07-001724PL Department Of Health, Board Of Medicine vs. Vasundhara Iyengar, M.D. Status: Closed Recommended Order on Thursday, January 31, 2008.

Summary: Physician failed to examine or monitor the patient and assumed the patient (who had been moved to the Intensive Care Unit) had been discharged.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, BOARD OF )

MEDICINE , )

)

Petitioner , )

)

vs. ) Case No. 07 - 1724PL

)

VASUNDHARA IYENGAR, M.D. , )

)

Respondent . )

)

RECOMMENDE D ORDER

On September 20, 2007, a formal administrative hearing in

this case was held in Orlando, Florida, before William F.

Quattlebaum, Administrative Law Judge, Division of

Administrative Hearings.

APPEARANCES

For Petitioner: Jennifer Forshey, Esquir e

Dorys H. Penton, Esquire

Department of Health

4052 Bald Cypress Way, Bin C - 65

Tallahassee, Florida 32399 - 3265

For Respondent: H. Roger Lutz, Esquire

Lutz, Bobo & Telfair, P.A.

2 North Tamiami Trail, Suite 500

Sarasota, Florida 34236

H. Gregory McNeill, Esquire

Lowndes, Drosdick, Doster

Kantor & Reed, P.A.

Post Office Box 2809

Orlando, Florida 32802 - 2809

STATEMENT OF THE ISSUE S

The issue s in this case are whether the allegations of the

Administrative Complaint are correct, and , if so, wh at penalty

should be imposed.

PRELIMINARY STATEMENT

By Amended Administrative Complaint dated January 16, 2007,

the Department of Health (Petitioner) alleged that Vasundhara

I y engar, M.D. (Respondent) , violated S ubs ection 458.331(1)(t),

Florida Statutes ( 2002), by failing to adequately assess or

treat a patient's condition on March 17 and 18, 2003. The

Respondent disputed the allegations and requested a formal

administrative hearing. By letter dated April 17, 2007, the

Petitioner forwarded the matter to the Division of

Administrative Hearings, which scheduled and conducted the

hearing.

At the hearing, the Petitioner presented the testimony of

one witness and had E xhibits lettered A through E admitted into

evidence. The Respondent presented the testimony of two

witnesses, testified on her own behalf , and had E xhibits

numbered 1 and 2 admitted into evidence.

The hearing T ranscript was filed on October 15, 2007. As

stipulated by the parties, both parties filed Proposed

Recommended Orders on November 27, 200 7, that have been

considered in the preparat ion of this Recommended Order.

FINDINGS OF FACT

1. The Respondent is a licensed medical doctor, holding

license number 44726.

2. At all times material to this case, the Respondent was

a physician holding board certifications in internal medicine,

hematology , and oncology.

3. Patient 1 was a patient of another hematologist,

Dr. Thomas Katta. On March 17, 2003, Dr. Katta had Patient 1

admitted via the patient's internist (Dr. Frank Leiva) to Sand

Lake Hospital in Orlando .

4. The patient was anemic and thrombocytopenic and had

been previously diagnosed with autoimmune hemolytic anemia, the

treatment for which was transfusion. Failure to transfuse a

person suffering from autoimmune hemolytic anemia can lead to

death, and such a transfusion had been ordered for the patient.

5. Dr. Katta apparently had personal obligations for the

evening of March 17, 2003 , and for the following day, and , in

the late afternoon of March 17, 200 3 , he asked the Respondent to

"cove r" his hospitalized patients. T he Respondent agreed to do

so.

6. Dr. Katta's office transmitted a list of the patients

by fax to the Respondent's office. The list contained the full

names and locations of Dr. Katta's other hospitalized patients,

but ide ntified Patient 1 only by last name and diagnosis

("AIHA"). The fax did not indicate the patient's first name or

gender and did not specifically id entify the patient's location.

7. The Respondent made no attempt to obtain additional

informatio n from Dr. Katta or his staff.

8. The lab work performed upon admission to the hospital

indicated that the patient was severely anemic and had a

critically low platelet count.

9. At approximately 6:30 p . m . on March 17, 2003, the

Respondent received a telephone call through her answering

service from a hospital nurse who reported that the patient was

severely anemic and that there were problems obtaining a proper

blood match for the transfusion. The Respondent advised the

nurse to call the blood bank and tell them t o find the least

incompatible blood and get the transfusion done. The Respondent

did not inquire as to the patient's name or location.

10. At about 10:19 p.m. on March 17, 200 3 , the Respondent

was again contacted by a hospital nurse, who advised that t he

patient was short of breath and had tachycardia at 133 beats per

minute. The nurse also advised that the blood bank had been

unable to find an appropriate match for the previously ordered

transfu sion and that the tra nsfusion remained uncompleted.

11. The Respondent directed the nurse to contact the

patient's primary care physician or the cardiologist on call,

but did not ask the identity of either practitioner. The

nursing notes indicate that the Respondent stated that she did

not pr ovide treatment fo r tachycardia and did not beli eve that

Dr. Katta did either.

12. The Respondent also advised the nurse to call the

blood bank and direct them to find the least incompatible blood

and perform the transfusion. The Respondent did not inquire as

to the patie nt's name or location and provided no other

direction to the reporting nurse.

13. On the next day, March 18, 200 3 , at about 6:15 a.m.,

the Respondent was contacted by a hospital nurse, who advised

that the transfusion had still not taken place. The Respo ndent

took no action and provided no direction to the reporting nurse.

The Respondent did not inquire as to t he patient's name or

location.

14. Later duri ng the morning of March 18, 2003 , the

Respondent attempted to locate the patient while making he r

ro unds but was unsuccessful.

15. In attempting to locate the patient, the Respondent

talked with various hospital personnel, but had no information

other than the patient's last name and diagnosis. Based on her

inability to obtain any additional informatio n, the Respondent

assumed that the patient had been transfused and discharged.

16. The patient had not been discharged, but had been

transferred to an intensive care unit in the hospital. The

transfusion had not ye t occurred.

17. Patient 1 died on March 20, 2003.

18. The Respondent was unaware of the patient's death

until she saw Dr. Katta at the hospital, at which time he

questioned her about the patient and informed her that the

patient was dead.

19. The Petitioner presented the testimony of Dr. Howa rd

Abel, M.D., regarding whether the Respondent met the standard of

care in her treatment of the patient. Dr. Abel's testimony

regarding the standard of care issue s is credited and is

accepted.

20. As to the issue of the uncompleted transfusion, the

evid ence establishes that the transfusion did not occur while

the Respondent provided hematological care for Patient 1. The

Respondent should have personally contacted the blood bank to

identify the cause of the inability to provide blood for the

transfusion and determine whether another option was available.

21. The Respondent should have responded to the 10:19 p.m.

call on March 17 by personally examining the patient and

reviewing the history and lab test results. While the

Respondent's directive to contac t a cardiologist was not

inappropriate, breathing difficulties and tachycardia are

symptomatic of severe anemia for which hematological care was

required. If the Respondent determined that the symptoms were

cardiac - related, the Respondent should have pers onally made the

cardiology referral and provided the information to the

cardiologist. The Respondent did not do so and was unaware o f

the cardiologist's identity.

22. A review of additional lab test results including

observation and evaluation of blood s mears would have provided

useful information as to whether the patient's condition was

deteriorating and to whether the patient was developing

thrombotic thrombocytopenic purpura ("TTP"), a serious condition

which, left untreated, is fatal in not less than 90 percent of

cases. The blood smears had been performed by the time of the

phone call, but the Respondent reviewed no lab test results and

made no inq uiries related to the results.

23. The failure to review la b test results may have

delayed a diagnosis of TTP. While there was some disagreement

between testifying witnesses as to whether or not the patient

had TTP, Dr. Katta ordered that the patient be treated for TTP

immediately upon his return on March 19, 2003, and there is no

evidence that Dr. Katta treated the patient for TTP without

reasonable cause to do so. The evidence clearly establishes

that the Respondent failed to review the patient's test results

that could have provided timely and useful information regarding

the pat ient's condition.

24. As to the Respondent's failure to locate the patient

on March 18, 2003, the Respondent testified that the patient's

last name was common, but the Respondent had not called Dr.

Katta at the time she received the faxed list of his

hospitalized patients to ob tain addit ional identifying

information.

25. The Respondent did not request the information from

the nursing staff during any of the telephone calls and made no

effort to obtain the information prior to arriving at the

hospital to ma ke her rounds.

26. Th e Respondent would have become aware of the

patient's location ha d she attended to the patient's breathing

difficulties and tachycardia on the night of March 17. She

would have also likely reviewed the medical records and would

have become aware of the ad mitting physician as well as other

information rega rding the patient's condition.

27. The Respondent consulted with hospital personnel on

March 18, 2003, in attempting to identify those patients

admitted by Dr. Kat ta. There were approximately ten to 12 o ther

hospitalized patients with the same last name, none of which had

been admitted by Dr. Katta. The Respondent was unaware that the

patient had been admitted under Dr. Leiva's name. The

Respondent did not visit the ten to 12 patients with the same

last name to locate the one for which she was responsible.

28. The Respondent did not contact the blood bank, which

had been having difficulty providing transfusion blood to the

patient. It is reasonable to assume that the blood bank,

charged with the respon sibility to provide the appropriate blood

supplies to the patient, would have been aware of the patient's

location, and could have provided it to the Respondent.

29. The Respondent made no effort to identify patients

located in the hospital's intensive ca re units, despite the

critical nature of the patient's condition at last report. Had

she done so, she w ould have located the patient.

30. The Respondent presented testimony that it was not

uncommon for a physician, unable to locate a hospitalized

patient , to routinely assume that the patient has been

appropriately treated and has been discharged, or is deceased.

However, the Respondent testified that it was unusual for her

not to be able to identify and locate a patient.

31. Even assuming that such prac tice is routine, it is

unlikely that such an assumption could reasonably be made in the

case at issue here, where the Respondent did not know the

patient's name, had never seen the patient, had personally

reviewed no medical records, was unable to find any one in the

hospital who could provide her with any information, and at last

communication with the nursing staff had been told that a

critically - needed transfusion had not occurred. The testimony

is not credited and is rejected.

CONCLUSIONS OF LAW

32. T he Division of Administrative Hearings has

jurisdiction over the parties to and the subject matter of this

proceeding. §§ 120.569 and 120.57, Fla . Stat . (2007 ).

33. The Respondent is the state agency charged with

regulating the practice of medicine. § 2 0.43 and Ch . 456 and

Ch. 458, Fla . Stat . (2003).

34. The Administrative Complaint charges the Respondent

with a violation of S ubs ection 458.331(1)(t), Florida Statutes

(2002), which provides in relevant part as follows:

( 1) The following acts constitute grounds

for denial of a license or disciplinary

action, as specified in s. 456.072(2):

* * *

(t) Gross or repeated malpractice or the

failure to practice medicine with that level

of care, skill, and treatment which is

recognized by a reasonably prudent similar

physician as being acceptable under similar

conditions and circumstances. The board

shall give great weight to the provisions of

s. 766.102 when enforcing this paragraph.

As used in this paragraph, "repeated

malpractice" includes, but is not limited

to, three or more claims for medical

malpractice within the previous 5 - year

period resulting in indemnities being paid

in excess of $25,000 each to the claimant in

a judgment or settlement and which incidents

involved negligent conduct by the physician.

As used in this paragraph, "gross

malpractice" or "the failure to practice

medicine with that level of care, skill, and

treatment which is recognized by a

reasonably prudent similar physician as

being acceptable under similar conditions

and cir cumstances," shall not be construed

so as to require more than one instance,

event, or act. Nothing in this paragraph

shall be construed to require that a

physician be incompetent to practice

medicine in order to be disciplined pursuant

to this paragraph.

35. The Administrative Complaint alleges that the

Respondent violated the referenced statute by failing to

adequately assess or treat the patient's condition on March 17

and 18, 2003.

36. The Petitioner has the burden of proving by clear and

convincin g evidence the allegations set forth in the

Administrative Complaint against the Respondent. Department of

Banking and Finance v. Osborne Stern and Company , 670 So . 2d

932, 935 (Fla. 1996) ; Ferris v. Turlington , 510 So. 2d 292 (Fla.

1987).

37. Clear and convincing evidence is that which is

credible, precise, explicit , and lacking confusion as to the

facts in issue. The evidence must be of such weight that it

produces in the mind of the trier of fact the firm belief of

conviction, without hesitancy, as to the truth of the

allegations. Slomowitz v. Walker , 429 So. 2d 797, 800 (Fla. 4th

DCA 1983). In this case, the burden has been met.

38. The evidence establishes that the Respondent failed to

practice medicine with that level of care, skill, and treatmen t

which is recognized by a reasonably prudent similar physician as

being acceptable under similar conditions and circumstances.

39. The Respondent failed to properly identify and locate

the patient, failed to examine or properly treat the patient,

faile d to review lab test results, and failed to contact the

blood bank to assess the cause for the failure to perform

critical medical treatment. Additionally, the Respondent,

absent any supporting information, inappropriately assumed that

a patient, who had been moved into an intensive care unit, had

been discharged from the hospital.

40. Florida Administrative Code Rule 64B8 - 8.001 sets forth

the disciplinary guidelines applicable to the statutory

violation s relevant to this proceeding.

41. Florida Administ rative Code Rule 64B8 - 8.001(2)(t)3.

provides that the penalty for a first offense of S ubs ection

458 . 331(1)(t), Florida Statutes, ranges from a minimum penalty

of two years ' probation to revocation or denial of licensure and

an administrative fine of $1,000 to $10,000.

42. Florida Administrative Code Rule 64B8 - 8.001(3)

provides as follows:

Aggravating and Mitigating Circumstances.

Based upon consideration of aggravating and

mitigating factors present in an individual

case, the Board may deviate from the

pen alties recommended above. The Board

shall consider as aggravating or mitigating

factors the following:

(a) Exposure of patient or public to injury

or potential injury, physical or otherwise:

none, slight, severe, or death;

(b) Legal status at the time of the

offense: no restraints, or legal

constraints;

(c) The number of counts or separate

offenses established;

(d) The number of times the same offense or

offenses have previously been committed by

the licensee or applicant;

(e) The disciplinary hi story of the

applicant or licensee in any jurisdiction

and the length of practice;

(f) Pecuniary benefit or self - gain inuring

to the applicant or licensee;

(g) The involvement in any violation of

Section 458.331, F.S., of the provision of

controlled su bstances for trade, barter or

sale, by a licensee. In such cases, the

Board will deviate from the penalties

recommended above and impose suspension or

revocation of licensure.

(h) Where a licensee has been charged with

violating the standard of care pur suant to

Section 458.331(1)(t), F.S., but the

licensee, who is also the records owner

pursuant to Section 456.057(1), F.S., fails

to keep and/or produce the medical records.

(i) Any other relevant mitigating factors.

43. The Respondent has had no prior disciplinary action

taken against her license.

44. The evidence establishes that the patient's medical

condition was complex , and there were multiple systemic issues

that may have contributed to the outcome. However, the risk of

injury or potential inju ry related to the Respondent's actions

in this case is clear. The Respondent failed to appropriately

respond to the information provided telephonically by the nurse

and failed to review medical records and examine the patient.

The patient's condition det eriorated during the time that the

Respondent was responsible for Dr. Katta's hospitalized

patients. Further, upon being unable to locate the patient at

the hospital when making her rounds on March 18, 2003, the

Respondent assumed , without any supporting information, that the

patient had been transfused and discharged, essentially

abandoning her responsibility to treat the patient.

Accordingly, the following disposition is recommended.

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusion s of

Law, it is RECOMMENDED that the Department of Health enter a

f inal o rder finding Vasundhara I y engar, M.D., in violation of

S ubs ection 458.331(1)(t), Florida Statutes (2002), and imposing

a penalty as follows: a three - year period of probation ; a fine

of $10,000; and such additional community service and continuing

education requirements as the Department of Health determines

necessary.

DONE AND ENTERED this 31st day of January, 2008 , in

Tallahassee, Leon County, Florida.

S

WILLIAM F. QUATTLEBAUM

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 wit h the Clerk of the

Division of Administrative Hearings

this 31st day of January , 2008 .

COPIES FURNISHED :

Jennifer Forshey, Esquire

Dorys H. Penton, Esquire

Department of Health

4052 Bald Cypress Way, Bin C - 65

Tallahassee, Florida 32399 - 3265

H. Gregory McNeill, Esquire

Lowndes, Drosdick, Doster

Kantor & Reed, P.A.

Post Office Box 2809

Orlando, Florida 32802 - 2809

H. Roger Lutz , Esquire

Lutz, Bobo & Telfair, P.A.

2 North Tamiami Trail, Suite 500

Sarasota, Florida 34236

Josefina M. Tamayo, General C ounsel

Department of Health

4052 Bald Cypress Way, Bin A - 02

Tallahassee, Florida 32399 - 1701

Larry McPherson, Executive Director

Board of Medicine

4052 Bald Cypress Way

Tallahassee, Florida 32399 - 1701

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties h ave 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.