked if leaning to the side was normal for him and they told them it was not normal. They asked if his face drooping was:normal and they said, "no." They did a stress test and he was weaker on one side. He fell to the'side when they stood him up and stated they thought he had a stroke when they took him out:on a stretcher. Staff ‘B’ stated she felt like Resident #1 should have went out to the hospital the first time Staff ‘“ called the RCC. Resident #1 stated he felt like a hot rod was stabbing through his eye. It was not normal for him to come out of his room and complain d. Interview with the RCC about Resident #1 on 10/8/13 at about 2:15 pm. She stated that Staff ‘A’ called her orice for Resident #1's headache and she asked Staff ‘A’ if he had anything she could give him for pain and Staff ‘A’ said a brand name medication for Acetaminophen. The RCC said, " well give him that." Staff‘A’ called back later and stated he was throwing up and she told Staff‘ A” to send him to the hospital. It started about 1:00 am and she did not know how long in between before Staff ‘A’ called the second time. She stated she did not remember exact times “because it happened almost a year ago. 7 San et ecngioeeanygmeninepe bier see mane nt egress nemsmmn enue on Sibuset einer arsine ' i t ; @. Review of the EMS report dated 4/30/13. It indicated that the stroke alert was called at 3:28 am and Resident #1 arrived at the hospital at 3:43 am. ) f. Review of the hospital Emergency Department Note - Phiysician final report dated 4/30/13. It noted that the physician spoke directly to the staff at the facility and was told that at 11:00 pm or so Resident #1 had severe pain behind his right eye. He walked out to the nursing — station to request help. Resident #1 sat down in a chair near the nutsing station and stayed there for the next few hours. Somewhere between 3:00 and 3:15 am Resident #1 became less responsive and vomited and developed slurred speech. Facility staff did not notice left sided weakness. At the hospital Resident #1 was diagnosed with intracerebral hemorrhage (a type of stroke where an artery bursts in the brain and causes bleeding in the brain). g. Death. The hospital death record indicated that the resident died at 7:25 am on 4/30/13. h. Interview with the RCC on 10/8/13 at about 2:40 pm. Stafflet them know if residents-are sick and then they contact the nurse (a home health nurse because the facility has no nursés) and she comes to evaluate. If the nutse states they need-to go out to hospital then they send them. If it's night time staff call her (the RCC) and then the nurse is called and the nurse still comes to assess. They and the nurse might say to go ahead and send out. i. Interview with the executive director (ED). The ED revealed that Resident #1 's family was adamant about not sending him out to the hospital (not specifically talking about this event, but Previous ones). ; . _ j. Review of the hospital Emergency Department Note ~ Nursing final report dated 4/30/13. It revealed that EMS reported that the family was not thrilled with the idea of the resident being transported to the hospital. cde esate aspen era ety tatoo so tenn tnsennnenntammpanma aea i i 1 i i i i | | | k. Review of the facility's medical emergencies policy. It was located on page 93 and 94 of its Assisted Living Policy and Procedure Manual. Section 1 indicated that the administrator should be. contacted immediately and section 2 indicated that the administrator makes the determination of the severity of the situation. Section 3 indicated that the community summons emergency medical services by calling 911 when the resident exhibits signs and symptoms of distress and /or emergency : condition, One example included was sudden onset of severe pain. Resident #1 had indicated to staff that he felt like a hot rod was stabbing through his eye but medical care was still delayed for hours. 9. Florida’s law regatding residents having the right to a safe and decent living environment free from abuse and neglect is stated as follows: B r : ; i 429.28 Resident bill of rights.— . (1) No resident of a facility shall be deprived of any civil or legal rights, | ‘ benefits, or privileges. guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States.as a resident of a facility. Every resident of a facility shall have the right to: (a) Live ina safe and decent living environment, free from abuse and neglect. Section 429.28, Fla. Stat. (2013) 10. In sum, the facility failed to ensure that Resident #1 was free from neglect, to wit, he did not __ receive timely and appropriate medical care which led to extreme continual pain because he first alerted staff between the 10:30 to 11:30 pm time frame on.4/29/13 that he was in extreme pain but, despite his, e. g., repeated complaints of extreme pain, panic yelling, expressing his fear of dying alone, vomiting, lack of vision, crazy vitals, aspirating, leaning to the side and drooping face, 911 was not notified until about 3:30 atv the next iiditiing, an inappropriate delay of several hours. 11. Respondent was cited fora Class Il violation, defined as follows: 408.813 Administrative fines; violations.—As a penalty for any violation of this part, authorizing statutes, or applicable rules, the agency may impose an administrative fine. (2) Violations of this part, authorizing statutes, or applicable rules shall be _ Classified according to the nature of the violation and the gravity of its probable effect on clients. .» Violations shall be classified:on the written notice as follows: (b) Class “II” violations are those conditions or‘oceurrences related to the operation and maintenance of a provider or to the care of clients which the agency _ determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. The agency shall impose an administrative fine as provided by law for a cited class II violation. A’fine shall be levied notwithstanding the correction of the violation. Section 408.813, Fla, Stat. (2013) 12. Florida-law states as follows as regards the fine for an ALF for a Class II violation: 429.19 Violations; imposition of administrative fines; grounds.— (1) In addition to the requirements of part II of chapter 408, the agency shall impose an administrative fine in the manner provided in chapter 120 for the violation of any provision of this part, part II of chapter 408, and applicable rules by an assisted living facility, for the actions of any person subject to level 2 background screening under s. 408.809, for the actions of any facility employee, or for an intentional or negligent act seriously affecting the health, safety, or welfare of a resident of the facility. (2) Each violation of this part and adopted rules shall be classified ‘according to the nature of the violation and the gravity of its probable efféct on facility residents. The agency shall indicate the classification on the written notice of the violation as follows: {b) Class “II” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class II violation i inan n amount not less than $1,000 and een HOE ENCE $5,000 Lor CAC Via data (3) For purposes of this section, in determining if a penalty is.to be imposed and in fixing the amount of the fine, the agency shall consider the following factors: (a) The gravity of the violation, including the probability that death or serious physical or emotional harm to a resident will result or has resulted, the severity of the action or potential harm, and the extent to which the provisions of the applicable laws or rules were violated. (b) Actions taken by the owner or administrator to correct violations. “~(e) ~~ Any previous violations: d)- The financial benefit to the facility of committing or continuing the violation, (e) The licensed capacity of the facility. Section 429.19, Fla. Stat, (2013) smear mre erin nites teins ingest cnn ee ne ene WHEREFORE, the Agency intends to-impose a $2,000 fine agninst Respondent pursuant to Sections 408.813 and 429, 19, Fla, Stat. (2013). COUNT Il - $1,000 UNCORRECTED CLASS III FINE (Case No. 2014002084; State Tag A0010 — Admissions —-Continued Residency) 13. The Agency re-alleges and incorporates paragraphs | - 5 as if fully set forth herein. fa survey - 11/21/13 (paras 14 —19) 14. A complaint investigation (CCR#2013012071) was conducted on 21 November, 2013. 15. Based upon record review the facility failed to ensure that an interdisciplinary care plan was developed and implemented for Resident #1, an 89 year old female receiving hospice care and services. A 11/21/13 review of her records showed that although she was retained at the facility on | hospice care it failed to develop and implement an interdisciplinary care plan developed by hospice. in coordination with her and/or another responsible party in order to meet her needs. 16. Florida law provides as follows as regards an ALF resident receiving hospice services: 58A-5.0181 Admission Procedures, “Appropriateness “of Placement and Continued Residency Criteria. (4) CONTINUED RESIDENCY. Except as follows in paragtaphs (a) through (e) of this subsection, criteria for continued residency in any licensed facility shall be the same as the criteria for admission. As part of the continued residency criteria, a resident must have a face-to-face medical examination by a licensed health. care provider at least every 3 years after the initial assessment, or after a significant change, whichever comes first. A significant change is defined in Rule 58A-5.0131, F.A.C. The results of the examination must be recorded on AHCA Form 1823, which is incorporated by reference in paragraph (2)(b) of this rule. The form must be completed in accordance with that paragraph. After the effective date of this rule, providers shall have up to 12 months to comply with this requirement. ©) A terminally ill resident who no longer meets the criteria for continued residency may continue to reside in the facility if the following conditions are met: 1. The resident qualifies for, is admitted to, and consents to the services of.a licensed 8 hospice which coordinates and ensures the provision of any additional care and . services that may be needed; 2. Continued residency is agreeable to the resident and the facility; 3, An interdisciplinary care plan is developed and implemented by a licensed hospice in consultation with the facility. Facility staff may provide any nursing service permitted under the facility’s license and total help with the activities of daily living; and : 4. Documentation of the requirements of this paragraph is maintained in the resident's file. Rule 58A-5.0181, F.A.C, | 17. Insum, the facility failed to develop and implement Resident #1’s interdisciplinary plan for hospice care and services. | 18. Petitioner cited Respondent for a Class III violation, defined as follows:. 408.813 Administrative fines; violations.—As a penalty for any violation of this part, authorizing statutes, or applicable rules, the agency may impose an administrative fine. (2) Violations of this part, authorizing statutes, or applicable rules shall be classified according to the nature of the violation and the gravity of its probable effect on clients, ~ .,. Violations shall be classified on the written notice as follows: (c) Class “IIT” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which emotional health, safety, or security of clients, other than class J or class II violations. The agency shall impose an administrative fine as provided in this section for a cited class III violation, A citation for a class TII violation must specify the time within which the violation is required tobe corrected, If a class III violation is corrected within the time specified, a fine may not be imposed, Section 408.813, Fla. Stat. (2013) 19. By letter dated 9 December, 2013, Respondent was notified of a mandatory correction date of 30 days from the letter’s 9 December date, to wit, on or about 9 January, 2014. 2% Survey - 1/31/14 (paras 20 - 25) 20. A revisit survey was conducted on 31 January, 2014, to check on the deficiencies cited during 9 the first survey on 21 November, 2013. 21, a, Based upon record review the facility failed to ensure that an interdisciplinary care plan was developed and implemented for resident #1, an 89 year old female receiving hospice care and services, . b. An 11/21/13 review of Resident #1’s records showed that although she was retained at the facility on hospice care it failed to develop and implement an interdisciplinary care plan with, hospice in coordination with her and/or another responsible party to meet her needs. c. During the revisit survey an interdisciplinary care plan was still not available for her. The facility had a hospice ‘Interdisciplinary Care Plans’ form which was a blank form with the words "Interdiciplinary Care Plans" hand written at the top of the page labeled as a "HHA Plan of Care and Note", The rest of the page corisisted of a check list to indicate the information for all areas pertaining to pain level, mental status, bathing, grooming, dressing, nutrition, activity tolerance and transfer. In sum, the form was empty in content and did not meet the intent of the requirement. d. During a staff interview the surveyor determined that they did not have a good discussion that they were going to develop their own form for this purpose. 22. Insum, the facility failed to correct the prior deficiency by still not having developed and implemented the required interdisciplinary care plan for Resident #1 who was still receiving hospice care and services. 23. Florida law regarding an ALF resident receiving hospice services is cited in paragraph 16. 24. Petitioner cited Respondent for a Class III violation, defined in paragraph 18. 10 25. The'same constitutes an uncorrected Class III violation with the fine determined as follows: WHEREFORE, the Agency intends to impose a $1,000 fine against Respondent, an ALF 429,19 - Violations; imposition of adminisirative fines; grounds.— (1) Inaddition to the requirements of part II of chapter 408, the agency “shall impose an administrative fine in the manner provided:in chapter 120 for the violation of any provision of this part, part II of chapter 408, and applicable rules by an assisted living facility ... - (2) Each violation of this part:and adopted rules shall be classified - according to the nature of the violation and the gravity ofits probable: effect on facility residents. The agency shall indicate the classification on the written notice of the violation as follows: (c) Class “III” violations are defined in s. 408.813. The agency shall impose an administrative fine for a cited class III violation in an amount not less than $500 and not exceeding $1,000 for each violation. Section 429.19, Fla. Stat. (2012) in the State of Florida, pursuant to § 429,19 (2) (c), Fla. Stat. (2013). +k Submitted this @ day of April, 2014. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION 525 Mirror Lake Dr. N., Ste 330 Ph: (727) 552-1942 Fax: -1440 david.selby@ahca.myflorida.com _ By: z Q Edwin D. Selby Assistant General Counsel Fla. Bar No, 262587 41 | | i | 4 Le i j H 4 / L i : i L i f i f St Petersburg, FL 33701 5 i t i * : i i | i
The Issue Whether the Petitioner demonstrated that she was terminated from employment by Respondent as the result of an unlawful employment practice based on her race, or as retaliation for Petitioner’s opposition to a practice which is an unlawful employment practice.
Findings Of Fact Respondent is a provider of health-care services that receives funding from the West Volusia Hospital Authority (WVHA). Respondent operates health clinics in Pierson, DeLand, and Deltona, Florida. Petitioner was employed by Respondent as a Certified Medical Assistant on September 25, 2009. After a period of time in Respondent’s Pierson office, Petitioner was transferred to Respondent’s DeLand office. Petitioner’s duties included those as a referral clerk. In that capacity, Petitioner arranged, scheduled, and coordinated referrals from Respondent’s medical providers to outside physicians and laboratories. Petitioner also performed blood-draws, Pap smears, and related services. Petitioner was frequently behind in her referrals. Petitioner sought assistance with her referrals. Taken in the light most favorable to Petitioner, an employee of Respondent with some apparent supervisory authority denied her requests, and advised other employees that they were not to assist Petitioner in catching up. In October 2010, Petitioner was assigned to Respondent’s newly created Emergency Room Diversion (ERD) program. That assignment caused a change in Petitioner’s shift from the 9:00 a.m. to 5:00 p.m. shift, to the 12:00 p.m. to 8:30 p.m. shift. She was returned to her normal day shift in mid-November. The disruption in her standard shift caused Petitioner to fall further behind in her referrals. To minimize the problem, nurses began to make referrals for their doctors when they had the time. On November 19, 2010, Petitioner called Juanita McNeil, an elected commissioner of the WVHA, to discuss what Petitioner perceived to be sub-standard patient care that, in some cases, related to referrals that were not being timely completed, and for which Petitioner was receiving no assistance. Petitioner asked Ms. McNeil to keep their conversation confidential because she feared that she would be terminated for going outside of the chain of command. Later in the day on November 19, 2010, Petitioner was presented with a separation notice by which she was terminated from employment. The separation notice listed four reasons for her termination. The reasons were “employee not doing job in a timely manner, being rude with patients, being rude with other employees, [and] insubordination (calling the WVHA) instead of talking with appropriate supervisors.” During the hearing, Petitioner admitted that “100% of the reason that I was fired is because of me calling the WVHA.” Upon follow up inquiry, Petitioner reiterated that she was terminated for insubordination in bypassing her supervisors to contact a WVHA commissioner, and that reason formed the basis for her complaint that she had been the subject of discrimination or retaliation. Petitioner knew of no other employee that ever communicated directly with a WVHA commissioner, or that ever escaped disciplinary sanctions for having done so. Thus, there was no comparator upon which to measure whether Petitioner was treated differently under like circumstances as a result of her race. Petitioner’s admission of the basis for her termination is dispositive of this case. Being terminated for insubordination, in the absence of evidence that persons outside of her protected class were treated differently, is not related to Petitioner’s race. Petitioner’s admission demonstrates that her claim is not founded on an unlawful employment practice based on her race, or retaliation for Petitioner’s opposition to a practice which is an unlawful employment practice. Based on Petitioner’s admission, the undersigned concluded that there was no legal basis upon which relief could be ordered under the Florida Civil Rights Act. Thus, the final hearing was adjourned.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Florida Commission on Human Relations issue a final order dismissing Petitioner’s Petition for Relief. DONE AND ENTERED this 10th day of October, 2012, in Tallahassee, Leon County, Florida. S E. GARY EARLY Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 10th day of October, 2012.
The Issue The issues in this case are whether Respondent committed the allegations contained in the Administrative Complaint and, if so, the penalty that should be imposed.
Findings Of Fact The Parties Petitioner Department of Health has regulatory jurisdiction over licensed osteopathic physicians such as Respondent. In particular, Petitioner is authorized to file and prosecute an administrative complaint, as it has done in this instance, when a panel of the Board of Osteopathic Medicine has found probable cause to suspect that the licensee has committed one or more disciplinable offenses. At all times material to this proceeding, Respondent was licensed to practice osteopathic medicine in the State of Florida, having been issued license number OS 10658. Background On February 3, 2012, T.S., a 26-year-old single mother, presented to Respondent's medical office as a new obstetrical patient. At that time, T.S. was carrying her third child. For the next five months, T.S. and Respondent enjoyed what was, by all appearances, a productive and appropriate physician-patient relationship. However, as discussed below, Respondent would transgress the bounds of that relationship during an office visit on the evening of July 11, 2012. First, though, it is necessary to sketch the relevant background. On the morning of July 11, 2012, T.S.——who was then nine months pregnant——appeared at Respondent's office for a routine examination. During the visit, T.S. advised Respondent that she was experiencing substantial cramping and discomfort. In response to these complaints, Respondent performed a pelvic examination and a sonogram, both of which yielded normal results. Later that day, at approximately 4:00 or 4:30 p.m., T.S. telephoned Respondent's office and informed his staff of a new symptom: namely, that significant pain was making it difficult to lift her right arm. Although a member of the staff advised T.S. that she could be seen immediately, logistical constraints made it impossible for her to report to Respondent's office prior to the close of business. Over the course of the next several hours, T.S. communicated with Respondent by phone and text (his cell number was available to all patients) concerning the new symptom and her preference to be seen that evening. Ultimately, Respondent informed T.S., via a text message sent at approximately 6:15 p.m., that she could meet him at his office for an examination. The Misconduct T.S. arrived at the office at 6:30 p.m., whereupon Respondent unlocked the front door and invited T.S. inside. Upon entering the lobby area, which was only partially illuminated, T.S. saw no sign of Respondent's office staff. At that point, Respondent asked T.S. to sign a form that read as follows: I give consent to be seen at Dr. Miller's office, by Dr. Miller, without an assistant present, at my request, in order to have a medically urgent need addressed. The foregoing document, although signed by T.S., is of dubious propriety, as obstetrical treatment without a chaperone present is rarely, if ever, appropriate.3/ This issue is of no moment, however, for most of what occurred next——as established by the credible testimony of T.S. and Petitioner's expert witness——was not a legitimate medical examination but, rather, nonconsensual sexual contact perpetrated under the guise of an examination. Upon the execution of the "consent" document, Respondent directed T.S. to an examination room and informed her that the likely cause of her arm pain was either a clogged milk duct or the positioning of the fetus. Respondent then requested that T.S. disrobe her upper body, at which point he left the room for a few moments. Upon his return, Respondent asked T.S. to recline on the examination table, purportedly so he could examine her right breast to rule out the possibility of a clogged duct. T.S. complied and, for the next 30 to 45 seconds, Respondent squeezed her breast in a manner quite dissimilar to examinations she had undergone in the past. In particular, T.S. thought it peculiar that Respondent "cupped" her entire breast with his hand——as opposed to examining the breast from the outside in with the pads of his fingers.4/ Even more troublingly, Respondent asked T.S., while his hand was still in contact with her breast, whether "it felt good."5/ After removing his hand from T.S.'s breast, Respondent remarked to T.S. that her arm pain was not the result of a clogged milk duct. Respondent further stated that her symptoms would be assuaged upon the baby's delivery, an event which, according to him, could be facilitated by sexual activity. Before proceeding further, it is important to note that T.S.'s symptoms of arm pain arguably warranted, at most, a legitimate breast examination. In other words, there were no symptoms or aspects of T.S.'s history that justified a pelvic examination at that time,6/ particularly since Respondent had performed such a procedure (along with a sonogram) earlier in the day. Nevertheless, Respondent informed T.S. that he "needed" to measure the dilation of her cervix; then, in a disturbing and conspicuous departure from accepted obstetrical practice,7/ Respondent applied lubricant to one of his ungloved hands. Moments later, Respondent inserted two fingers into T.S.'s vagina and, for the next 30 seconds or so, positioned his penetrating hand in such a manner that his thumb was in continuous contact with T.S.'s clitoris——something that would never occur during a proper examination.8/ Tellingly, this was not the only physical contact incongruous with a legitimate pelvic examination, for at one point Respondent used his free hand to pull on one of T.S.'s nipples.9/ By now suspicious of Respondent's conduct, T.S. attempted to maneuver her body toward the head of the examination table. As she did so, Respondent began to remove his fingers from T.S.'s vagina while stating that she "needed to have sex" in order to induce labor. This could be accomplished, Respondent further suggested, by having sex with him, an invitation T.S. sensibly declined.10/ On the heels of this rejection, Respondent told T.S. that the only other means of inducing labor would be to "strip her membranes." Owing perhaps to an urgent desire to give birth——the reader should recall that she was nine months pregnant and in significant discomfort——T.S. acceded to Respondent's suggestion. Respondent then penetrated T.S.'s vagina with his (ungloved) hand for a second time and, prior to the removal of his fingers, repeatedly implored T.S. to engage in sexual intercourse with him.11/ When T.S. refused and tried to move to the other end of the table, Respondent grabbed her by the hips and pulled his midsection into her exposed vaginal area. By virtue of this aggression, T.S. could feel that Respondent's penis, albeit clothed, was erect.12/ Wishing to extricate herself from this situation, T.S. pushed Respondent away, at which point he attempted to "laugh off" his abhorrent behavior. T.S. dressed herself and, a short time later, drove to the home of an acquaintance to seek advice. Later that evening, T.S. made a report of the incident to the appropriate authorities,13/ which ultimately resulted in the filing of the Complaint at issue in this proceeding. Ultimate Factual Determinations It is determined, as a matter of ultimate fact, that Respondent is guilty of violating section 459.015(1)(l), as charged in Count I of the Complaint. It is further determined, as a matter of ultimate fact, that Respondent is guilty of violating section 456.072(1)(v) and, in turn, section 459.015(1)(pp), as alleged in Count II of the complaint.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by the Board of Osteopathic Medicine finding Respondent guilty of Counts I and II of the Administrative Complaint; revoking Respondent's license to practice osteopathic medicine; and imposing a fine of $10,000.00. DONE AND ENTERED this 30th day of July, 2014, in Tallahassee, Leon County, Florida. S EDWARD T. BAUER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 30th day of July, 2014.
The Issue Whether Respondent's license to practice medicine should be revoked, or otherwise disciplined, on the ground that he, as alleged, violated the Medical Practice Act, Section 458.1201(1)(m), Florida Statutes (1978), and Section 458.331(1)(t), Florida Statutes (1979), by engaging in immoral, unprofessional con duct, incompetence, negligence, or willful misconduct, including failure to conform to the prevailing medical practice in the field of psychiatry.
Findings Of Fact Based upon the evidence presented at hearing, the following facts are determined: I. The Doctor Respondent, Michael L. Solloway, M.D. ("SOLLOWAY") is licensed to practice medicine in Florida under License No. 11845, issued by the Board of Medical Examiners. He obtained his medical degree from the University of Miami, interned in the United States Air Force, was honorably discharged, and returned to Miami in 1968 to begin a three-year residency training program at Jackson Memorial Hospital. In 1971, he opened a private office at Suite 720, Dupont Plaza Center, Miami, Florida, and has continuously engaged in the practice of psychiatry at that location since that time. (P.E. 4.) II. The Patient On May 9, 1973, SOLLOWAY began treating, Sandra A. Lerner, a 19-year- old female. She continued receiving long-term dynamic psychotherapy from SOLLOWAY for over three (3) years--until May 16, 1977--the date when the complained-of sexual misconduct allegedly occurred. The only significant interruption of psychotherapy treatment occurred between September 30, 1974, and July 11, 1975, for reasons which are immaterial here. (Testimony of Lerner; P.E. 1, 4.) In 1973, Sandra Lerner was diagnosed by SOLLOWAY as suffering from a personality disorder--known as borderline personality. Her disorder manifested itself in poor impulse control, somatic symptoms (such as severe headaches), difficulty in relating to others and forming personal relationships, occasional hystrionic behavior, including severe rage reactions and depression when thwarted by others, and no-addictive dependence on drugs. Prior to her referral to SOLLOWAY, she had been hospitalized after an overdose of Quaaludes and received psychological testing from Gloria O. Greenberg, Ph.D., a psychologist. These tests indicated that Miss Lerner was an infantile, egocentric, hostile individual--one who had been lonely, withdrawn, and alienated for a long period of time. She had a conflicting relationship with her father which caused her serious sexual problems and an intense fear of male sexuality. Dr. Greenberg predicted that, in psychotheraphy, Miss Lerner could be expected to be childish, demanding, and manipulative. (Testimony of Lerner; P.E. 1, 2, 4.) III. The Psychiatrist-Patient Relationship During the course of her psychotherapy, Miss Lerner was a sick and troubled woman, erratic, unpredictable in behavior, and desperately needing to form and maintain a personal relationship. Her therapy sessions with SOLLOWAY, held once or twice a weak, allowed her to experience complex psychological phenomenon known as "transference". She began to feel sexual fantasies and form a personal attachment toward SOLLOWAY; she idealized him and saw him as a nurturing father figure. "Transference" is frequently experienced in psychotherapy; it can be a valuable therapeutic tool to help patients understand and overcome their illness. In this case, SOLLOWAY was aware that "transference" was taking place during his extended therapy sessions with Miss Lerner. However, instead of maintaining a professional detachment, SOLLOWAY began to experience personal and subjective feelings toward Miss Lerner, a form of "counter-transference". Prior to May 16, 1977--the date of his alleged sexual misconduct with Miss Lerner--SOLLOWAY had twice discussed with Miss Lerner that, if they engaged in dating and a social relationship, their psychotherapeutic, doctor-patient relationship must end. 2/ (Testimony of Lerner, Hamilton, Holzberg; P.E. 4, 9.) IV. Sexual Activity During Therapy On May 16, 1977, at 5:00 or 6:00 p.m., Miss Lerner arrived at SOLLOWAY's office for her regular psychotherapy appointment. She was "high", having just taken one-half a Quaalude capsule. After entering his office, their conversation turned to the nature of their relationship. SOLLOWAY told her that he could be her boyfriend if she understood that he could never again be her doctor. 3/ After acknowledging such, she went to the door and locked it, as instructed by SOLLOWAY. At the time, she sensed what he was going to do, and felt he was testing her; she feared his rejection. He then told her to take her clothes off; after she complied, he did likewise, and both engaged in sexual intercourse. (Testimony of Lerner; P.E. 4, 9.) After that day, Miss Lerner no longer received psychotherapy treatment from SOLLOWAY. They began a stormy social relationship and briefly cohabited from June, 1978, to January, 1979, when SOLLOWAY moved out. His rejection made her hostile, angry, and vindictive. She began a campaign to harass and annoy SOLLOWAY at his home--resulting in the issuance of a temporary injunction to restrain her. Her harassment of SOLLOWAY was consistent with her personality disorder--a disorder with which she continued to be afflicted. (Testimony of Lerner, Hamilton, Holzberg; P.E. 4, R.E. 1, 2.) V. Prescription of Drugs to Sandra Lerner: Inappropriate Medical Practice SOLLOWAY prescribed the following mood altering drugs for Sandra Lerner on the dates and in the amounts indicated: DATE DRUGS NO. OF PILLS 7/5/78 Sopor 7 7/12/78 Sopor 7 9/22/78 Quaalude or 15 Sopor 9/30/78 Quaalude or 7 Sopor 10/17/78 Quaalude or 7 Sopor 11/27/78 Quaalude or 7 Sopor 11/30/78 Quaalude or 3 Sopor 12/23/78 Quaalude or 14 Sopor 12/27/78 Percodan 30 1/2/79 Quaalude or 14 Sopor (Prehearing Stipulation of Respondent, Paragraph V, Testimony of Lerner.) Miss Lerner had a drug abuse history well known to SOLLOWAY, including Seconal and Quaalude overdoses in 1973 and a Quaalude overdose in January, 1977. By prescribing the drugs indicated in paragraph 7, supra, to Miss Lerner, a person known by him to abuse Quaaludes, SOLLOWAY engaged in an inappropriate medical practice; furthermore, the prescriptions of tranquilizers and mood altering drugs on December 27, 1978, and January 2, 1979, were excessive in quantity, irrespective of the patient's ailment which they were intended to remedy. (Testimony of Shellow.) SOLLOWAY prescribed the above drugs to Miss Lerner at a time when she was his close friend, not his patient. Such prescription of drugs to a non- patient does not constitute a deviation from an acceptable standard of medical practice, as long as the prescription is for the benefit of the individual. (Testimony of Lerner, Rose; P.E. 4.) Evidence was offered to show that SOLLOWAY used certain drugs for recreational purposes and that he prescribed drugs to others for such purposes. Such evidence, except insofar as it applies to prescriptions to Miss Lerner, is outside the scope of the DEPARTMENT's charges against him. To the extent the DEPARTMENT asserts that the prescription of drugs to Miss Lerner, as indicated above, was contrary to acceptable medical practice because she subsequently used them for recreational purposes, such assertion is unsupported by persuasive evidence. The only testimony offered to establish such a preposition was that of Miss Lerner; her credibility was impeached by her subjective demeanor, bias, evasiveness, and expressed hostility toward SOLLOWAY. (Testimony of Lerner.) VI. Medical Ethics: Sexual Activity Between Psychiatrist and Patient Prohibited Sexual activity between a psychiatrist and patient is unethical, and proscribed by the Principles of Medical Ethics, with Annotations Especially Applicable to Psychiatry (1978 Edition Revised) . The Annotations, supra, stress the paramount importance of the psychiatrist's duty to avoid gratifying of his own needs by exploiting a patient: This becomes particularly important because of the essentially private, highly personal, and sometimes intensely emotional nature of the relationship established with the psy- chiatrist. Further, the necessary intensity of the therapeutic relationship may tend to acti- vate sexual and other needs and fantasies on the part of both patient and therapist, while weakening the objectivity necessary for control . . . Section I, Paragraph 1 and 2, Principles with Annotations. VII. Investigation and Hearing by South Florida Psychiatric Society At all times material hereto, SOLLOWAY was a member of the South Florida Psychiatric Society, Inc., a district branch of the American Psychiatric Association. Membership in the Society is limited to psychiatrists practicing in the south Florida area. Miss Lerner filed with the Society a complaint charging SOLLOWAY with unethical conduct. On August 14, 1979, the Ethics Committee of the Society met to investigate the complaint and formulate a recommendation. (testimony of Holzberg; P.E. 10.) At the Ethics Committee hearing, SOLLOWAY was charged with violating Section 1, Paragraphs 1 and 2 of the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry by (1) exploiting his patient and gratifying his own needs by engaging in sexual activity with Miss Lerner; and (2) prescribing drugs (Quaalude and Dexedrine) to Miss Lerner for non- therapeutic purposes. Miss Lerner testified, and was aided by Norma Hamilton, M.D., a psychiatrist assigned to assist in presenting her complaint. SOLLOWAY was accorded the right to confront his accuser, was represented by counsel, and was present throughout the hearing. He testified in his own behalf, and answered questions of the Committee members. At the conclusion of the hearing, the Committee unanimously sustained the charge that SOLLOWAY engaged in sexual intercourse with Miss Lerner, his patient, and exploited her to gratify his own needs, it unanimously concluded, therefore, that he was guilty of unethical conduct in violation of Section I, Paragraphs 1 and 2 of the Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry and recommended (by 4-1 vote) that he be suspended from the Society for a period of 12 months. As to the other charge, the Committee concluded that insufficient evidence was presented to support the allegation that SOLLOWAY prescribed drugs for non-therapeutic purposes, and recommended that no action be taken. On August 14, 1979, the Executive Council of the Society considered, and adopted the Committee's recommendations; by letter dated August 24, 1979, the Council recommended to the American Psychiatric Association that SOLLOWAY be suspended from membership for 12 months. That suspension recommendation is still pending, and no final action by the Association has been taken. (Testimony of Holzberg, Hamilton; P.E. 9, 10.) VIII. Termination and Sexual Activity: Breach of Accepted Standard of Care The medical ethic which prohibits sexual activity between a psychiatrist and patient applies only if a psychiatrist-patient relationship exists. The essence of SOLLOWAY's defense is that the psychiatrist-patient relationship between he and Miss Lerner ended, by mutual agreement, during the beginning of the May 16, 1977, therapy session, and prior to any sexual activity: Q. (By Mr. Glass) Dr. Solloway, you indi- cated that, in your opinion, your pro- fessional relationship as a psychiatrist to Sandra Lerner as a patient was ter- minated on May 16 of 1977. In what fashion was it terminated, how was it terminated? A. (Dr. Solloway) I suggested that it be terminated, and she agreed. Q. (Mr. Glass) And in your opinion it was terminated on that date? A. (Dr. Solloway) Absolutely. (Deposition of Michael L. Solloway; Pg. 54, P.E. 4.) Under acceptable psychiatric practice, termination of the psychiatrist-patient relationship--the ending of the psychotherapeutic bond-- requires more than the consent or acquiescence of the patient, or the stopping of formal therapy sessions. In psychotherapy, termination refers to a psychological process which takes place between the doctor and patient. 4/ They work through this transitional process together. It does not occur at any particular moment of time; the manner and length of time required will depend on the circumstances of the case--such as the condition of the patient, and nature of the doctor-patient relationship. When a patient suggests ending the psychotherapeutic relationship, the psychiatrist's task is to be supportive and allow the patient to work through the process. Not infrequently, the desire to end psychotherapy is influenced by the patient's mental or emotional illness. (Testimony of Hamilton, Holzberg, Shellow.) Under the circumstances of this case, the manner in which SOLLOWAY attempted to abruptly terminate his psychiatrist- patient relationship with Miss Lerner deviated from and breached the prevailing and accepted psychiatric standard of care and practice in his community. SOLLOWAY recognized, prior to May 16, that he was losing his objectivity toward Miss Lerner and that he was experiencing subjective feelings toward her. He was reciprocating her "transference" with his own "counter-transference"; nonetheless, instead of working through with his patient an acceptable termination of their relationship, he used her consent to termination as an opportunity to act out his "counter-transference" --by engaging in sexual activity with her. SOLLOWAY has admitted that his attempt to terminate the relationship was ineffective: Dr. Nixon: "I can understand that at the time your judgement was clouded by the counter-trans- ference. As you look back on it do you believe now that treatment can--that a doctor-patient relationship can be terminated where there is such a transference and counter-transference in that fashion?" Dr. Solloway: "No, obviously not. " (Pg. 62, P.E. 9.) (Testimony of Hamilton, Shellow, Holzberg; P.E. 4, 9.) SOLLOWAY's attempted termination of his psychiatrist- patient relationship with Miss Lerner on May 16, 1977, deviated from the accepted standard, and was not effective. By his subsequent acting out of his own counter-transference toward Miss Lerner, he sexually exploited his patient to gratify his own needs. Such conduct by SOLLOWAY was unethical, unprofessional, and deviated from the prevailing and acceptable practice in the field of psychiatry. His actions caused Miss Lerner a lengthy period of anxiety, and it will be difficult for her to reestablish a relationship with another psychiatrist which is necessary for effective treatment. (Testimony of Hamilton, Holzberg, Shellow, Lerner; P.E. 4, 9.)
Conclusions Conclusions: Respondent violated Sections 458.1201 (1)(m), Florida Statutes (1978), 458.331(1) Florida Statutes (1979), by attempting to terminate the psychiatrist-patient re- lationship with a female patient, and then sexually exploiting her for the purpose of gratifying his own needs. Insufficient evidence was presented to establish that his subsequent prescription of drugs to that patient violated the Medical Practice Act. Recommendation: Suspend Respondent's license to practice medicine for a period of one (1) year.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED: That the DEPARTMENT suspend Respondent Michael L. Solloway's license to practice medicine, License No. 11845, for a period of one (1) year. DONE AND ENTERED this 12th day of November, 1980, in Tallahassee, Florida. R. L. CALEEN, JR. Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 FILED with the Clerk of the Division of Administrative Hearings this 12th day of November, 1980.
Findings Of Fact Petitioner is the governmental agency responsible for issuing licenses to practice veterinary medicine. Petitioner is also responsible for regulating the practice of veterinary medicine. Respondent is licensed as a veterinarian pursuant to license number VM 0002578. Respondent practices veterinarian medicine in Orlando, Florida. Kari On May 5, 1993, Respondent performed an ovariohysterectomy on a feline ("Kari"). An ovariohysterectomy is the surgical removal of the uterus and both ovaries, i.e., a "spay." Respondent failed to remove the left ovary from "Kari." During the surgery, Respondent noted that the ovary was not on the gauze where Respondent had placed the right ovary and other incidental material that Respondent removed surgically. 3/ Respondent searched inside and outside the surgical area for about an hour but could not locate the ovary. Respondent noted in the medical record that an ovarian remnant may have been left in the cat. Respondent advised the owner that if the cat went into heat she should bring the cat back for exploratory surgery to attempt to find and remove the remnant. On July 12, 1993, 4/ the owner observed "Kari" in heat and returned the cat to Respondent. Respondent performed exploratory surgery in an attempt to find an ovarian remnant. Respondent spent approximately one hour searching for microscopic tissue that could be the ovarian remnant. He cleaned the ovarian ligaments in the area of the left and right ovaries, searched the peritoneal area, and searched the adjacent organs. Respondent removed some material but did not locate and remove an ovarian remnant. Respondent advised the owner that he did not find a remnant but that he thought he had removed all of the ovary. Respondent instructed the owner to advise him if the cat came back into heat. Respondent did not charge the owner for the second surgery. In August, 1993, the owner advised Respondent that the cat was in heat. The owner was unwilling to have Respondent perform surgery again. Respondent advised the owner to see a surgical specialist at Respondent's expense. On November 18, 1993, the owner took "Kari" to the Kissimmee Animal Hospital. Medical tests established the cat's estrogen level to be 43.4 pg/ml. The normal estrogen level for a spayed cat is below 25 pg/ml. The treating physician at Kissimmee Animal Hospital referred the owner to a specialist for a third surgery. The owner did not want to subject the cat to a third surgery or incur additional veterinary expenses. On February 16, 1994, "Kari" died. The owner had a necropsy performed. The left ovary was still present in the cat. The pathologist who performed the necropsy retrieved the left ovary from the cat. He initially identified the ovary by visual examination and subsequently confirmed his initial identification on histopathology. The histopathology examination revealed that the ovary and oviduct fimbria were normal. The ovary was the original ovary in its original anatomic position. The ovary was attached to the ligaments that attach the ovary to the dorsal abdominal wall and posterior part. The pathologist found no suture on the ligament that attaches the left ovary to the posterior wall of the abdomen. Respondent's treatment of "Kari," including Respondent's failure to remove the left ovary, did not cause the cat to die. The cat died from a massive infection in the abdominal cavity. The cause of infection could not be determined. Based upon the type and severity of the infection, it could not have begun more than two weeks before the cat's death on February 16, 1994. Respondent last treated "Kari" on July 12, 1993. Neither Respondent nor the treating physicians at Kissimmee Animal Hospital detected any infection in the cat. Dudley On September 7, 1994, Robert and Susan Micalizio took their dog ("Dudley") to a veterinarian who diagnosed the dog as having kidney stones. On September 8, 1994, the owners brought Dudley to Respondent for a separate opinion. Respondent confirmed the original diagnosis. Respondent performed a urinary catheterization. The catheterization failed to unblock the dog's urinary tract. On September 9, 1994, Respondent performed a cystotomy and urethrostomy on "Dudley." Respondent made three separate incisions in the dog's bladder to determine if kidney stones were present. Respondent did not take x-rays before performing surgery on the dog. Respondent's failure to take radiographs prior to surgery in order to properly diagnose the problem departed from the standard of care in the community. Respondent found no kidney stones in the dog's bladder or urethra. Respondent discharged the dog. The dog's urinary symptoms persisted after Respondent released the dog on September 9, 1994. The dog's condition worsened. On September 13, 1994, the owners took "Dudley" to an emergency clinic. X-rays disclosed the presence of kidney stones in the dog's urethra and bladder. The emergency clinic diagnosed the dog with kidney failure. On September 16, 1994, "Dudley" underwent a successful cystotomy and urethrostomy at another animal clinic. It was necessary to perform a cystotomy and urethrostomy to remove the kidney stones and successfully treat the dog. Respondent performed the appropriate procedures but failed to locate the kidney stones, extract them, and otherwise treat the dog appropriately. Respondent reimbursed the owners for the costs of his procedures. Respondent paid for the cost of the subsequent surgical procedures required to treat "Dudley." Penalty Respondent was incompetent and negligent in his care of "Kari." Respondent failed to remove all of the left ovary from "Kari" after two surgical attempts to do so. "Kari" went into heat several more times and endured a second surgery as a result of Respondent's incompetence and negligence. Respondent was incompetent and negligent in his care of "Dudley." Respondent failed to take x-rays prior to performing surgery. Although the surgery Respondent performed ultimately proved to be necessary to treat "Dudley," Respondent failed to detect kidney stones at the time Respondent performed surgery and failed to correct the condition causing "Dudley's" problems. As a result, the dog suffered longer and endured additional surgery. The incompetence and negligence committed by Respondent did not involve deceit, fraud, or misconduct. Respondent did not mislead the owners of either animal. Respondent's incompetence and negligence did not result in the death or serious injury of either animal. Respondent made a reasonable effort to locate the ovary he left in "Kari." Respondent either reimbursed or offered to reimburse the owners of each animal for expenses incurred by them as a result of Respondent's incompetence and negligence. Respondent has no history of prior disciplinary action against him. Respondent has performed over 20,000 spay procedures without incident. Veterinarians leave ovaries, or ovarian remnants, in approximately three percent of spayed animals. Respondent readily admits his lack of care in the treatment of "Dudley." 4 Subject Matter Index Petitioner maintains an index of its agency orders. Petitioner's index is not alphabetical, hierarchical, or numbered sequentially. Petitioner's index does not contain indentations below the subject headings or titles which are more specific than the subject heading or title. The index does not contain cross- referenced common and colloquial words as required by Florida Administrative Code Rule 1S-6.008. 5/ Petitioner's index complies with the requirements of Section 120.53(2)(a)3. In lieu of a hierarchical subject matter index, Petitioner maintains an electronic database that allows users, including Respondent, to research and retrieve the full text of agency orders through an ad hoc indexing system prescribed by statute. Petitioner's electronic database contains complete case files related to any final order issued by Petitioner from July 1, 1992, to the present. The files include administrative complaints, settlement agreements, and orders. Any person may access this information between 8:00 a.m. and 5:00 p.m. Monday through Friday, either in person, by mail, or by telephone. Respondent is able to determine those final orders that involve the statutory or rule violations for which Respondent is charged. Respondent's search of Petitioner's index revealed that Petitioner has never suspended or revoked a license for the same or similar charges as those against Respondent. Petitioner has not revoked the licenses of veterinarians for more serious offenses. Petitioner has imposed a reprimand, required direct supervised probation, or mandatory appearances before Petitioner in only two cases in which the veterinarian's treatment of the animal did not result in the death of the animal treated. Both of those cases involved charges more serious than those against Respondent. Petitioner has imposed the sanctions of suspension, direct supervision, and fines in excess of $500 only where a violation of the law has occurred and the veterinarian's treatment resulted in the death of the animal treated. Respondent's treatment did not result in the death of either animal treated by Respondent.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Petitioner enter a Final Order finding Respondent guilty of violating Section 474.214(1)(r), imposing a fine of $499, requiring Respondent to attend 4.9 hours of continuing education courses, and placing Respondent on probation for one year without requiring mandatory appearances in front of Petitioner. The costs of compliance with the final order are the obligation of Respondent. RECOMMENDED this 6th day of August, 1996, in Tallahassee, Florida. DANIEL S. 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 6th day of August, 1996.
The Issue The following are the issues presented: Whether the Division of Administrative Hearings (“DOAH”) has jurisdiction to determine the claim of Petitioners Wal-Mart, Inc. (“Wal-Mart”) and Sedgwick CMS (“Sedgwick”) to relief under section 440.13(8) and (11), Florida Statutes; If DOAH has jurisdiction, whether Petitioners have standing to raise the issue of medical overutilization; If DOAH has jurisdiction and the Petitioners have standing, whether Petitioners are estopped from seeking reimbursement of any monies paid to Intervenors Florida Institute for Neurologic Rehabilitation (“FINR”) and Fruitville Holdings - Oppidan, Inc. (“Oppidan”); If DOAH has jurisdiction and Petitioners have standing and are not estopped, whether Intervenors engaged in overutilization of medical care in their care and treatment of the injured worker, D.F.; Whether Respondent, Department of Financial Services, Division of Workers’ Compensation (the “Department), has the authority to order Intervenors to reimburse Petitioners for payments related to overutilization by Intervenors in the medical care of D.F.; and If the Department has such authority, how much money should Intervenors be ordered to reimburse Petitioners.
Findings Of Fact Based on the oral and documentary evidence adduced at the final hearing, and the entire record in this proceeding, the following Findings of Fact are made: The Department is the state agency responsible for administering the Workers’ Compensation Law, chapter 440, Florida Statutes. Section 440.13 governs the Department’s responsibilities and procedures for overseeing the provision by employers to their employees of “such medically necessary remedial treatment, care, and attendance for such period as the nature of the injury or the process of recovery may require, which is in accordance with established practice parameters and protocols of treatment as provided for in this chapter ” § 440.13(2)(a), Fla. Stat. Petitioner Wal-Mart is an “employer” as that term is defined in section 440.02(16). Petitioner Sedgwick acts as a workers' compensation servicing agent or “third party administrator” (“TPA”) for Wal-Mart and is a workers’ compensation “carrier” as defined in section 440.13(1)(c). D.F. is an “employee” as that term is defined in section 440.02(15). In 2003, during the course of his employment with Wal- Mart in Sarasota, D.F. fell approximately six feet from a ladder to the ground, landing on his left side and striking his head. D.F. was diagnosed with a traumatic brain injury. Through Sedgwick, Wal-Mart accepted the compensability of D.F.'s injuries under the law and began furnishing “medically necessary treatment, care and attendance” to D.F. as required by section 440.13(2). In the immediate aftermath of the accident, D.F. was treated at Sarasota Memorial Hospital, where he was diagnosed with cephalgia (headache), left flank contusion, and cervical strain. He was later seen at First Care in Sarasota with complaints of headache, and by a Dr. Barnea (no first name in the record) with complaints of headaches, dizziness, backaches, trouble with memory, and an inability to taste food. D.F. was also seen by Dr. Hal Pineless, a neurologist at the Neurocare Institute of Central Florida, who diagnosed D.F. with a cerebral concussion with post-concussive syndrome, post-concussive headaches, depression, and anosmia (loss of the sense of smell). In January 2005, D.F. took a handful of pills in what was at least a suicidal gesture, if not a serious attempt to kill himself. He was admitted to the Halifax Medical Center, and a Baker Act2/ proceeding was initiated against him. Although D.F. was found not to meet the criteria for involuntary hospitalization at that point, three months later he was referred by James Hutchens, his attorney, to Dr. Howard Goldman, a psychiatrist, because of the attorney's fear that D.F. would again attempt to harm himself. In February 2007, D.F. was evaluated at FINR, an inpatient neurologic rehabilitation facility in Wauchula. FINR recommended inpatient treatment for D.F. at their facility for an initial period of 30 to 60 days. The cost of the treatment was set at $950 a day. Susan Smith was the Sedgwick claims adjuster assigned to D.F.’s claim. Relying on the expertise of the physicians at FINR, Ms. Smith agreed to the admission and the price. Ms. Smith testified that when she took over the case, there were five physicians treating D.F., including a neurologist, a psychotherapist, a psychiatrist, and a physiatrist. The physicians were all requesting different courses of treatment and were prescribing medications that were in some instances contraindicated with each other. The physicians were not communicating with each other. D.F.’s case was “just a mess.” Ms. Smith stated that FINR seemed to present an opportunity for D.F. to receive all of his treatments in one place, with one physician in charge, in a coordinated fashion. D.F. was admitted to FINR in March 2007. Dr. Jorge J. Villalba, the medical director of FINR, diagnosed D.F.'s medical conditions as post-traumatic headaches, anxiety, and depression. FINR provided monthly reports of D.F.'s progress to Sedgwick. D.F.’s treatment was administered by a team of physicians at FINR and consisted of medical monitoring, occupational therapy, physical therapy, and speech therapy. D.F. was provided vocational rehabilitation in FINR’s computer lab and in the wood shop, where he worked on sanding, staining, and building wood products. In August 2007, D.F. was transferred to Oppidan, an assisted living facility, as a “step down” in treatment from the inpatient FINR facility. Oppidan is affiliated with FINR, which does all of the billing for both entities. Again relying on the expertise of the physicians, Ms. Smith agreed to the transfer and to the $850 per day cost of care at Oppidan. Oppidan provided monthly reports to Sedgwick similar to those provided by FINR. These reports, later characterized as "boilerplate" by the Department’s expert medical advisor, Dr. Matthew Imfeld, showed that D.F. was receiving treatment similar to that which he had received at FINR, i.e., medical monitoring, occupational therapy, physical therapy, speech therapy, and vocational therapy. D.F. remained at Oppidan from August 2007 until August 2011, more than four years after his initial admission to FINR. Ms. Smith testified that she was in constant contact with the treatment facility and persistently inquired as to when D.F. would be ready for release from the facility. Ms. Smith noted a pattern in which D.F. would seem to improve to the point of discharge and then suffer some form of relapse or new symptom that would preclude his discharge. Increased symptoms included complaints of personality changes, anxiety, syncopal episodes accompanied by frequent falls, medication adjustments, emotional withdrawal, suspected Parkinson's syndrome, ringworm, shoulder problems, ringing in the ears, and anhedonia.3/ Petitioners worked with Oppidan’s medical staff to determine conditions for D.F.’s discharge from Oppidan. On January 9, 2009, Petitioner’s then-counsel, Brian Bartley, discussed the situation with Dr. Villalba and Dr. Jeffrey Walden, D.F.’s neuropsychologist. They agreed that D.F.’s needs could potentially be met within an outpatient day program. At Mr. Bartley’s suggestion, Dr. Villalba and Dr. Walden investigated the Adult Daycare program at Manatee Glens, a behavioral health hospital with an outpatient component. Though they rejected Manatee Glens as an appropriate placement, Drs. Villalba and Walden sent Mr. Bartley a letter, dated January 15, 2009, that outlined the components they felt necessary for an acceptable outpatient program: [D.F.] requires comprehensive case management services to oversee his program, assist with making and following-up on appointments, assist in managing his benefits, and coordinate his care. [D.F.] will require oversight of his medications. We feel that a home health nurse or, alternately, a nurse on site at a potential discharge site, would be necessary to provide for this need by packing his medication box with him, assessing him for possible side effects, overseeing a schedule of routine labs, etc. His wife can assist with prompting him at his medication times as necessary during non-program hours, but we do not recommend that she have primary responsibility for managing his medications or medical status. [D.F.] will require reliable transportation to and from his program and ancillary appointments. His wife will not be able to be his sole source of transportation. First, the only licensed and tagged vehicle they own is an old van that has had multiple reliability issues. Second, his wife has her own ongoing medical concerns that may interfere with her capacity to provide reliable transportation even with a working vehicle. [D.F.] requires activities that challenge him to be in the community and addressing his anxiety and panic symptoms. As such, a club-house model day program will be inadequate. He requires a vocational program where he is in a workplace, managing interpersonal relationships, and working on specified tasks. He has thus far been able to manage such assignments only with the assistance of a one-to-one job coach on the site with him and working at his side. As such, job coaching services will be required for all vocational hours. [D.F.] requires community recreational activities to further challenge his capacity to cope and master anxiety-producing situations with less structure than a workplace. His present program addressed this need through one-to-one lunch outings, fishing trips, etc. During these activities, he is encouraged to use the coping strategies developed in his psychotherapy sessions to manage and persevere despite his debilitating anxiety. [D.F.] requires a quiet place to which he can temporarily retreat and regroup between community-based activities. He can become overwhelmed in busy and chaotic environments such as a room with loud music or television playing, a busy game room, or an activity center. He has coping strategies he utilizes when he must be in such environments, but the availability of a place where he can escape such over- stimulation is required to facilitate his participation in his activities. [D.F.] requires continued participation in weekly cognitive-behavioral psychotherapy. He also requires regular contact with a neurologist and a neuropsychiatrist. His current program includes massage therapy as well to address his shoulder and to assist with relaxation skills. He also receives assistance with the management of his personal budget, including development of computer-based budgeting program, planning of future expenses and anticipated income, and development of financial priorities. He will require continued assistance in this area as well. We hope this adequately describes the services we feel will be required to address [D.F.’s] needs in an outpatient environment. Please feel free to contact us with any comments or questions you may have. We will gladly review any proposed discharge site and offer our thoughts regarding the acceptability of such a site to meet his needs. The record indicates that Mr. Bartley suggested at least one more potential discharge site to the medical staff at Oppidan. In a letter dated March 27, 2009, Drs. Villalba and Walden stopped short of rejecting this option outright but did set forth a list of concerns and requests for further information regarding the details of the proposed treatment. The record does not indicate whether Mr. Bartley followed up on these concerns and requests, or whether Petitioners proposed another outpatient program for D.F. By the time of D.F.’s discharge, FINR and Oppidan’s billed charges for his treatment totaled $1,451,301.27. Wal- Mart, through Sedgwick, paid these bills in full without disallowance, adjustment, or reduction. At all times relevant, Ms. Smith relied upon the expertise of the medical staff at FINR and Oppidan’s facilities confirming that the treatment being provided was medically necessary. Ms. Smith also understood that D.F. had been "Baker Acted" and feared that he might harm himself if Oppidan discharged him upon her disallowance of the charges for his treatment. Though they continued paying the charges during D.F.’s stay at Oppidan, Petitioners noted the mounting costs and apparently endless course of treatment. Petitioners referred D.F. to Glenn J. Larrabee, Ph.D., a diplomate in clinical neuropsychology, who examined D.F. on September 28 through 30 and October 5, 2009, and reviewed all of his available medical records. Dr. Larrabee produced a 41-page report, dated November 9, 2009. The report concluded that D.F.’s medical records “suggest that at worst, he suffered a mild traumatic brain injury of an uncomplicated nature, given normal CT Scan the day of injury and multiple subsequent normal CT Scans of the brain.” Dr. Larrabee noted that recovery from such an uncomplicated injury is usually three months at most and that D.F. had no cognitive or emotional complaints in follow-up visits shortly after the injury. It was only a few weeks later that he displayed the symptoms of anosmia. Dr. Larrabee’s examination of D.F. showed “deliberate feigning of odor identification in the left nostril, with significantly worse- than-chance performance, strongly supporting the feigning of anosmia.” Dr. Larrabee further noted evidence of normal neuropsychological test performance in D.F.’s initial neuropsychological evaluation with a Dr. Frank in early 2004, in a second neurological evaluation conducted by a Dr. Bosco in 2007, and in Dr. Larrabee’s own current examination. These results “strongly contradict the presence of any persistent deficit from his original mild traumatic brain injury.” In each of these tests, Dr. Larrabee also noted “evidence of invalid test performance with failure of symptom validity tests and measures of response bias,” a further indication that D.F. was deliberately feigning responses. Dr. Larrabee wrote that “[o]ther health care professionals have noted a motivational basis or non-neurologic basis to symptomatic complaint.” Dr. Salter in 2005 included “factitious disorder” as one of his diagnoses, and Dr. Tatum noted that D.F. displayed seizures without any indication of actual epilepsy. Dr. Larrabee concluded that, while there was “compelling evidence of malingering” on the neuropsychological examinations, other professionals have noted “significant personality disorder features” that could lead one to be dependent on the inpatient hospitalization setting. Dr. Larrabee found that there could be “a mix of intentional (i.e., malingering) and unintentional (psychiatric) factors” in the case of D.F. He recommended a one-month stay in a psychiatric facility for evaluation and treatment. Without such hospitalization, it could not be determined whether D.F. had a legitimate psychiatric disorder or whether such disorder was a consequence of his workplace injury. At about the same time as the referral to Dr. Larrabee, Petitioners began to explore legal channels to procure D.F.’s discharge from Oppidan. Petitioners sent the case file to an attorney, Edward Louis Stern, who testified at the final hearing. Mr. Stern testified that he met with D.F.'s attorney for the purpose of obtaining his cooperation in having D.F. discharged. Mr. Stern provided D.F.'s attorney with a copy of Dr. Larrabee’s report. Mr. Stern stated that D.F.'s attorney agreed in principle to the discharge of D.F. but wanted to identify the parameters that would be allowed by FINR/Oppidan for his safe release. To this end, a meeting was set up for June 3, 2010, that included the program director at FINR, the treating neuropsychologist, a vocational consultant, D.F., D.F.'s spouse, and D.F.'s attorney. Mr. Stern reported that no one at the meeting was willing to definitively identify the parameters of D.F.'s discharge. Mr. Stern left the meeting with the definite impression that D.F.’s attorney would not agree to D.F.’s discharge. He also believed that no one at the facility would be willing to identify parameters for discharge. Therefore, Mr. Stern and his clients decided to initiate formal overutilization proceedings based on peer review, pursuant to section 440.13(6). Mr. Stern noted that peer review requires two or more "physicians" to make an evaluation of the care in question. Petitioners had in hand only the opinion of Dr. Larrabee, a neuropsychologist whose non-physician opinion would not be admissible before a Judge of Compensation Claims. After some negotiation, D.F.’s attorney agreed to an examination by a psychiatrist. On September 3, 2010, Dr. R.J. Mignone, a board- certified psychiatrist practicing in Sarasota, evaluated D.F. at Petitioners' request. Dr. Mignone’s 35-page report included a detailed narrative of D.F.’s treatment history, Dr. Mignone’s examination, and his impressions and recommendations. In brief answers to a series of questions propounded by Petitioners, Dr. Mignone concluded that D.F.'s industrial accident was not "the major contributing cause" for the psychiatric care he had been receiving at FINR/Oppidan. Dr. Mignone found no DSM-IV Axis I psychiatric injury to D.F. and concluded that D.F.’s treatment at FINR/Oppidan was actually "psychiatrically contraindicated." Dr. Mignone concluded that it would be appropriate to discharge D.F. from Oppidan with the understanding that some regression should be expected once his “Axis II characteropathy” ceased to be reinforced by the inpatient setting. Dr. Mignone believed that D.F.'s medical professionals had been guilty of "walking on eggshells" in their treatment of him and that D.F.'s "acting out" behavior had been a major factor in FINR/Oppidan's program design. Dr. Mignone concluded that because D.F.’s condition was unrelated to his work injury, all of the treatment he had received at FINR and Oppidan constituted overutilization. After a great deal more legal jockeying, a second peer review was performed by Dr. Thomas Goldschmidt on January 7, 2011. Dr. Goldschmidt is a specialist in neurology and psychiatry, and was specifically recommended by Dr. Mignone to perform an examination of D.F. However, because D.F.’s attorney declined to allow the examination, Dr. Goldschmidt’s opinion was based on his review of the medical record and Dr. Mignone’s evaluation. He summarized his findings as follows: The claimant experienced MTBI [mild traumatic brain injury] on May 9, 2003. He reported loss of consciousness for seconds and was able to drive himself home afterwards. Serial evaluations over time have chronicled multiple normal CT brain scans, normal forty-eight hour EEG monitoring suggesting PNES [psychogenic nonepileptic seizures, i.e., seizures with a psychological cause], symptom exaggeration/malingering on neuropsychological testing, pertinacious somatic preoccupation with trait characterological disturbance consistent with passive-dependent underpinnings, and counter-therapeutic institutionalization at OPPIDAN. As such, the claimant’s clinical course has iatrogenically served to enhance his misguided perception of being “brain injured” in pursuit of satisfying his formidable but chronically frustrated dependency needs. Furthermore, his clinical course is atypical for MTBI and cannot be objectivity [sic] reconciled with the neuropsychological or clinical data provided for my review. From a non-organic perspective, the claimant has parlayed his seven year old MTBI into a state of invalidism largely facilitated by OPPIDAN. In effect, his illness-behavior has been iatrogenically perpetuated by reinforcing the notion of “brain injury” and treatment of psychogenic-mediated symptomatology unrelated to his 2003 work injury. Negotiations continued and a private mediation resulted in a negotiated settlement between Petitioners and D.F. The parties agreed that Petitioners would no longer be responsible for workers’ compensation benefits as of the date the agreement was signed, though D.F. would continue to receive payments for lost wages and supplemental benefits. It was agreed that Petitioners would cease making payments to FINR/Oppidan on August 30, 2011, the date that D.F.’s residency would discontinue. In light of Petitioners’ suspicions regarding D.F.’s possible malingering, it is reasonable to ask why they never disallowed or adjusted any of the bills generated by FINR/Oppidan’s treatment of D.F. Mr. Stern testified that Petitioners did not unilaterally disallow payment out of fear that FINR/Oppidan might retaliate against D.F. by immediately discharging him, thereby risking another suicide attempt and possible tort liability for Petitioners.4/ Petitioners also feared that unilateral disallowance of payments could negatively affect their ongoing negotiations with D.F.’s counsel regarding voluntary discharge from Oppidan. On January 28, 2011, Petitioners filed the Reimbursement Petition with the Department, naming FINR and Oppidan as respondents and expressly disclaiming any direct reimbursement dispute with D.F. The Reimbursement Petition recited the history of D.F.’s treatment. It did not name a specific instance of overutilization; rather, it stated that all of D.F.’s treatment by FINR and Oppidan constituted overutilization. The Reimbursement Petition requested that the Department, “in accordance with Section 440.13(6), Florida Statutes . . . disallow the payment of services previously paid by the Petitioner[s] and reimburse Petitioners all sums paid.” The Reimbursement Petition also requested the return of payments made by Petitioners in accordance with section 440.13(11)(a).5/ Attached to the Reimbursement Petition was a copy of DFS Form 3160-0023, entitled “Petition for Resolution of Reimbursement Dispute,” executed by Wal-Mart and Sedgwick. Just below the title of DFS Form 3160-0023 is the following statement: “A Petition for Resolution of Reimbursement Dispute must be served on the Agency within 30 days after the Petitioner’s receipt of a notice of disallowance or adjustment of payment, pursuant to 69L-31.008, Florida Administrative Code.” Section 440.13(7)(a) likewise provides, in relevant part: Any health care provider, carrier, or employer who elects to contest the disallowance or adjustment of payment by a carrier under subsection (6) must, within 30 days after receipt of notice of disallowance or adjustment of payment, petition the department to resolve the dispute. The petitioner must serve a copy of the petition on the carrier and on all affected parties by certified mail. The petition must be accompanied by all documents and records that support the allegations contained in the petition. Failure of a petitioner to submit such documentation to the department results in dismissal of the petition. FINR and Oppidan filed a Motion to Dismiss the Reimbursement Petition arguing that jurisdiction for a reimbursement review can be invoked only where a medical bill has been disallowed or adjusted for payment. They further argued that Petitioners could not invoke the Department’s jurisdiction to conduct a mandatory utilization review under section 440.13(6) because of that subsection’s provision that if a carrier finds that overutilization of medical services has occurred, the carrier “must disallow or adjust payment for such services.” FINR/Oppidan argued that the dispute mechanism afforded a carrier under section 440.13 is limited to disallowing or adjusting a payment, which triggers the filing of a petition by the health care provider and a response from the carrier. Given that the Sedgwick did not disallow or adjust any payments, the Reimbursement Petition should be dismissed. As a result of the Reimbursement Petition, the Department initiated an investigation of FINR/Oppidan and of Dr. Villalba individually as medical director of FINR/Oppidan pursuant to section 440.13(11). Eric Lloyd, who at the time was program administrator of the office of medical services in the Division of Workers’ Compensation, testified that the Department did not then have a formalized method for reporting provider violations and that the language of 440.13(7) makes it clear that only a health care provider may pursue a petition for resolution of a reimbursement dispute. Mr. Lloyd stated that the Department therefore treated the Reimbursement Petition as a report of provider violation and converted the matter into a review under section 440.13(11). Delays in the resolution of the audit were caused by the need to advertise for and contract the services of an Expert Medical Advisor (“EMA”) pursuant to section 440.13(9). The Department’s initial contracting efforts were futile. Two contracted EMAs disqualified themselves for conflicts of interest. The Department finally engaged the services of a certified EMA, Dr. Imfeld, a specialist in the field of physical medicine and rehabilitation. Dr. Imfeld reviewed D.F.'s medical records from FINR/Oppidan, as well as the reports from the various doctors that were provided to the Department by the parties. Petitioners provided documents pursuant to a “Health Care Provider Violation Referral Document Request” issued by the Department on March 31, 2011, and a “Health Care Provider Violation Referral Document Request Addendum” issued by the Department on April 4, 2011. Both documents required the carrier to submit various forms of documentation. The Department’s initial document request states that the Reimbursement Petition alleged “that services rendered by Dr. Jorge Villalba, M.D. (hereinafter “Provider”), for the treatment rendered to the above referenced injured employee while an inpatient at FINR/OPPIDAN was in excess of established practice parameters and protocols of treatment established in Chapter 440, Florida Statutes.” In fact, the Reimbursement Petition made its allegations against FINR and Oppidan as institutions. Dr. Villalba was not mentioned by name in the Reimbursement Petition. The only reference to him was a statement that “[b]oth entities seemingly have the same medical director or attending physician.” Pamela Macon, bureau chief of the bureau of monitoring and audit in the Division of Workers’ Compensation, conceded at the hearing that it was her office that decided to include Dr. Villalba in the investigation because he was the medical director of the facilities. The language of the document requests plainly reflects an attempt to impute to Petitioners the Department’s own decision at the outset of the investigation to focus on Dr. Villalba individually. The end result of the investigation was that charges were brought against Dr. Villalba, but not against FINR or Oppidan as institutions. As explained more fully below, the case against Dr. Villalba was settled. No case was ever brought against the institutions. The following colloquy at the hearing is between Ms. Macon and counsel for Petitioners: Q. And as I understand it, you added Dr. Villalba to the case because he would have been, as the medical director, responsible for any medical care that was provided within the facility and he then should be responsible? A. Yes. Q. That’s why you added him? A. Correct. Q. But then you changed your mind and determined that he wasn’t involved with it at all, so you weren’t going to give – you weren’t going to penalize him? A. Right, that he didn’t render the direct care. Q. Okay. Did you ever make a determination who did the direct care? A. Not to my knowledge, no. Mr. Lloyd testified as to a policy dispute within the agency as to whether a “health care provider” violation may be brought only against individual health care providers or whether a facility can also be found in violation and sanctioned. He acknowledged that the statutory term “health care provider” explicitly includes health care facilities, but cited the difficulty involved in disciplining a facility such as FINR, which treats multiple injured workers. If the Department bars an entire facility, it would affect not just the individual injured worker whose treatment is in question but any others the facility is treating now or in the future.6/ In his report, dated August 12, 2013, Dr. Imfeld concluded that while D.F.'s 2003 accident resulted in a mild traumatic brain injury, it did not cause a seizure disorder or Parkinson's disease. He further concluded that all of the inpatient treatment from FINR/Oppidan was excessive and not medically necessary. On September 23, 2013, the Department entered its “Report of Health Care Provider Investigation and Notice of Intent to Impose Penalties Pursuant to §440.13, F.S.”7/ The Notice of Intent was directed to Dr. Villalba individually and stated as follows, in relevant part: The record in this matter, corroborated by the EMA opinion, evidences certain care that was neither medically necessary nor clinically appropriate for D.F.'s compensable condition. Accordingly, the Department finds that because of your role at FINR and OPPIDAN, you have directly or indirectly engaged in a pattern or practice of overutilization or a violation of Chapter 440, Florida Statutes, in the treatment rendered to D.F. Dr. Villalba filed a Petition for Formal Administrative Hearing on October 7, 2013, in response to the Notice of Intent. The Department and Dr. Villalba agreed to hold the case in abeyance rather than forward it to DOAH. The case was ultimately settled, the parties entering into a Settlement Stipulation for Consent Order on May 13, 2014. The settlement provided that the Department would withdraw and dismiss its Notice of Intent and that Dr. Villalba would withdraw and dismiss his petition for an administrative hearing with prejudice. Mr. Lloyd testified that after the Notice of Intent was filed against Dr. Villalba, the Department received a Recommended Order from an Administrative Law Judge in another DOAH case in which the Department had issued a Notice of Intent against an individual physician for overutilization. The Recommended Order was “pretty critical of the Department and the process that was involved,” and the Department felt obliged to enter a settlement for attorney’s fees. Mr. Lloyd testified that the Department believed Dr. Villalba’s case had “the same shortcomings” as that earlier case. Mr. Lloyd stated that this belief played a large role in the decision to settle with Dr. Villalba in lieu of trying to prove a difficult case of overutilization in a formal proceeding. Wal-Mart and Sedgwick were given no notice of the settlement negotiations or the entry of the Settlement Stipulation for Consent Order between the Department and Dr. Villalba. Mr. Lloyd testified that there is no statutory obligation for the Department to apprise the complainant of the status of the Department’s investigations. On March 23, 2015, the Department issued an order titled “Workers’ Compensation Medical Services Reimbursement Dispute Dismissal” that purported to dispose of the Reimbursement Petition filed by Wal-Mart and Sedgwick on January 28, 2011. The order provided as follows, in relevant part: There is no information to suggest that Wal- Mart, Inc. or Sedgwick CMS discontinued authorization for treatment and care for [D.F.] by the Respondent herein during the specified dates of service. * * * The issues raised by Wal-Mart, Inc. and Sedgwick CMS are utilization review issues, not appropriate for resolution in reimbursement dispute resolution proceedings under section 440.13(7), Florida Statutes. The utilization issues were resolved by the Department in its MSS Case No. ROV00039 and Department Case No. 143376 [i.e., the case against Dr. Villalba that was dismissed via Consent Order]. Therefore, this Petition for Resolution of Reimbursement Dispute in MMS Case No. 20110531-001 is hereby DISMISSED.
Recommendation Based on the foregoing, it is, therefore, RECOMMENDED that the Department of Financial Services, Division of Workers’ Compensation, issue a final order dismissing the Petition for Formal Administrative Hearing. DONE AND ENTERED this 19th day of February, 2016, in Tallahassee, Leon County, Florida. S LAWRENCE P. STEVENSON Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 19th day of February, 2016.
The Issue The issues for consideration are those allegations set forth in an Administrative Complaint brought by the State of Florida Department of Professional Regulation (Department), in which the Respondent, Scarlett Jones, R.N., is accused of various violations of Chapter 464, Florida Statutes. Through Count One it is said that the Respondent transcribed an order for Heparin to be administered to the patient K.W. as 15,000 units when the physician's order quoted the dosage as 5,000 units, and that the patient was given two dosages at 15,000 units as opposed to the required 5,000 units. In an additional accusation against the Respondent, related to patient care, Respondent is said to have failed to indicate in the patient K.W.'s nursing notes, on or about May 16, 1988, that an administration of Aminophylline was to be restarted during the 11:00 p.m. to 7:00 a.m. shift. Further, it is alleged that this substance was not restarted until 8:00 a.m. on the next day as discovered by a subsequent shift employee. As a consequence, Respondent is said to have violated Section 464.018(1) (f), Florida Statutes, related to alleged unprofessional conduct. Count Two to the Administrative Complaint alleges that on or about June 4, 1988, the Respondent who was assigned to care for the patient E.J., was told by a co-worker that the patient had fallen out of bed and soiled himself and that the Respondent failed to respond to the patient's needs after repeated requests. Eventually, it is alleged that the patient's wife assisted him back to bed and the co-worker took care of the patient's hygiene. As a consequence, Respondent is said to have violated Section 464.018(1)(f), Florida Statutes, related to unprofessional conduct and that she violated Section 464.018(1)(j), Florida Statutes, for knowingly violating a rule or order of the Board of Nursing. Finally, the third count of the Administrative Complaint alleges that the Respondent, on or about June 14, 1988, was found asleep while on duty in violation of Section 464.018(1)(f), Florida Statutes, an act of unprofessional conduct, including, but not limited to, the failure to conform to minimum standards of acceptable and prevailing nursing practice. For these alleged violations, the Department seeks to impose disciplinary action which could include revocation or suspension, the imposition of an administrative fine and/or other relief which the Board of Nursing might deem appropriate.
Findings Of Fact During the relevant periods under consideration in this Administrative Complaint the Respondent was licensed by the Department as a registered nurse and subject to the jurisdiction of the Board of Nursing in disciplinary matters. The license number was 1702172. On April 11, 1988, Respondent took employment with Gadsden Memorial Hospital in Gadsden County, Florida, in a position of charge nurse on the Medical-Surgical Pediatrics Unit, also known as "Med-Surg. Ped." That unit provides short term acute care for post-operative patients, acute medical patients, and acute pediatric patients, some of which require 24-hour observation. Response to the needs of the patients is given by three nursing shifts in each day which begins with shifts of 7:00 a.m. to 3:00 p.m., followed by the 3:00 p.m. to 11:00 p.m. and then 11:00 p.m. to 7:00 a.m. on the following morning. Upon hiring, Respondent was assigned to the work the 11:00 p.m. to 7:00 a.m. and was the only registered nurse on duty during that shift. Among the responsibilities of the charge nurse at the time under examination here, was the assessment of patients on the unit as well as an awareness of the abilities of those other employees who were working in this shift. This was in an effort to provide direct supervision of critical care patients and included supervision of activities performed by a Nurse Technician. Respondent was more directly responsible for critical patients. Other duties included making frequent rounds and checking vital signs in an attempt to insure that the patients were stable. Respondent as charge nurse on "Med-Surg. Ped." could not leave the floor without notification of the house supervisor, another registered nurse. This person would replace the Respondent on those occasions where the Respondent would need to vacate the floor. In addition it was expected that the Respondent would notify those personnel who were working with her on the unit, where she intended to go and how long she would be gone. Before departing it was expected that the Respondent would check the stability of patients. physician's Orders were written on March 2D, 1988, in anticipation of the admission of patient K.W. to Gadsden Memorial Hospital to "Med. Surg Ped." The admission was under orders by Dr. Halpren. Among those orders was the prescription of Heparin, 5,000 units, subcutaneously every 12 hours. The Physician's Orders in terms of legibility are not immediately discernible but can be read with a relatively careful observation of the physician's orders. A copy of those may be found at Petitioner's Exhibit No. 5 admitted into evidence. The problem that tends to arise is that on the line which immediately follows the orders related to Heparin 5,000 units, is found the word hysterectomy written in such a fashion that the initial portion of the letter "H" might be seen as being placed on the prior line giving the unit dosage of the Heparin the appearance of being 15,000 units as opposed to 5,000 units. On April 11, 1988, K.W. was admitted to Gadsden Memorial Hospital as anticipated. At the time of admission the Physician's Orders previously described were provided. Surgery was scheduled and the patient file was made on "Med-Surg. Ped." Under the practices within this hospital, the ward clerk was responsible for transcribing physician's orders onto the patient's Medication Administration Record. This was done here by the ward clerk, S. Diggs. This is to be checked for accuracy by the charge nurse, to include Respondent, with the fixing of the signature to this Medication Administration Record verifying the accuracy of the clerk's entries. Respondent initialed the Medication Administration Record for the patient designating that Heparin in the amount of 15,000 units Q-12, meaning to be given every 12 hours was the requirement, and had been administered in that dosage. This may be seen in a copy of the Medication Administration Record which is part of Petitioner's Exhibit No. The patient was to undergo extensive abdominal surgery, to include the possibility of a hysterectomy and the incorrect administration of Heparin might promote problems with bleeding. The incorrect amount of Heparin as a 15,000 unit dosage was given to K.W. on two occasions. Another patient who was admitted to the ward which Respondent was responsible for as charge nurse was the patient A.W. Physician's Orders were written for that patient by Dr. Woodward on May 16, 1988. A copy of the Physician's Orders may be found at Petitioner's Exhibit No. 6 admitted into evidence. Among the substances prescribed was Aminophylline drip 20 milligrams per hour I.V. This patient had been admitted to the pediatric unit with a diagnosis of asthma and prescribed the Aminophylline to aid the patient's breathing. It was expected that patient A.W. was to be administered two dosages of Aminophylline, an intermediate dosage to be given every few hours in a larger quantity, and a continuous drip to run at 20 milligrams per hour. Within Petitioner's Exhibit No. 6 are nursing notes made by Respondent concerning A.W. On May 17, 1988, between the hours of 12:00 a.m. and 2:00 a.m. it is noted that Respondent was having trouble with patient A.W.'s I.V. She states that the I.V. site was assessed and had to be pulled and that she was not able to reinsert due to the uncooperative nature of this child. The I.V. was restarted by the house supervisor nurse. An entry at 6:30 a.m. made by the Respondent describes the I.V. position as acceptable. When the shift changed at 7:00 a.m. the new charge nurse did not find the Aminophylline drip in progress, as called for, and this is noted in a 7:30 a.m. entry made by this registered nurse, Sherry Shiro. Petitioner's Exhibit No. 4 admitted into evidence is a Confidential Incident Report prepared by the Gadsden Memorial Hospital concerning allegations against the Respondent. They have to do with an alleged incident that occurred around 5:00 a.m. and contain the purported observations by Lucinda Mack, a licensed practical nurse on duty at that time, and they were received on June 15, 1988, by Carol Riddle, R.N., Director of Nursing at Gadsden Memorial Hospital, and the person responsible for investigating this matter. The copy of the Confidential Incident Report contained observations about the alleged failure of treatment by the Respondent directed in the matter of the patient E.J. These remarks are hearsay. They do not corroborate competent evidence at hearing concerning any oversight by the Respondent in the treatment of the patient E.J. On or about June 14, 1988, the Director of Nursing, Carol Riddle, called the night supervisor Michelle Warring at 2:00 a.m. to ascertain if the Respondent was on duty. Respondent was working on that date. At 2:15 a.m. Warring advised Riddle that the Respondent could not be found and Riddle went to the hospital at that time. When she arrived at the facility at 3:00 a.m. she went to "Med-Surg. Ped." where she was informed by the communications clerk that Lucinda Mack, LPN, was the only nurse on duty in that unit, and that the clerk did not know where Respondent could be found. Riddle and Warring then looked through the patient rooms in "Med-Surg. Ped." but could not find the Respondent. One and a half hours after commencing the search Riddle located the Respondent in a different wing of the hospital which contains a respiratory therapy manager's office. Respondent was there with her husband asleep, with the door locked and lights off. At that time she was the only registered nurse on duty in "Med-Surg. Ped." which had six patients receiving care on that evening. Respondent was not performing her duties or supervising those other persons who worked with her on the unit. Respondent had been observed asleep at her nurses' station desk on several other occasions by Dale Storey, a registered nurse working at the Gadsden Memorial Hospital. Linda Reed, a nurse technician at Gadsden Memorial Hospital had observed the Respondent asleep on duty. As commented on by nurse Riddle, who is qualified to give expert opinion testimony about the performance of the Respondent in her nursing practice, the conduct set out before in these findings of fact constitutes unprofessional conduct in the practice of nursing, in a situation which the Respondent knew what her duties were as charge nurse and failed to perform them at an adequate level.
Recommendation Based upon the findings of fact and conclusions of law, it is RECOMMENDED: That a final order be entered which fines the Respondent in the amount of $1,000 for the violation related to the care of patient K.W. as set out in Count One and for sleeping on duty as set out in Count Three. And, finds that the violation related to patient A.W. as set out in Count One and the violation alleged in Count Two related to the patient E.J. were not proven. DONE and ENTERED this 19 day of April, 1989, in Tallahassee, Leon County, Florida. CHARLES C. ADAMS 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 19 day of April, 1989. APPENDIX TO RECOMMENDED ORDER CASE NO. 88-5719 Petitioner's fact finding is subordinate to the finding in the Recommended Order with exception of paragraph 16 which is not relevant and reference within paragraph 34 to the date June 24, 1988, which should have been June 14, 1988. COPIES FURNISHED: Lisa M. Bassett, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Scarlett Jones 2636 Mission Road, #138 Tallahassee, Florida 32302 Judy Ritter, Executive Director Florida Board of Nursing 111 East Coastline Drive, Room 504 Jacksonville, Florida 32202 Kenneth E. Easley, Esquire General Counsel Department of professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
The Issue The issue is whether Respondent's Florida license to practice medicine should be revoked for malpractice under section 458.331(1)(t), Florida Statutes (2006).
Findings Of Fact Respondent is licensed to practice medicine in Florida, holding license number ME 66823. He is a radiologist and is certified by the American Board of Orthopedic Radiology and Diagnostic Radiology. On June 17, 2004, the Board of Medicine (Board) disciplined Respondent's medical license by issuing a letter of concern, imposing a $15,000 fine, assessing $4,010.59 in costs, requiring eight hours of continuing medical education, and prohibiting him from treating or prescribing medication to members of his family. On or about October 4, 2006, while working at Drew Medical, Inc., Respondent performed a diagnostic procedure called an intravenous pyelogram (IVP) without tomograms for Patient G.P., who had complained of right-side pain and had a history of kidney stones. An IVP without tomograms is a series of time- lapse x-rays using a dye material to provide radiographically contrasting images to detect a stone in a kidney or ureter. The resulting x-ray images revealed a partial obstructing stone in the right-side kidney/ureter area, which Respondent detected and reported. One of the resulting x-ray images contained an anomaly having the classical appearance of an abdominal aortic aneurysm, including conspicuous tissue displacement and rim calcification. It had an elongated, water balloon-type appearance with calcifications on one of the walls. It was alarming or life- threatening in size, such that it could cause death by bleeding. Respondent did not mention the aneurysm in his report or recommend any further evaluation of the anomaly. Although he was tasked to look for kidney stones, Respondent's failure to report the aneurysm or recommend any further evaluation of the anomaly fell below the level of care, skill, and treatment that is recognized by reasonably prudent, similar physicians as being acceptable. Patient G.P. was admitted to Orlando Regional Hospital with a ruptured abdominal aortic aneurysm on October 6, 2006. Attempts were made to repair the rupture, but they were not successful. The patient died on October 12, 2006. By his conduct in disappearing without a trace, despite the diligent efforts of DOH to find him, and not participating in any manner in the hearing he requested to dispute the Administrative Complaint, Respondent effectively abandoned his license to practice medicine in Florida.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Medicine enter a final order finding Respondent guilty of medical malpractice, revoking his medical license, and imposing a $10,000 administrative fine. DONE AND ENTERED this 25th day of July, 2012, in Tallahassee, Leon County, Florida. S J. LAWRENCE JOHNSTON Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 25th day of July, 2012. COPIES FURNISHED: Greg S. Marr, Esquire Department of Health Bin C-65 4052 Bald Cypress Way Tallahassee, Florida 32399-3265 Robert Dean Marshall, M.D. Apartment 310 400 East Colonial Drive Orlando, Florida 32803 Robert Dean Marshall, M.D. 5987 Southwest Moore Street Palm City, Florida 34990 Jennifer A. Tschetter, General Counsel Department of Health 4052 Bald Cypress Way, Bin A-02 Tallahassee, Florida 32399-1701 Joy Tootle, Executive Director Board of Medicine Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701
The Issue The issue to be resolved in this proceeding concerns whether disciplinary action should be imposed against the licensure of Douglas R. Shanklin, M.D., the Respondent, for allegedly falsely testifying that he had not been issued a "Letter of Guidance", in violation of Section 458.331(1)(k), Florida Statutes.
Findings Of Fact At all times material hereto, the Respondent was a physician licensed in the State of Florida. He holds license number ME0009372. The Petitioner is an agency of the State of Florida charged with regulating the licensure status and related practice standards of physicians in Florida, including making investigations and bringing Administrative Complaints against those physicians, in their licensure status, believed to be departing from those practice standards. On January 8, 1993, the Respondent testified as a defense witness, by deposition, in a medical malpractice case. The case style was Faircloth v. Coastal Empire Pathology Services, P.C., et al. The trial occurred in Savannah, Georgia. During his deposition, the Respondent was asked three times, by opposing counsel, if he had ever been issued a Letter of Guidance by any state licensing agency. The Respondent stated three times that, indeed, he had not. In fact, on May 15, 1984, a Probable Cause Panel of the Board of Medical Examiners in Florida considered a complaint against the Respondent. The Probable Cause Panel made a determination that while probable cause existed to believe that the Respondent had violated the provisions of the Medical Practice Act, the complaint should be dismissed with a Letter of Guidance. The Board stated in its Order that: Probable cause exists to believe that subject has violated the provisions of the Medical Practice Act. In light of the circumstances presented, however, this case should be and the same is hereby dismissed with a letter of guidance to subject. Thereafter, an undated letter was sent to and received by the Respondent. See Petitioner's Exhibit 2 in evidence. The Closing Order was never mailed to, nor received, by the Respondent. The Respondent was unaware of the Closing Order until March of 1993, when the investigation in this case was commenced and at which time he was first supplied a copy of that Closing Order of the Board's Probable Cause Panel. The Petitioner's Exhibit 2 in evidence, the undated letter, is not entitled or otherwise delineated as a "Letter of Guidance" and at no place in the letter is the word "guide" or "guidance" used. Consequently, at the time the Respondent received the letter, which is Exhibit 2, he did not understand or perceive it to be a Letter of Guidance but, rather, understood it to be a letter of closing indicating that he had prevailed in the complaint case. On January 8, 1993, when the Respondent testified at the deposition referenced above, he did not have in mind, nor did he remember, the undated letter. On January 8, 1993, when he testified at that deposition that he had not been issued the Letter of Guidance, he believed he was answering those questions truthfully. He did not know or understand that he had been issued a Letter of Guidance. On January 8, 1993, when he testified at the deposition, he did not testify falsely, because he had not been given the Closing Order at the time that the undated letter (Exhibit 2) was received. He thus did not understand that undated letter to be a Letter of Guidance from the then Department of Professional Regulation. He was never served a copy of the actual Closing Order which might have explained the situation to him. Consequently, he had a genuine, good-faith belief that he had not been issued a Letter of Guidance. Because his belief was genuine and he had no specific intent to tell a false story in those particulars, he made no false or fraudulent representation and committed no deception in conjunction with his answers to those questions at his deposition.
Recommendation Having considered the foregoing Findings of Fact, Conclusions of Law, the evidence or record, the candor and credibility of the witnesses, it is RECOMMENDED that a Final Order be entered finding the Respondent not guilty of violating Section 458.331(1)(k), Florida Statutes, and that the Complaint be dismissed in its entirely. DONE AND ENTERED this 3rd day of May, 1995, 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 3rd day of May, 1995. APPENDIX TO RECOMMENDED ORDER, CASE NO. 94-5903 Petitioner's Proposed Findings of Fact 1-3. Accepted. 4-6. Rejected, as not entirely in accord with the greater weight of the evidence and as subordinate to the Hearing Officer's findings of fact on this subject matter. Respondent's Proposed Findings of Fact 1-11. Accepted. COPIES FURNISHED: Steven Rothenburg, Senior Attorney Agency for Health Care Administration 9125 Bay Plaza Boulevard Suite 210 Tampa, FL 33619 Larry G. Turner, Esquire Post Office Box 508 Gainesville, FL 32602 Dr. Marm Harris Executive Director Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Tom Wallace, Assistant Director Agency for Health Care Administration The Atrium, Suite 301 325 John Knox Road Tallahassee, FL 32303
