99-002325 Board Of Clinical Laboratory Personnel vs. James A. Beyer
 Status: Closed
Recommended Order on Wednesday, September 8, 1999.


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Summary: Evidence failed to show clearly that Respondent was the technologist responsible for erroneous test results.

1STATE OF FLORIDA

4DIVISION OF ADMINISTRATIVE HEARINGS

8DEPARTMENT OF HEALTH, BOARD OF )

14CLINICAL LABORATORY PERSONNEL, )

18)

19Petitioner, )

21)

22vs. ) Case No. 99-2325C

27)

28JAMES A. BEYER, )

32)

33Respondent. )

35___________________________________)

36RECOMMENDED ORDER

38A hearing was held in this case in Fort Myers, Florida, on

50July 29, 1999, before Arnold H. Pollock, an Administrative Law

60Judge with the Division of Administrative Hearings.

67APPEARANCES

68For Petitioner: Howard M. Bernstein, Esquire

74Agency for Health Care

78Administration

79Post Office Box 14229

83Tallahassee, Florida 32317-4229

86For Respondent: James A. Beyer, pro se

932501 8th Street West

97Lehigh Acres, Florida 33971

101STATEMENT OF THE ISSUE

105The issue for consideration in this case is whether

114Respondent's license as a medical technologist in Florida should

123be disciplined because of the matters alleged in the

132Administrative Complaint filed herein.

136PRELIMINARY MATTERS

138By Administrative Complaint dated June 1, 1998, the Agency

147for Health Care Administration charged Respondent, James A.

155Beyer, with failing to follow the procedures for specimen

164handling and processing, test analyses, and reporting and

172maintaining records of patient test results in the clinical

181laboratory in which he worked, in violation of Rule

19064B-13.003(2)(b), Florida Administrative Code, and Section

196483.825(7), Florida Statutes. Respondent requested formal

202hearing on the allegations, and this hearing ensued.

210At the hearing, the Agency presented the testimony of Martha

220Sunyog, administrative director of the laboratory at Naples

228Community Hospital, and Donna Teague, records custodian for

236Naples Community Hospital. The Agency also introduced

243Petitioner's Exhibits 1 and 2. Respondent testified in his own

253behalf. He introduced no exhibits.

258A Transcript of the proceedings was furnished. Counsel for

267Petitioner submitted matters in writing after hearing which were

276carefully considered in the preparation of this Recommended

284Order.

285FINDINGS OF FACT

2881. At all times pertinent to the issues herein, the Board

299of Clinical Laboratory Personnel was the state agency in Florida

309responsible for the regulation of the medical technology

317profession in this state, and for the licensing of medical

327technologists in Florida. Respondent, James A. Beyer, was

335licensed as a medical technologist under license number

343JC0033961, originally issued on November 27, 1995, and current

352until June 30, 2000.

3562. On February 23, 1996, B.A., a 21-year-old female, was

366admitted to Naples Community Hospital complaining of increasing

374abdominal pain. Laboratory tests run on the patient indicated

383she was undergoing an ectopic pregnancy. A diagnostic

391laporoscopy was performed, as were subsequent laporotomy and left

400salpingectomy with lysis of adhesions. It was also determined

409she had severe pelvic inflammatory disease with bilateral

417tubo-ovarian complexes. As a result, she was placed on drug and

428antibiotic therapy which improved her condition. The pathology

436report based on the surgery performed on the patient revealed no

447evidence of intrauterine pregnancy in the fallopian tube

455specimen. She was discharged from the hospital on February 29,

4651996. Final diagnosis, as indicated on the discharge summary,

474was "left ectopic pregnancy" with secondary diagnoses of chronic

483pelvic inflammatory disease and extensive pelvic adhesions.

4903. Notwithstanding the final diagnosis, as noted on the

499discharge summary, the Agency contends a second pregnancy test

508done on the patient revealed she was not pregnant. The

518laboratory tests giving rise to the allegedly erroneous initial

527diagnosis were processed in the hospital's lab by one of two

538technologists. Respondent was one of the two. It appears the

548test results for patient B.A. were confused in the lab with those

560of another patient.

5634. No evidence was presented to show who actually handled

573and processed B.A.'s specimen, nor was any evidence introduced by

583Petitioner to show what the laboratory's appropriate procedures

591were. However, Respondent's initials were entered into the

599computer as having done the allegedly erroneous test.

6075. Respondent labeled the incident regrettable, as indeed

615it was. He admits that human error caused the mix-up in

626specimens, but notes that the incident took place in the primary

637care chemistry section of the laboratory which was staffed by

647several different individuals. He claims it is impossible to

656determine who was responsible for the error. Respondent has no

666memory of doing the procedure and does not believe he did it.

678His belief is based on several factors.

6856. The first of these is that for the error to have

697occurred, there would have to have been at least two specimens

708present: that of B.A. and that of another patient. The

718demographic information relating to B.A. would have to have been

728placed on the analyzer with the specimen from the other patient.

739When Respondent does this test, it is his procedure to hold the

751specimen in his hand while he reads the label and enters the

763patient identification information into the analyzer computer.

770Then he labels the serum cup to be used with the same patient

783identification information as is on the specimen container he is

793holding. Before running the test, he verifies the identification

802number on the test sample cup against the identification number

812in the computer, and it is inconceivable to him that he would

824have picked up another patient's sample and placed a portion of

835it on the instrument instead of the sample on which he was

847working.

8487. Another reason he believes he did not commit the error

859is that the incident was thoroughly and promptly investigated by

869laboratory and hospital personnel, and the human error cause was

879treated without placing blame on anyone. No disciplinary action

888was taken against him by the hospital, and he is still employed

900by Naples Community Hospital in the laboratory in the same

910position as before the incident occurred. His annual ratings

919before and after the incident have been "meets" or "exceeds"

929standards.

9308. Respondent is of the opinion that the Department of

940Health's investigation into the incident was superficial at best

949and lacks concrete evidence to support the claims of misconduct

959made.

9609. Petitioner presented no information to indicate what are

969the appropriate procedures to be followed in the laboratory for

979the procedure in issue.

983CONCLUSIONS OF LAW

98610. The Division of Administrative Hearings has

993jurisdiction over the parties and the subject matter in this

1003case. Section 120.57(1), Florida Statutes.

100811. Petitioner seeks to discipline Respondent's license as

1016a medical technologist, alleging that he failed to follow proper

1026and established laboratory procedures in the incident involving

1034patient B.A., which resulted in test results from another

1043patient's sample being identified as that of B.A. Petitioner

1052alleges this is a violation of Section 483.825(7), Florida

1061Statutes.

106212. Section 483.825(7), Florida Statutes, permits

1068disciplinary action against a licensee who has: " violat[ ed] or

1078aid[ ed] or abett[ ed] in the violation of any provision of this

1091part, or the rules adopted hereunder." If, as alleged,

1100Respondent violated Rule 64B3-13.003(2)(b), Florida

1105Administrative Code, such code violation would constitute a

1113violation of the statute as well.

111913. Rule 64B-13.003(2)(b), Florida Administrative Code,

1125requires a technologist to follow the clinical laboratory's

1133procedures for specimen handling and processing, test analyses,

1141and reporting and maintaining records of patient test results.

1150If Petitioner proved that Respondent violated that professional

1158standard, that would constitute a violation upon which to base

1168discipline of his license.

117214. Petitioner carries the burden of proof in this matter,

1182however, and that burden requires it to prove Respondent's guilt

1192of the matters alleged by clear and convincing evidence. Osborne

1202vs. Ster & Co. , 670 So. 2d.932, (Fla. 1996); Ferris v.

1213Turlington , 570 So. 2d 212, (Fla. 1987). Here, Petitioner has

1223shown that a mistake was made in the laboratory, and that

1234Respondent worked in the laboratory. It has not, however,

1243presented any evidence to demonstrate what is the proper

1252procedural standard for this test.

125715. Respondent admits that his initials were placed in the

1267computer for this test. However, the evidence of record does not

1278clearly or convincingly establish Respondent's guilt of the

1286matters alleged.

1288RECOMMENDATION

1289Based on the foregoing Findings of Fact and Conclusions of

1299Law, it is recommended that the Board of Clinical Laboratory

1309Personnel enter a final order dismissing the Administrative

1317Complaint against Respondent.

1320DONE AND ENTERED this 8th day of September, 1999, in

1330Tallahassee, Leon County, Florida.

1334___________________________________

1335ARNOLD H. POLLOCK

1338Administrative Law Judge

1341Division of Administrative Hearings

1345The DeSoto Building

13481230 Apalachee Parkway

1351Tallahassee, Florida 32399-3060

1354(850) 488-9675 SUNCOM 278-9675

1358Fax Filing (850) 921-6947

1362www.doah.state.fl.us

1363Filed with the Clerk of the

1369Division of Administrative Hearings

1373this 8th day of September, 1999.

1379COPIES FURNISHED:

1381Howard M. Bernstein, Esquire

1385Agency for Health Care

1389Administration

1390Post Office Box 14229

1394Tallahassee, Florida 32317-4229

1397James A. Beyer

14002501 8th Street West

1404Lehigh Acres, Florida 33971

1408Angela T. Hall, Agency Clerk

1413Department of Health

1416Bin A02

14182020 Capital Circle, Southeast

1422Tallahassee, Florida 32399-1701

1425Pete Peterson, General Counsel

1429Department of Health

1432Bin A02

14342020 Capital Circle, Southeast

1438Tallahassee, Florida 32399-1701

1441Eric G. Walker, Executive Director

1446Board of Clinical Laboratory Personnel

1451Department of Health

14541940 North Monroe Street

1458Tallahassee, Florida 32399-0792

1461NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

1467All parties have the right to submit written exceptions within 15

1478days from the date of this Recommended Order. Any exceptions to

1489this Recommended Order should be filed with the agency that will

1500issue the Final Order in this case.

Select the PDF icon to view the document.
PDF
Date
Proceedings
PDF:
Date: 07/06/2004
Proceedings: Final Order filed.
PDF:
Date: 12/07/1999
Proceedings: Agency Final Order
PDF:
Date: 09/08/1999
Proceedings: Recommended Order
PDF:
Date: 09/08/1999
Proceedings: Recommended Order sent out. CASE CLOSED. Hearing held 7/29/99.
Date: 09/01/1999
Proceedings: (Petitioner) Closing Argument filed.
Date: 08/06/1999
Proceedings: Transcript filed.
Date: 07/29/1999
Proceedings: CASE STATUS: Hearing Held.
Date: 06/22/1999
Proceedings: Notice of Hearing sent out. (hearing set for 7/29/99; 9:30am; Ft. Myers)
Date: 06/09/1999
Proceedings: Letter to Judge Pollock from J. Beyer Re: Unilateral response (filed via facsimile).
Date: 05/27/1999
Proceedings: Initial Order issued.
Date: 05/25/1999
Proceedings: Agency Referral Letter; Administrative Complaint; Election of Rights filed.

Case Information

Judge:
ARNOLD H. POLLOCK
Date Filed:
05/25/1999
Date Assignment:
05/27/1999
Last Docket Entry:
07/06/2004
Location:
Fort Myers, Florida
District:
Middle
Agency:
ADOPTED IN TOTO
 

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