02-004285PL Department Of Health, Board Of Medicine vs. Teodulo Reyes Mationg, Jr. Status: Closed Recommended Order on Thursday, July 3, 2003.

Summary: Doctor failed to order a stat neurological consult for patient who was having a stroke.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, )

BOARD OF MEDICINE, )

)

Petitioner, )

)

vs. ) Case No. 02 - 4285PL

)

TEODULO REYES MATIONG, JR., )

)

Respondent. )

__________________________________)

RECOMMENDED ORDER

Pursuant to notice, a final hearing was held in this case

on February 25 and 26, 2003, in Tampa, Florida, before Susan

B. Kirkland, a designated Administrative Law Judge of the

Division of Administrative Hearings.

APPEARANCES

For Petitioner: James W. Earl, Esquire

Department of Health

4052 Bald Cypress Way, Bin C - 65

Tallahassee, Florida 32399 - 3265

For Respondent: A. S. Weekley, Jr., Esquire

Holland & Knight, LLP

400 North A shley Drive, Suite 2300

Tampa, Florida 33602

STATEMENT OF THE ISSUES

Whether Respondent violated Subsections 458.331(1)(m) and

458.331(1)(t), Florida Statutes, and, if so, what discipline

should be imposed.

PRELIMINARY STATEMENT

O n August 15, 2002, Petitioner, Department of Health

(Department), filed a two - count Administrative Complaint

against Respondent, Teodulo Reyes Mationg, Jr. (Dr. Mationg),

alleging that he had violated Subsections 458.331(1)(m) and

458.331(1)(t), Florida St atutes. Dr. Mationg requested an

administrative hearing, and the case was forwarded to the

Division of Administrative Hearings on October 10, 2002, for

assignment of an Administrative Law Judge to conduct the final

hearing.

The final hearing was scheduled for January 7 and 8,

2003. On December 5, 2002, Dr. Mationg filed a Motion for

Continuance, which was granted by O rder dated December 13,

2002. The final hearing was re - scheduled for February 25 and

26, 2003.

On December 12, 2002, Petitioner filed Petit ioner's

Motion for Leave to Amend the Administrative Complaint. The

M otion was granted by O rder dated December 18, 2002. On

February 12, 2003, Petitioner filed Petitioner's Motion for

Leave to Amend the Administrative Complaint. An O rder

G ranting L eave to A mend the Administrative Complaint was

issued on February 13, 2003.

The parties filed a Joint Prehearing Stipulation and

stipulated to certain facts contained in S ection e of the

Joint Prehearing Stipulation. Those facts have been

incorporated in this Recommended Order.

At the final hearing, Petitioner called the following

witnesses: Marcia Wild, Hazel Mahoney, Timothy Mark Harberts,

John Michael Culligan, and Harry Curtis Benson, M.D.

Petitioner's Exhibits 1 through 5 were admitted in evidence.

Resp ondent testified in his own behalf and called Mohan Kutty,

M.D. and Siddharth H. Shah, M.D. Respondent's Exhibits A, B,

D, E, and F were admitted in evidence. Joint Exhibit 1 was

admitted in evidence.

The parties agreed to file their proposed recommended

orders within 20 days of the filing of the transcript. The

two - volume Transcript was filed on March 17, 2003. The

parties timely filed their Proposed Recommended Orders.

FINDINGS OF FACT

1. The Department is the State agency charged with

regulating the practice of medicine pursuant to Section 20.43

and Chapters 456 and 458, Florida Statutes.

2. At all times material to this proceeding, Dr. Mationg

was a licensed physician in the State of Florida. His

license, numbered ME 0028183, was issued on April 1 3, 1976.

3. Dr. Mationg is the primary care physician of A.A.

Dr. Mationg referred A.A. to Dr. Steven Schafer, an orthopedic

surgeon, for pain in the right shoulder, which was found to

require arthroscopic surgery and repair of a rotator cuff.

4. On J anuary 10, 2000, A.A. was admitted to Regional

Medical Center Bayonet Point (Bayonet Point) for surgery. At

the time of his admission to the hospital, A.A. was 65 years

old and suffered from numerous medical problems. He had

cardiomyopathy, meaning his h eart was enlarged and not

functioning properly. A.A. had high blood pressure and a

history of heavy smoking. He had generalized arteriosclerosis

and peripheral artery disease. A.A. had previously had

surgeries involving the placement of a stint and angi oplasty.

Based on his medical history, A.A. was subject to a stroke and

a heart attack.

5. Prior to his admission to the hospital, A.A. had been

taking aspirin daily. Approximately three days prior to

surgery, A.A. was directed by Dr. Schafer to discont inue

taking aspirin. The aspirin was discontinued to reduce the

risk of A.A.'s blood not being able to clot sufficiently.

6. The hospital records of A.A. contain a request for

consultation with Dr. Mationg for medical management dated

January 10, 2000. The discharge summary shows that the

medical evaluation was obtained so that A.A. could be followed

by his primary care physician for his hypertension and other

medical history.

7. Dr. Schafer performed the surgical procedure on A.A.

on January 10, 2000. A.A. had some respiratory problems, and

Dr. Mationg ordered a pulmonary consultation with Dr. Patel

the afternoon of January 10, 2000. Because of the respiratory

problems, A.A. was placed on a ventilator and transferred to

the intensive care unit. On J anuary 11, 2000, Dr. Patel

extubated A.A., which means that A.A. was taken off the

ventilator.

8. On January 11, 2000, Dr. Mationg saw A.A. at 9:00 a.m.

and wrote and signed an order for lasix and lanoxin for A.A.

9. Around 3:15 a.m. on January 12, 2000, A.A. was

awakened for respiratory therapy and experienced numbness in

his left arm and slurring of speech. When A.A. smiled, the

left side of his mouth remained flat while the right side

turned up. The nurse on duty was called, and he observed

A.A.'s sym ptoms. A.A.'s symptoms indicated that he was having

a stroke. Nurse Culligan notified Drs. Schafer and Mationg.

10. Dr. Mationg did not come to the hospital to evaluate

A.A. The standard of care would have required him to come to

the hospital to evalua te A.A. because A.A. was exhibiting the

symptoms of a stroke. Instead of coming to the hospital to do

an evaluation, Dr. Mationg gave the following orders

telephonically to Nurse Culligan at 4 a.m., on January 12,

2000:

T.O. Dr. Mationg/M. Culligan

do CT head [without] contrast today a.m.

do carotid doppler study today a.m.

consult Dr. S. Shah for neuro eval.

get speech therapy eval. and video swallow

today.

Nurse Culligan wrote the orders on A.A.'s chart; Dr. Mationg

later countersigned the orders.

11. The term "stat" in medical parlance means

immediately or as soon as possible. An order is not presumed

to be stat if the order does not specify that it is stat. The

tests and consultation which Dr. Mationg ordered at 4 a.m., on

January 12, 2000, were not ordered to be implemented stat.

The standard of care for treating A.A. required that Dr.

Mationg order a stat neurological consultation and a stat head

CT scan.

12. Bayonet Point has established policies for its

imaging services department, including CT services. The

normal hours for CT services are 7 a.m. to 11 p.m., Monday

through Sunday. After normal hours, the services are provided

on - call. Bayonet Point's call - back procedures include the

following:

When an emergent radiologic procedure is

ordered after hours, the Radiology

personnel will contact the appropriate on

call technologist via the hospital

operator. Once the procedure is complete,

the Technologist will call the Radiologist

on call and then transmit those images via

Teleradiography.

Defin ition of an emergent procedure: In -

house STAT, Emergency Department physician

requesting radiologist interpretation, any

outpatient whose physician requests

immediate radiologist interpretation or

"wet reading."

13. Prior to A.A.'s experiencing the symp toms of a

stroke at 3:15 a.m., no orders had been given for A.A. to

resume taking aspirin. At 10 p.m. on January 10, 2000, Dr.

Schafer ordered that "till further notified" all medications

taken by mouth which could be taken intravenously were to be

admini stered via an IV. Aspirin could not be administered

intravenously. Because Dr. Schafer had ordered that aspirin

therapy be stopped prior to surgery, it would be the

responsibility of Dr. Schafer to order the aspirin to be

restarted.

14. Dr. Schafer was at A.A.'s bedside at 8:30 a.m., on

January 12, 2000. Dr. Schafer noted that a head CT scan was

ordered for that morning and that the patient was on his way

down for the test. Dr. Schafer also noted that a neurological

evaluation had been ordered for A.A. for that morning.

15. The hospital records show that at 8:50 a.m., on

January 12, 2000, a call was made to Dr. Shah's answering

service, requesting a neurological consultation. The request

for consultation form, which was filled out after Dr.

Schafer's visit at 8:30 a.m., indicated that the request was

an emergency request. The request for consultation form was

filled out by someone other than the nurse who charted Dr.

Mationg's verbal order for a neurological consultation. Based

on the evidence presen ted, the request for a neurological

consultation was not treated as an emergency request until

after Dr. Schafer saw A.A. at 8:30 a.m.

16. Tissue Plaminogen Activators (TPA) are used to

dissolve clots which may be causing a stroke. The use of TPA

is li mited to a three - hour window following the onset of

stroke symptoms. Dr. Mationg did consider the use of TPA, but

felt that it was contraindicated based on the recent surgery.

This opinion was confirmed at final hearing by a neurologist.

CONCLUSIONS OF L AW

17. The Division of Administrative Hearings has

jurisdiction over the parties to and the subject matter of

this proceeding. Sections 120.569 and 120.57, Florida

Statutes.

18. The Department alleged in Count I of the Second

Amended Administrative Comp laint that Dr. Mationg violated

Subsection 458.331(1)(t), Florida Statutes, which provides

that a physician may be disciplined for "the failure to

practice medicine with that level of care, skill, and

treatment which is recognized by a reasonably prudent s imilar

physician as being acceptable under similar conditions and

circumstances." The Department alleged that Dr. Mationg

violated Subsection 458.331(1)(t), Florida Statutes, in the

following ways:

a. By failing to re - institute aspirin

therapy to Pati ent A.A. after the right

shoulder arthroscopy and open rotator cuff

repair performed on January 10, 2000.

b. By failing to present to evaluate

Patient A.A. immediately after being

notified of Patient A.A.'s slurred speech

and paresis of his right arm a nd leg on

January 12, 2000.

c. By failing to order a stat CT scan

of Patient A.A.'s brain after being

notified of Patient A.A.'s slurred speech

and paresis of his right arm and leg on

January 12, 2000.

d. By failing to order a stat

neurological con sult after being notified

of Patient A.A.'s slurred speech and

paresis of his right arm and leg on January

12, 2000.

e. By failing to immediately consider

TPA in consultation with a Neurologist

after being notified of Patient A.A.'s

slurred speech and paresis of his right arm

and leg on January 12, 2000.

f. By failing to perform a complete

history and physical examination of Patient

A.A.

19. The Department has failed to establish by clear and

convincing evidence that Dr. Mationg violated Subsectio n

458.331(1)(t), Florida Statutes, by failing to reinstitute

aspirin therapy after A.A.'s surgery. Having ordered the

aspirin to be discontinued, Dr. Schafer would be the one who

would decide when the aspirin therapy could be resumed.

Additionally, A.A. was unable to resume taking any aspirin

until at least after he had been extubated, which was late in

the afternoon of January 11, 2000.

20. The Department has established by clear and

convincing evidence that Dr. Mationg violated Subsection

458.331(1)(t) , Florida Statutes, by failing to present to A.A.

immediately after being advised of A.A.'s symptoms at 4 a.m.

on January 12, 2000. A.A. was having a stroke, and the

evidence does not establish that A.A.'s condition was

stabilized when Dr. Mationg was not ified of A.A.'s symptoms.

Thus, the standard of care required Dr. Mationg to come to the

hospital to evaluate A.A.'s condition.

21. The Department has established by clear and

convincing evidence that Dr. Mationg violated Subsection

458.331(1)(t), Florid a Statutes, by failing to order a stat

head CT scan, when he gave his orders at 4 a.m., on January

12, 2000. The standard of care required that a stat CT scan

be ordered, and Dr. Mationg did not do so.

22. The Department has established by clear and

conv incing evidence that Dr. Mationg violated Section

458.331(1)(t), Florida Statutes, by failing to order a stat

neurological consultation. A.A. was in the process of having

a stroke when Dr. Mationg was notified of A.A.'s symptoms.

The standard of care req uired that a neurological consultation

be ordered stat, and Dr. Mationg did not do so. Dr. Mationg's

argument that the nurse should have known under the

circumstances that the consultation order was to be preformed

stat even though not given as a stat ord er is without merit.

An order is not considered a stat order unless it is given as

a stat order.

23. The Department has failed to establish that Dr.

Mationg did not consider the use of TPA. He did consider it

and felt it was contraindicated because of the recent surgery.

24. The Department alleged in Count II of the Second

Amended Administrative Complaint that Dr. Mationg violated

Subsection 458.331(1)(m), Florida Statutes, by failing to

document a complete history and physical examination of A.A.

and by failing to document a discharge summary for A.A. The

Department conceded in its Proposed Recommended Order that the

Department failed to establish by clear and convincing

evidence that Dr. Mationg violated Subsection 458.331(1)(m),

Florida Statutes.

2 5. The Department has established by clear and

convincing evidence that Dr. Mationg is guilty of failure to

practice medicine with that level of care, skill, and

treatment, which is recognized as being acceptable under

similar conditions and circumstances .

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions

of Law, it is RECOMMENDED that a Final Order be entered

finding that Dr. Mationg violated Subsection 458.331(1)(t),

Florida Statutes; finding that Dr. Mationg did not violate

Subsec tion 458.331(1)(m), Florida Statutes; placing Dr.

Mationg on two years probation; imposing an administrative

fine of $5,000; and requiring that Dr. Mationg attend ten

hours of continuing medical education courses in the diagnosis

and treatment of strokes a nd four hours of continuing medical

education courses in risk management.

DONE AND ENTERED this 3rd day of July, 2003, in

Tallahassee, Leon County, Florida.

S

___________________________________

SUSAN B. KIRKLAND

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 th e Clerk of the

Division of Administrative Hearings

this 3rd day of July, 2003.

COPIES FURNISHED:

James W. Earl, Esquire

Department of Health

4052 Bald Cypress Way, Bin C - 65

Tallahassee, Florida 3 2399 - 3265

A. S. Weekley, Jr., Esquire

Holland & Knight, LLP

400 North Ashley Drive, Suite 2300

Tampa, Florida 33602

Larry McPherson, Executive Director

Board of Medicine

Department of Health

4052 Bald Cypress Way

Tallahassee, Florida 32399 - 1701

R. S. Power, Agency Clerk

Department of Health

4052 Bald Cypress Way, Bin A - 02

Tallahassee, Florida 32399 - 1701

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within

15 days from the date of this Recommended Order . Any

exceptions to this Recommended Order should be filed with the

agency that will issue the Final Order in this case.