20-003062PL Department Of Health, Board Of Nursing vs. Alejandro Perez, A.P.R.N.
 Status: Closed
Recommended Order on Monday, May 3, 2021.


View Dockets  
Summary: APRN performed intravitreal injections into the eyes of three patients resulting in blindness. APRN had no written protocol for the procedure, was unsupervised, unqualified, and represented himself as a doctor. Recommend revocation of license.

1S TATE OF F LORIDA

6D IVISION OF A DMINISTRATIVE H EARINGS

13D EPARTMENT OF H EALTH , B OARD OF

21N URSING ,

23Petitioner ,

24vs. Case Nos. 20 - 3057PL

3020 - 3062PL

33A LEJANDRO P EREZ , A.P.R.N. , 20 - 3066PL

41Respondent .

43/

44R ECOMMENDED O RDER

48On October 28 and 29 , 2020, Robert E. Meale, Administrative Law Judge

60of the Division of Administrative Hearings (DOAH), conducted the final

70hearing by Zoom.

73A PPEARANCES

75For Petiti oner: Dirlie Anna McDonald, Esquire

82Nicole M. DiBartolomeo, Esquire

86Department of Health

894052 Bald Cypress Way, Bin C - 65

97Tallahassee, Florida 32399

100For Respondent: Dwight Oneal Slater, Esquire

106Cohn Slater, P.A.

1093689 C oolidge Court, Unit 3

115Tallahassee, Florida 32311

118S TATEMENT OF T HE I SSUE S

126The issues are whether, during 2015, Respondent held himself out as a

138Ñ doctor of medicine, Ò even though he did not hold a license to practice

153medicine in Florida, in violation of section 456.072(1)(m), Florida Statutes

163(2014); whether, during 2015, Respondent exceeded the scope of his advanced

174practice registered nursing (APRN) 1 license modifier by removing adipose

184tissue from a patient Ô s abdomen, performing intravitreous injec tions of the

197processed tissue into both eyes of a patient, and failing to have a protocol in

212place for the removal of abdominal adipose tissue and the intravitreous

223injection of any material into a living person, in violation of section

235456.072(1)(o); and, if so, the penalty that should be imposed.

245P RELIMINARY S TATEMENT

249These three cases involve similar allegations concerning three patients.

258The Administrative Complaint alleges that, at all material times, Respondent

268was an APRN, holding license number APR N 9201869, and he was employed

281by U.S. Stem Cell Clinic (the Clinic), which was an affiliate of Bioheart, Inc.

295In DOAH Case 20 - 3057PL, the Administrative Complaint alleges that

306E.K., an 88 - year - old female with macular degeneration, presented to the

320Clinic for a Ñ stem cell Ò injection on May 15, 2015. Allegedly, E.K. had

335previously been evaluated and approved for the procedure by Shareen

345Greenbaum, an M.D. specializing in ophthalmology. On May 15, Respondent

355allegedly represented himself to E.K. and her niec e, B.K. , as Ñ Dr. Perez Ò and

371allegedly held himself out to the public as Ñ Alex Perez, D[octor of] M[edicine],

385NP - C , Ò on the website of the Clinic, where he was referred to as Ñ Dr. Perez, Ò

405even though Respondent did not hold a license to practice medicine.

416On May 15, Respondent allegedly performed a procedure to remove

426adipose, or fat, tissue from E.K. Ô s abdomen and intravitreously inject the

439tissue, after processing, into both eyes of the patient. On May 15, E.K.

452allegedly experienced complications, includi ng bilateral retinal detachment

460and blindness, due to the intravitreal injections of the product created from

4721 Until 2018, an APRN was known as an Ñ advanced registered nurse practitioner .Ò For ease

489of reference, this recommended order will use only the current title.

500the adipose tissue. Due to the injections, E.K. allegedly became legally blind

512with no light perception in either eye.

519In 2015, Respondent allege dly did not have an APRN protocol in place

532covering the removal of abdominal fat tissue or injection of any material

544intravitreously into a living person.

549Count I of the Administrative Complaint alleges that section 456.072(1)(o)

559provides that discipline may be imposed if a licensee practices or offers to

572practice beyond the scope permitted by law or accepts or performs

583professional responsibilities that the licensee knows, or has reason to know,

594he is not competent to perform. Count I alleges that Respond ent exceeded the

608scope of his APRN license by removing fat tissue from E.K. Ô s abdomen,

622performing intravitreous injections into both of E.K. Ô s eyes, and failing to

635have in place an APRN protocol covering the removal of abdominal fat tissue

648or injection of any material intravitreously into living persons.

657Count II of the Administrative Complaint alleges that section

666456.072(1)(m) provides that discipline may be imposed if a licensee makes

677deceptive, untrue, or fraudulent representations in or relation to th e practice

689of a profession or employs a trick or scheme in , or relat ing or relat ed to , the

707practice of a profession. Count II alleges that Respondent made deceptive,

718untrue, or fraudulent representations related to the practice of his profession

729by represe nting himself to E.K. and B.C. as Ñ Dr. Perez Ò and by holding

745himself out to the public as Ñ Alex Perez, DM, NP - C ,Ò on the Clinic Ô s website,

765which addressed him as Ñ Dr. Perez. Ò

773The Administrative Complaint seeks the full range of penalties through

783revocatio n.

785Counts I and II of the Administrative Complaints in DOAH Case

796Nos. 20 - 3062PL and 20 - 3066PL are identical to Counts I and II of the

813Administrative Complaint in DOAH Case No. 20 - 3057PL, except for the facts

826set forth immediate below.

830In DOAH Case No. 20 - 3062PL, the Administrative Complaint alleges that

842P.B., a 77 - year - old female with macular degeneration, presented to the Clinic

857for a Ñ stem cell Ò injection into both eyes on June 16, 2015. Allegedly, P.B. had

874previously been evaluated and approved for the procedure by William

884Mestrezat, an M.D. specializing in the retina, and Dr. Greenbaum. On

895June 16, Respondent allegedly represented himself to P.B. as Ñ Dr. Perez Ò and

909held himself out to the public as Ñ Alex Perez, DM, NP - C , Ò on the website of

928the Clinic, where he was referred to as Ñ Dr. Perez, Ò even though Respondent

943did not hold a license to practice medicine.

951On May 16, Respondent allegedly performed a procedure to remove fat

962tissue from P.B. Ô s abdomen and intravitreously inject the tissue, after

974proces sing, into both eyes of the patient. On May 15, P.B. allegedly

987experienced complications, including bleeding from the eyes, due to the

997intravitreous injections of the product created from the fat tissue. Due to the

1010injections, P.B. allegedly became legally blind with no light perception in

1021either eye.

1023In DOAH Case No. 20 - 3066PL, the Administrative Complaint alleges that

1035E.N., a 75 - year - old female with macular degeneration, presented to the Clinic

1050for a Ñ stem cell Ò injection into both eyes on June 16, 2015. Allegedly, E . N . had

1070previously been evaluated and approved for the procedure by Dr. Greenbaum.

1081On June 16, Respondent allegedly represented himself to E.N. as Ñ Dr. Perez Ò

1095and held himself out to the public as Ñ Alex Perez, DM, NP - C , Ò on the website

1114of the Clinic, where he was referred to as Ñ Dr. Perez, Ò even though

1129Respondent did not hold a license to practice medicine.

1138On June 16, Respondent allegedly performed a procedure to remove fat

1149tissue from E.N. Ô s abdomen and intravitreously inject the tissue, aft er

1162processing, into both eyes of the patient. On June 16, E.N. allegedly

1174experienced complications, including nausea, vomiting, and loss of

1182consciousness due to the intravitreous injections of the product created from

1193the fat tissue. Due to the injections, E . N . allegedly became legally blind with

1209no light perception in either eye.

1215For each of the three cases, Respondent requested a hearing involving

1226disputed issues of fact . On July 29, 2020, the administrative law judge issued

1240an O rder consolidating the th ree cases.

1248At the hearing, Petitioner called 11 witnesses and offered into evidence

1259nine exhibits: Petitioner Exhibits 1 through 4 and 6 through 10. Respondent

1271called one witness and offered two exhibits into e vidence: Respondent Ô s

1284Exhibits A and B. All e xhibits were admitted except for Respondent Ô s

1298Exhibit A. However, Respondent Ô s exhibits are in Spanish, and Respondent

1310has not provided an interpretation of either of them.

1319The two - volume Transcript was filed on November 13, 2020. Petitioner

1331timely filed its P roposed R ecommended O rder on January 11, 2021. On the

1346same date, Respondent Ô s counsel requested additional time within which to

1358file his P roposed R ecommended O rder due to a recent case of Covid - 19. On

1376January 12, 2021, the administrative law judge ext ended Respondent Ô s

1388deadline to January 14 , 2021 . Because Respondent would have the advantage

1400of having read Petitioner Ô s P roposed R ecommended O rder before filing

1414Respondent Ô s P roposed R ecommended O rder, the O rder allowed Petitioner an

1429opportunity to file a response to Respondent Ô s P roposed R ecommended O rder

1444by January 19 , 2021 . Petitioner filed a five - page response on January 19,

14592021, which Respondent moved to strike as unauthorized under the law. The

1471administrative law judge denied the motion to strike by O rder entered

1483January 20 , 2021 .

1487The parties Ô proposed recommended orders were taken into consideration

1497in the drafting of this Recommended Order. On April 20, 2021, this case was

1511transferred to the undersigned due to the inability of Judge Meale to final ize

1525the Recommended Order. However, prior to the transfer, Judge Meale had

1536drafted a significant portion of this Recommended Order, including his

1546Findings of Fact and credibility determinations. The undersigned reviewed

1555the T ranscript and all exhibits prio r to editing and finalizing this

1568Recommended Order.

1570Unless otherwise indicated, all statutory references are to the versions in

1581effect at the time of the alleged violations.

1589F INDINGS OF F ACT

1594The Parties

15961. Petitioner is the state agency charged with regula ting the practice of

1609nursing pursuant to section 20.43, and chapter s 456 and 464 , Florida

1621Statutes .

16232. Respondent was born and raised in Cuba, where he obtained a licensed

1636practical nurse degree and, in 1995, Respondent earned a Doctor of Medicine

1648degree and moved to Florida. On two occasions, Respondent failed to pass

1660the examinations in Florida for licensure as a medical doctor.

16703. Respondent obtained a Florida license as a registered nurse in 2005

1682and, in March 2015, a license modifier as an APRN. Respondent Ô s highest

1696relevant education in the United States is a Master of Science degree in

1709nursing awarded in December 2014 from the south Florida campus of the

1721University of Turabo. A couple of months later, the American Academy of

1733Nurse Practitioners certified R espondent as a Family Nurse Practitioner.

17434. The transfer of processed fat tissue into the eye is thought, by some, to

1758treat conditions of the eye, such as dry macular degeneration, to be part of

1772regenerative medicine. This so - called Ñ stem cell injection proc edure Ò

1785( Ñ procedure Ò ) comprises three steps: ( 1) removing the fat tissue, usually from

1801the abdomen; ( 2) processing the fat tissue to prepare it for injection; and ( 3)

1817injecting the processed fat tissue into the vitreous cavity at the back of the

1831eye.

18325. Follo wing the completion of his medical education in Cuba, Respondent

1844obtained varying degrees of training and experience in the each of the three

1857steps of the procedure. Respondent testified that he trained with a

1868Ñ specialist, Ò possibly an ophthalmologist, in intravitreal injections. This

1878covered such topics as the choice of syringe, the preparation of the patient,

1891maintaining an open eye, the choice of a substance to stabilize the inside and

1905outside eye, and the angle of the needle to the surface of the eye at the point

1922of injection. Respondent also obtained training in intranasal and

1931intraarterial injections, the latter of which is the more complicated.

1941Respondent obtained a certificate in Mexico for completing the training in

1952the removal of tissue from bone m arrow. Respondent did not detail his

1965training or experience in processing removed fat tissue.

19736. Through much of Latin America, Respondent has injected processed fat

1984tissue, at the rate of about ten patients over one week , and has trained other

1999healthcare pro viders to perform these procedures. Respondent also testified

2009that he had performed a dozen intravitreal injections of processed fat tissue

2021in Mexico and Chile prior to the three injections at issue in this case, so it

2037seems that most of his experience did not involve intravitreal injections.

20487. Respondent Ô s only evidence of purported Ñ stem cell Ò experience was

2062assisting in bone marrow aspiration, not surgical adipose tissue removal or

2073intravitreal injections.

20758. Respondent admitted that he had never performed i ntravitreal

2085injections under the supervision of an ophthalmologist, a medical doctor of

2096any type, or in a supervised training program prior to performing

2107intravitreal injections on Patients E.K., E.N., and P.B. in May and June of

21202015 . Respondent failed to provide any evidence that he was educated or

2133supervised by a licensed physician in the performance of these procedures

2144prior to performing them on Patients E.K., E.N., and P.B.

2154Performance of the Procedure by Respondent at the Clinic

21639. Respondent Ô s first i ntravitreal injection of fat tissue at the Clinic took

2178place in April 2015, about one month after he had completed the educational

2191requirement for this APRN license modifier. Having retained Respondent as

2201an independent contractor, the Clinic called him a few days before an

2213upcoming intravitreal stem cell injection to confirm his availability. The

2223Clinic paid Respondent $500 per procedure, for which it charged each

2234patient $5000. Although the Clinic operated this program as an FDA -

2246registered clinical trial, all procedures were Ñ patient funded treatment, Ò and

2258the Clinic was not affiliated with any educational or research institution

2269investigating stem - cell treatment of eye diseases or disorders.

227910. The three patients involved in this case are , or were , E.K., P.B ., and

2294E.N. E.K. Ô s procedure took place on May 15, 2015, and P.B. and E.N. Ô s

2311procedures took place on June 16, 2015. Each patient suffered from dry

2323macular degeneration. Each patient was sighted at the time of the

2334procedure, at the end of which, each patie nt was substantially blind. At the

2348time of each patient Ô s procedure, E.K., who died five years after her

2362procedure, was 89 years old and resided in Oklahoma. P.B. was 77 years old

2376and resided in southwest Florida, and E.N. was 72 years old and resided in

2390M issouri, where she had taught research methods to graduate students at

2402the University of Missouri.

240611. At the time of the subject procedures, the Clinic was affiliated with

2419Bioheart, Inc., a publicly traded corporation. Key employees of the Clinic

2430included Kr istin Comella, who served as the chief scientist of the Clinic and

2444chief scientific officer of Bioheart and holds bachelor Ô s and master Ô s degrees

2459in chemical engineering, and Dr. Antonio Blanco, who is an internist in

2471Hollywood, Florida , with 26 years of p ractice and the medical director of the

2485Clinic and holds a medical degree from Georgetown University. The Clinic Ô s

2498website adds that Ms. Comella is in the top 50 of global stem - cell

2513influencers.

251412. E.K. and E.N. testified that they learned about or confirmed their

2526interest in the Clinic by an online search of clinical trials of stem - cell

2541treatment for dry macular degeneration. Neither patient differentiated

2549between patient - funded clinical trials, such as these, and clinical trials

2561whose treatment costs were su bsidized by research centers, universities,

2571hospitals, and pharmaceutical manufacturers.

257513. E.K. Ô s medical records do not include any representations as to

2588Respondent Ô s status as a healthcare provider. E.K. and her niece, who

2601accompanied her, arrived in Fort Lauderdale in sufficient time for E.K. Ô s

2614pre - operative appointment with Dr. Greenbaum, an ophthalmologist

2623employed with the Hollywood Eye Clinic. Until she spoke with

2633Dr. Greenbaum, E.K. believed that Dr. Greenbaum would perform the

2643procedure, based on wha t she had been told by Clinic staff.

265514. At the pre - operative exam conducted by Dr. Greenbaum, E.K. and her

2669niece learned that Dr. Greenbaum would not be performing the procedure on

2681the following day. Dr. Greenbaum mentioned Respondent Ô s name, so the

2693niece ha d her husband research Respondent that night, but his research

2705revealed nothing.

270715. The next day, E . K. and her niece were introduced to Respondent by a

2723Clinic employee, likely Ms. Comella. The niece does not recall if the

2735employee referred to Respondent as a physician, but she assumed that he

2747was. She recalled only that the clinic employee introduced him by saying

2759that he was very experienced and had performed lots of stem cell injections

2772of this type. The niece recalled distinctly that Respondent introduced h imself

2784as a Ñ medical doctor. Ò Respondent denies doing so. The niece Ô s testimony is

2800credited based on the totality of the evidence.

280816. P.B. Ô s medical records do not include any representations as to

2821Respondent Ô s status as a healthcare provider except for the operative report,

2834which bears Respondent Ô s signature above Ñ Physician Signature. Ò Well prior

2847to the date of the procedure, P.B. called the Clinic, spoke with

2859Dr. Greenbaum and Ms. Comella, who informed her that Dr. Greenbaum

2870would perform the procedure. P. B. later arrived in Fort Lauderdale in time

2883for her pre - operative exam by Dr. Greenbaum, whose office told P.B. that

2897Dr. Greenbaum was no longer performing the procedure. P.B. assumed that

2908another ophthalmologist would perform the procedure.

291417. The next day, P.B. and a friend or family member, who had

2927accompanied her on the trip, met Ms. Comella and Respondent, whom

2938Ms. Comella introduced as Ñ Doctor Perez, Ò and he did not correct her. P.B.

2953asked him if he was an ophthalmologist, and Respondent replied, Ñ no, bu t

2967I Ô m well - trained in this procedure. Ò He never mentioned that, in terms of

2984Florida licensing, he was only a registered nurse or APRN and was not a

2998physician.

299918. E.N. Ô s medical records include the most references to Respondent Ô s

3013status as a healthcare provide r. These records include a page from the

3026Clinic Ô s website that was initialed and dated by E.N. , and prominently

3039identifies Respondent as a Ñ DM, NP - C, Ò meaning Ñ doctor of medicine Ò and

3056Ñ nurse practitioner -- certified. Ò The accompanying text discloses that

3067Ñ D r. Alejandro Perez Ò graduated from the University of Havana Medical

3080School in 1993 as a Ñ Doctor in Medicine Ò ; since 2007, he has conducted

3095innovative research on regenerative medicine with a focus on adult stem

3106cells from bone marrow and adipose tissue; Ñ D r. Perez Ò has worked on adult

3122stem cells to treat multiple chronic diseases; Ñ Dr. Perez Ò trains national and

3136foreign Ñ Medical Doctors Ò on the use of adult stem cells; and that Ñ[h] e

3152currently holds a National Board Certification as a Family Nurse

3162Practitio ner. Ò In three out of five references, the document refers to

3175Respondent as a Ñ doctor, Ò never disclosing that he was not a licensed

3189physician in Florida. This website page may have come into existence after

3201Respondent Ô s first patient encounter in this case in May 2015.

321319. Ms. Comella introduced Respondent to E.N. and her sister, who had

3225accompanied her on the trip, as Ñ Dr. Alex Perez. Ò Without stating his

3239specialization, Respondent told E.N. that he was a Ñ medical doctor Ò and was

3253proud of his Ñ profession, Ò whi ch, in context, meant the practice of medicine,

3268not nursing. Respondent wore a white jacket with a printed name tag, Ñ Alex

3282Perez, M.D. Ò At no time did Respondent reveal that his Florida licensure

3295was as a registered nurse or APRN and not a physician.

3306Lack of a Written Protocol

331120. As a licensed APRN, Respondent was required by section 464.012 and

3323Florida Administrative Code R ule 64B9 - 4.002 to practice under an APRN

3336protocol filed with the Board of Nursing . At all times material, the scope of

3351practice of a cert ified family nurse practitioner licensed in Florida as an

3364APRN did not include performing any invasive procedures, including

3373surgical removal of adipose tissue or intravitreal injections, without an

3383APRN Protocol on file that ensured physician supervision.

339121. By letter dated March 12, 2015, the Board of Nursing notified

3403Respondent that he was required to have an approved APRN protocol on file

3416with the Department Ñ within 30 days of employment. Ò Respondent was

3428employed in March 2015 at the time of receipt of the above - referenced letter.

344322. In May and June 2015, Respondent was aware of the protocol

3455requirement and the scope of practice as an APRN. He admitted that he

3468received the March 12, 2015, letter and failed to provide a protocol as

3481instructed.

348223. At no time did Re spondent ever obtain or file with the Board of

3497Nursing a written protocol between him and a supervising licensed

3507physician authorizing Respondent to perform the subject procedure.

3515Respondent claimed, alternatively, that Drs. Greenbaum and Blanco served

3524as his supervising physicians , but admitted that they served remotely and

3535without a signed written protocol.

3540Harm to the Patients

354424. The impact on the three patients of this unauthorized procedure

3555performed by Respondent was blindness and its incumbent, incalcu lable

3565damages, including, but not limited to, loss of independence, loss of mobility,

3577and loss of enjoyment of life . Respondent admitted that , if not for the

3591procedure, the three patients would likely not have been blind. 2

3602C ONCLUSIONS OF L AW

360725. DOAH has juri sdiction. §§ 120.569 and 120.57(1) , Fla. Stat. (2015).

361926. The Administrative C omplaints seek to suspend, revoke, or impose

3630other discipline upon a license. This proceeding is penal in nature. State ex

3643rel. Vining v. Fla. Real Estate Comm Ô n , 281 So. 2d 487, 4 91 (Fla. 1973).

3660Petitioner must prove the material allegations by clear and convincing

3670evidence. § 120.57(1)(j) , Fla. Stat. ; Dep Ô t of Banking & Fin. v. Osborne Stern

3685& Co. , 670 So. 2d 932 (Fla. 1996). Clear and convincing evidence is evidence

3699that is ÑÓ pre cise, explicit, lacking in confusion, and of such weight that it

37142 Respondent contends that it was not the injection which he performed, but rather the

3729separation a nd preparation of the stem cells from the fat tissue by other Clinic staff prior to

3747the injection that somehow caused the patients Ô blindness. No credible evidence regarding

3760this argument was presented.

3764produces a firm belief or conviction, without hesitation, about the matter in

3776issue. ÔÑ Robles - Martinez v. Diaz, Reus & Targ, LLP , 88 So. 3d 177, 179 n.3

3793(Fla. 3d DCA 2011)(citing Fla. Std. Ju ry Instr. (Civ.) 405.4).

3804Deceptive, Untrue, and Fraudulent Representations by Respondent

381127. Section 456.072(1)(m) prohibits Ñ [m]aking deceptive, untrue, or

3820fraudulent representations in or related to the practice of a profession or

3832employing a trick or schem e in or related to the practice of a profession. Ò

384828. Respondent Ô s actions at issue in this case involved patient evaluation

3861and treatment in or related to his practice as an APRN, Respondent Ô s

3875representation of himself in a clinical setting as a medical doct or, and

3888whether his performance of procedures that were within the scope of the

3900practice of medicine constituted making deceptive, untrue , or fraudulent

3909representations in or related to the practice of a profession. See Dep Ô t of

3924Health v. Zamek , Case No. 1 1 - 0546PL (DOAH July 28, 2011; DOH

3938Dec. 1 4 , 2011)(disciplining a physician after finding that the physician made

3950deceptive and untrue representations regarding his identity to patient by

3960failing to advise her that, although he was a Florida - licensed M.D., he was

3975not the physician that the patient believed to be treating her, Ñ due to lack of

3991an introduction and any form of identification on the lab coat -- if he was a

4007doctor or a physician Ô s assistant. Ò )

401629. Respondent Ô s conduct in introducing himself in a clinica l setting as

4030Ñ Dr. Perez, Ò allowing Clinic staff to introduce him to patients in his presence

4045as Ñ Dr. Perez, Ò allowing the Clinic to represent in his biography, which he

4060provided, that he was Ñ Dr. Perez, Ò and allowing the Clinic to fail to include

4076in that b iography that he was licensed in Florida as an ARNP, not as a

4092medical doctor, constitute s deceptive, untrue , or fraudulent representations

4101related to the practice of his profession.

410830. The fact that Respondent was licensed as a medical doctor in Cuba

4121did not exempt him from the requirements of being licensed as a medical

4134doctor in Florida prior to performing medical evaluation s , designating plans

4145of treatment, and treating patients including Patients E.K., E.N., and P.B.

4156in Florida.

415831. Petitioner proved by clear and convincing evidence that Respondent is

4169guilty of three counts of making deceptive, untrue, or fraudulent

4179representations related to the practice of medicine.

4186Respondent Ô s Practice Beyond the Scope Permitted by Law

419632. Section 456.072(1)(o) prohibits Ñ [p] r acticing or offering to practice

4208beyond the scope permitted by law. Ò Section 464.012(3) authorizes an APRN

4220to provide certain Ñ advanced - level nursing acts, Ò normally associated with a

4234medical, dental, or osteopathic licensee, if the APRN proceeds under a

4245Ñ written protocol, Ò which, among other things, specifies Ñ the medical acts to

4259be performed and the conditions for their performance. Ò § 464.003(2) , Fla.

4271Stat . The protocol must be in writing, signed by both parties, filed with

4285Petitioner, and specify what t he APRN may do in providing medical

4297treatment and what the supervising physician must do.

430533. Similarly, r ule 64B9 - 4.010, Standards for Protocols, provides that an

4318APRN Ñ shall only perform medical acts of diagnosis, treatment and

4329operation pursuant to a proto col between the APRN and a Florida - licensed

4343medical doctor, osteopathic physician or dentist. Ò It further provides that

4354Ñ the degree and method of supervision, determined by the APRN and the

4367physician È shall be specifically identified in the written protoc ol and shall

4380be appropriate for prudent healthcare providers under similar

4388circumstancesÈ . Ò

439134. Based upon section 464.012(3) and r ule 64B9 - 4.010, Respondent could

4404not practice in May and June of 2015 as an APRN at all, let alone perform

4420the procedures he perf ormed on Patients E.K., E.N. , and P.B., without filing

4433an acceptable protocol with the Board of Nursing that demonstrated a

4444collaborative practice agreement with a supervising physician. Respondent

4452should have had a protocol on file with Petitioner demonst rating

4463collaborative practice with a supervising physician that included performing

4472surgical removal of adipose tissue by any method or injecting any material

4484by intravitreal injection before performing any such procedures.

449235. Without meeting the requirements mandated in section 464.012(3)

4501and r ule 64B9 - 4.010 , Respondent was bound by the scope of his licensure as

4517a registered nurse.

452036. Furthermore, even if Respondent had properly filed an acceptable

4530protocol and practiced within a written collaborative agreement with a

4540physician or dentist when he treated Patients E.K., E.N., and P.B., the

4552procedures Respondent performed on these patients were Ñ under the scope of

4564the practice of medicine Ò and not advanced nursing practice, according to the

4577materials from Responden t and the C linic.

458537. Even if Respondent was operating under a proper protocol, and these

4597procedures were included in the scope of his licensure, the record does not

4610establish that he possessed the required competency to perform intravitreal

4620injections.

462138. Petiti oner proved by clear and convincing evidence that Respondent is

4633guilty of three counts of practicing or offering to practice beyond the scope

4646permitted by law or accepting and performing professional responsibilities

4655the licensee knows, or has reason to kn ow, the licensee is not competent to

4670perform.

4671Penalty Assessment

467339. Pursuant to section 464.018(5), the Board of Nursing is charged with

4685issuing rules to provide guidelines for the disposition of disciplinary cases

4696involving nursing licensees. Rule 64B9 - 8.00 6 sets forth the disciplinary

4708guidelines, range of penalties, and aggravating and mitigating factors to

4718Ñ assure protection of the public from nurses who do not meet minimum

4731requirements for safe practice or who pose a danger to the public. Ò

474440. Rule 64B9 - 8.006 (3)(l) provides that a first offense violation of

4757section 456.072(1)(m) merits discipline ranging from a reprimand and a

4767$250 fine to a $10,000 fine and suspension; a second offense merits a range

4782of a $500 fine and suspension to a $10,000 fine and revocat ion. There is no

4799provision for additional penalties for more than two violations of section

4810456.072(1)(m). This consolidated case demonstrates three violations of

4818section 456.072(1)(m).

482041. Rule 64B9 - 8.006(3)(k) provides that a first offense violation of secti on

4834456.072(1)(o) merits discipline ranging from a reprimand, a $250 fine, and

4845continuing education to revocation. There is no provision for additional

4855penalties for more than one violation of section 456.072(1)(o). This

4865consolidated case demonstrates three violations of section 456.072(1)(o).

4873Aggravating Factors

487542. Rule 64B 9 - 8.006(5) provides that the Board of Nursing is permitted to

4890deviate from its disciplinary guidelines for penalties, if certain factors are

4901present , including, but not limited to:

49071. the d anger to the public;

49142. refusal by the licensee to correct or stop violations;

49243. the actual damage (physical or otherwise) caused by the violation;

49354. the deterrent effect of the penalty imposed; and

49445. cost of treatment.

4948Danger to the Public

495243. An individu al who performs services for the public without the

4964required licensure, or practices beyond the scope of his licensure as in this

4977case, is a danger to the public because he is acting without board or

4991departmental oversight and without any kind of verificat ion that the person

5003is trained and able to perform the services of a licensed practitioner safely.

501644. The procedures at issue here are beyond the scope of the type of

5030license obtained by Respondent and have been identified as procedures

5040considered within the scope of the practice of medicine. It is clear from the

5054record that Respondent was not qualified to perform these procedures.

5064Respondent has admitted that these procedures were beyond the scope of his

5076license as an APRN and that he should not have performe d them at all.

5091Refusal to Correct or Stop Violations

509745. Patient s P.B. and E.N. were introduced to Respondent as Ñ Doctor Ò by

5112one of his colleagues or Respondent himself. For the introductions via one of

5125his colleagues, Respondent did not correct the reasonabl e assumption that

5136he was a licensed medical doctor in the United States. Further, when the

5149patients and their companions asked Respondent if he was an

5159ophthalmologist or other specialty physician, Respondent did not advise

5168them that he was not a licensed d octor at all.

517946. Respondent misstated to all the patients that he was certified to

5191perform the procedure and had received extensive training. Further, Patient

5201E.N. was required to sign a form for the procedure which referred to

5214Respondent as Ñ Dr. Perez. Ò

522047. Furt her, there were numerous instances during Respondent Ô s

5231performance of the procedures where Respondent could have notified

5240physicians to supervise or complete the procedure. Respondent stated that

5250he had an informal verbal agreement with Dr. Blanco and Dr. Greenbaum,

5262in which the physicians agreed to be available to Respondent for questions

5274or emergencies and to supervise the procedures if needed. However,

5284Respondent performed the procedures without the supervision of either

5293physician. There is no evidence t hat Respondent requested either physician

5304be present for the procedure. There is also no evidence that Respondent

5316sought either physicians Ô counsel at any time once it became apparent that

5329patients had begun to experience adverse effects from the procedure .

534048. At some point after Patient E.K. Ô s procedure on May 15, 2015, and

5355before Patients E.N. and P.B. Ô s procedures on June 16, 2015, Respondent

5368learned that Patient E.K. was blind due to the procedure he performed . Y e t,

5384he continued to perform at least two mor e of the same procedure, in the

5399same manner, without supervision and without physician guidance.

5407Actual Damage Caused by the Violations

541349. After Respondent performed the intravitreal injections on these three

5423patients, they rapidly became blind. Evidence con firmed that if not for the

5436procedure being performed, these patients would likely not have been blind

5447today (or in the case of Patient E.K., until the time of her death in April

54632020). Respondent admitted that if not for the procedure, the women would

5475like ly not have been blind. 3

548250. Patient E.K. experienced emotional damage in addition to blindness.

5492Patient E.K. developed an extreme fear of falling due to her inability to

5505maneuver properly without sight. Towards the end of her life, Patient E.K.

5517experienced su ch pain due to her blindness that she would often call out to

5532God that she wanted to die.

553851. To this day, Patient P.B. still experiences daily eye pain and requires

5551numerous medications and drops to alleviate the pain. Patient P.B. has

5562undergone at least two subsequent surgeries in an attempt to repair her

5574eyes. Because of Respondent Ô s decision to ignore his scope of practice,

5587Patient P.B. stated that Ñ [her] whole life is down the tubes, to be honest with

5603you. Ò

560552. Patient E.N. testified that the lack of ability t o engage in most of her

5621normal activities has led to a more isolated existence. Many of her former

5634activities involved frequent and relationship - building interactions with other

56443 While it is true, as Respondent argues, that all th ree patients signed informed consents

5660prior to the procedure acknowledging loss of vison was a potential side effect, none

5674authorized Respondent to practice beyond the scope permitted by law or to perform

5687procedures he knew or had reason to know he was not competent to perform .

5702individuals. After Respondent performed these procedures, Patient E.N. can

5711no longer participate in such activities. Further, Patient E.N. noted that

5722social services and programs are extremely limited for blind individuals.

573253. The patients relied, to their significant detriment, on the assurances

5743made by Respondent that he was properly qualified to perform these

5754procedures. The unfortunate reality is that Respondent admittedly was

5763n either authorized nor qualified to perform these procedures.

5772The Deterrent Effect of Revocation

577754. Respondent testified numerous times that because he was a do ctor in

5790Cuba, he believed he was different from other advanced practice nurses in

5802Florida with the same licensure and practitioner credentials. Respondent

5811believed he could perform services beyond the scope of his APRN license

5823because he felt his backgroun d made him superior to his professional nurse

5836peers. When Patient E.N. spoke to Respondent about his being a physician,

5848Respondent said Ñ he was a medical doctor, and he was proud of his

5862profession È he spoke very clearly and proudly of his profession. Ò

587455. Whe n Respondent found out that Patient E.K. experienced blindness

5885and eye damage after her procedure, he continued to perform the procedure,

5897which led to his blinding of two more patients.

590656. Respondent ignored the statutory requirements for supervision of his

5916p ractice as an APRN and Respondent continually failed to seek and/or follow

5929the guidance of available physicians in his treatment of these patients. The

5941Board of Nursing sent numerous letters during Respondent Ô s first years of

5954licensure as an APRN notifying him of his failure to submit appropriate

5966protocols.

596757. Based on Respondent Ô s attitude that he was superior to his peers, his

5982willingness to negligently or intentionally provide misleading information to

5991patients as to his license status in Florida, and his previous disregard for the

6005Board of Nursing Ô s statutory requirements, rules, and procedures,

6015Respondent will likely continue to disregard the statutory requirements,

6024rules, and procedures if he continues to hold his nursing license.

603558. By imposing the most se vere punishment allowed under the Board Ô s

6049disciplinary guideline s , Petitioner will send a message to its licensees that

6061performing procedures that exceed the scope and training of their license,

6072especially the complicated and dangerous procedures that were performed

6081here, will not be tolerated

6086The Costs of Treatment

609059. The Department has proven by clear and convincing evidence that the

6102costs of the treatment, both during and after the procedures, for Patients

6114E.K., E.N. , and P.B., and their families and careg ivers were extensive.

612660. Patients E.K., E.N., and P.B. incurred numerous medical and other

6137expenses post - procedures as a result of Respondent Ô s actions. All three

6151patients required emergent ophthalmologic intervention after their

6158procedures.

615961. Patient P.B. unde rwent at least two surgeries on her eyes since the

6173procedure and is required to treat her eyes with multiple medicated drops

6185daily, incurring prescription costs. She had to hire individuals to help her

6197with household cleaning. Patient P.B. Ô s daughter susta ined economic and

6209emotional costs associated with assuming the care of her mother, quitting

6220her job, and relocating her own family to Florida.

622962. After the procedure, Patient E.K. moved into an assisted living

6240facility because she needed assistance performing activities of daily living

6250due to her loss of sight.

625663. Patient E.N. also had to hire someone to assist with routine

6268household tasks, such as laundry and cooking, as she cannot see. Patient

6280E.N. is no longer able to practice her profession as a researcher an d

6294professor in an academic setting due to her loss of vision post - procedure.

630864. Respondent demonstrated a complete disregard for the laws

6317governing the practice of nursing in Florida and severely injured multiple

6328patients in the process. Based on the aggravat ing factors discussed above,

6340revocation of Respondent Ô s license is the only penalty that will adequately

6353protect the residents of this state.

6359R ECOMMENDATION

6361Based on the foregoing Findings of Fact and Conclusions of Law, it is

6374R ECOMMENDED that the Board o f Nursing enter a final order finding that

6388Respondent has violated sections 456.072(1)(o) and 456.072(1)(m) and

6396revoking Respondent Ô s license to practice as an advanced practice registered

6408nurse.

6409D ONE A ND E NTERED this 3 rd day of May , 2021 , in Tallahassee, Leon

6425County, Florida.

6427S

6428M ARY L I C REASY

6434Administrative Law Judge

64371230 Apalachee Parkway

6440Tallahassee, Florida 32399 - 3060

6445(850) 488 - 9675

6449www.doah.state.fl.us

6450Filed with the Clerk of the

6456Division of Administrative Hearings

6460this 3rd day of May , 2021 .

6467C OP IES F URNISHED :

6473Dirlie Anna McDonald, Esquire Dwight Oneal Slater, Esquire

6481Department of Health Cohn Slater, P.A.

64874052 Bald Cypress Way, Bin C - 65 3689 Coolidge C ourt, Unit 3

6501Tallahassee, Florida 32399 Tallahassee, Florida 32311

6507Nicole M. DiBartolomeo, Esquire Joe Baker, Jr., Exe cutive Director

6517Department of Health Board of Nursing

6523Office of the General Counsel Department of Health

65314052 Bald Cypress Way , Bin C - 65 4052 Bald Cypress Way, Bin C - 02

6547Tallahassee, Florida 32399 Tallahassee, Florida 32399

6553Louise St. Laurent, General Counsel Deborah McKeen, BS, CD - LPN

6564Department of Health Board of Nursing

65704052 Bald Cypress Way, Bin C - 65 Department of Health

6581Tallahassee, Florida 32399 4052 Bald Cypress Way, Bin D - 02

6592Tallahassee, Florida 32399

6595N OTICE OF R IGH T T O S UBMIT E XCEPTIONS

6607All parties have the right to submit written exceptions within 15 days from

6620the date of this Recommended Order. Any exceptions to this Recommended

6631Order should be filed with the agency that will issue the Final Order in this

6646case.

Select the PDF icon to view the document.
PDF
Date
Proceedings
PDF:
Date: 07/09/2021
Proceedings: Respondent's Exceptions to Recommended Order filed.
PDF:
Date: 07/09/2021
Proceedings: Petitioner's Response to Respondent's Exceptions to the Recommended Order filed.
PDF:
Date: 07/09/2021
Proceedings: Agency Final Order filed.
PDF:
Date: 07/06/2021
Proceedings: Agency Final Order
PDF:
Date: 06/04/2021
Proceedings: Order Denying Respondent's Motion for New Trial.
PDF:
Date: 05/19/2021
Proceedings: Petitioner's Response to Respondent's Motion for New Trial filed.
PDF:
Date: 05/18/2021
Proceedings: Respondent's Motion for New Trial filed.
PDF:
Date: 05/03/2021
Proceedings: Recommended Order
PDF:
Date: 05/03/2021
Proceedings: Recommended Order (hearing held October 28 and 29, 2020). CASE CLOSED.
PDF:
Date: 05/03/2021
Proceedings: Recommended Order cover letter identifying the hearing record referred to the Agency.
PDF:
Date: 04/20/2021
Proceedings: Notice of Transfer.
PDF:
Date: 01/20/2021
Proceedings: Order Denying Motion to Strike.
PDF:
Date: 01/20/2021
Proceedings: Petitioner's Response to Respondent's Motion to Strike filed.
PDF:
Date: 01/20/2021
Proceedings: Motion to Strike filed.
PDF:
Date: 01/19/2021
Proceedings: Petitioner's Response to Respondent's Proposed Recommended Order filed.
PDF:
Date: 01/13/2021
Proceedings: Respondent's Proposed Recommended Order filed.
PDF:
Date: 01/12/2021
Proceedings: Order Granting Motion for Extension of Time to File Proposed Recommended Order.
PDF:
Date: 01/11/2021
Proceedings: Petitioner's Response to Respondent's Second Motion for Extension of Time to File Proposed Recommended Order filed.
PDF:
Date: 01/11/2021
Proceedings: Petitioner's Proposed Recommended Order filed.
PDF:
Date: 01/11/2021
Proceedings: Motion for Extension of Time to File Response to Motion to Relinquish Jurisdiction filed.
PDF:
Date: 12/29/2020
Proceedings: Order Granting Extension of Time.
PDF:
Date: 12/28/2020
Proceedings: Motion for Extension of Time to File Proposed Recommended Order filed.
PDF:
Date: 12/11/2020
Proceedings: Order Granting Extension of Time.
PDF:
Date: 12/10/2020
Proceedings: Motion for Extension of Time to File Proposed Recommended Order filed.
PDF:
Date: 11/13/2020
Proceedings: Notice of Filing Transcript.
Date: 11/13/2020
Proceedings: Transcript (not available for viewing) filed.
PDF:
Date: 10/29/2020
Proceedings: Notice of Filing Petitioner's Exhibit 10 filed.
Date: 10/28/2020
Proceedings: CASE STATUS: Hearing Held.
PDF:
Date: 10/26/2020
Proceedings: Respondent's Exhibit List (with attached exhibits) filed.
PDF:
Date: 10/23/2020
Proceedings: Notice of Providing Witness Contacts filed.
Date: 10/22/2020
Proceedings: Petitioner's Proposed Exhibits filed (exhibits not available for viewing).
PDF:
Date: 10/22/2020
Proceedings: Joint Pre-Hearing Stipulation filed.
PDF:
Date: 09/29/2020
Proceedings: Petitioner's Motion for Official Recognition filed.
PDF:
Date: 09/23/2020
Proceedings: Petitioner's Notice of Service of Responses to Respondent's First Request for Interrogatories, First Request for Admissions, and First Request for Production filed.
PDF:
Date: 09/23/2020
Proceedings: Notice of Court Reporter filed.
PDF:
Date: 08/26/2020
Proceedings: Notice of Serving Respondent's First Request for Admissions, First Set of Interrogatories, and First Request for Production (filed in Case No. 20-003062PL).
PDF:
Date: 08/26/2020
Proceedings: Notice of Serving Respondent's First Request for Admissions, First Set of Interrogatories, and First Request for Production filed.
PDF:
Date: 08/24/2020
Proceedings: Order Granting Continuance and Rescheduling Hearing by Zoom Conference (hearing set for October 28 and 29, 2020; 9:00 a.m.; Tallahassee).
PDF:
Date: 08/21/2020
Proceedings: Unopposed Motion to Continue Final Hearing (filed in Case No. 20-003066PL).
PDF:
Date: 08/20/2020
Proceedings: Notice of Taking Deposition filed.
PDF:
Date: 08/19/2020
Proceedings: Notice of Court Reporter filed.
PDF:
Date: 08/18/2020
Proceedings: Notice of Intent to Seek Admission of Records Pursuant to Section 90.803(6)(c), Florida Statutes filed.
PDF:
Date: 08/18/2020
Proceedings: Joint Amended Response to Initial Order filed.
PDF:
Date: 07/29/2020
Proceedings: Notice of Appearance (Nicole DiBartolomeo) filed.
PDF:
Date: 07/29/2020
Proceedings: Notice of Hearing by Zoom Conference (hearing set for September 8 and 9, 2020; 9:00 a.m.; Tallahassee).
PDF:
Date: 07/29/2020
Proceedings: Order of Consolidation (DOAH Case Nos. 20-3057, 20-3062, 20-3066)
PDF:
Date: 07/16/2020
Proceedings: Joint Response to Initial Order filed.
PDF:
Date: 07/09/2020
Proceedings: Initial Order.
PDF:
Date: 07/08/2020
Proceedings: Notice of Serving Petitioner's First Request for Admissions, Petitioner's First Set of Interrogatories, and Petitioner's First Request for Production filed.
PDF:
Date: 07/08/2020
Proceedings: Motion for Abeyance filed.
PDF:
Date: 07/08/2020
Proceedings: Petition for Formal Administrative Hearing filed.
PDF:
Date: 07/08/2020
Proceedings: Administrative Complaint filed.
PDF:
Date: 07/08/2020
Proceedings: Agency referral filed.

Case Information

Judge:
MARY LI CREASY
Date Filed:
07/08/2020
Date Assignment:
04/20/2021
Last Docket Entry:
07/09/2021
Location:
Tallahassee, Florida
District:
Northern
Agency:
ADOPTED IN TOTO
Suffix:
PL
 

Counsels

Related Florida Statute(s) (7):