Found 407 Results Sorted by Case Date
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New Jersey – Gastroenterology – Pathology Diagnoses Polyp Removed During Colonoscopy As Adenocarcinoma



A payment of $775,000 had been made on the gastroenterologist’s behalf to settle a civil malpractice action brought against him by a patient.

It was alleged the gastroenterologist failed to follow-up on pathology results that revealed cancer after he had performed a colonoscopy on the patient, which led to a delay in the diagnosis of colorectal cancer.

On 8/12/2009, a 55-year-old woman presented to a gastroenterologist with complaints of abdominal pain and rectal bleeding.  The patient’s medical history revealed a family history of colon cancer.  The gastroenterologist recommended that the patient have a diagnostic colonoscopy to evaluate her persistent rectal symptoms.

On 9/17/2009, the gastroenterologist performed a colonoscopy on the patient.  During the procedure, the gastroenterologist identified internal hemorrhoids associated with a sessile polyp in the mid-rectum.  The gastroenterologist removed the polyp and submitted the specimen for pathologic analysis.  The patient was discharged from the hospital on 9/17/2009.

On 9/18/2009, pathology diagnosed the polyp to be a moderately differentiated adenocarcinoma arising within a tubular adenoma.  On 10/6/2009, the gastroenterologist entered a progress note in the patient’s hospital chart directly documenting the finding of adenocarcinoma made in the pathology report.  Despite entering that chart note, the gastroenterologist never advised the patient of the finding of adenocarcinoma that had been made.

The gastroenterologist thereafter had no further contact with the patient until he saw her in his office on 8/23/2010, approximately eleven months after the colonoscopy had been performed.  At that visit, the gastroenterologist diagnosed the patient with hemorrhoids and prescribed steroid suppositories; however, he once again failed to inform her of the finding of cancer that had been made following the September 2009 colonoscopy.  Additionally, the gastroenterologist did not then recommend that the patient schedule a repeat colonoscopy.

The patient ultimately had a repeat colonoscopy performed by another physician on 4/27/2011.  Following that procedure, she was found to have an invasive carcinoma of the mid-rectum, and she commenced receiving treatment for colon cancer.

When appearing before the panel, the gastroenterologist testified that he was aware of the pathology findings that had been made following the colonoscopy but did not specifically advise the patient of those findings because he considered the pathology findings to be “benign.”  The gastroenterologist further testified that he was confident that he had removed the entirety of the rectal polyp at the time of the colonoscopy.  The gastroenterologist maintains that, after completing the colonoscopy, he advised the patient that she would need to see him again in “about” a year, but there is no documentation in either the gastroenterologist’s medical record or the hospital chart which memorializes respondent’s having advised the patient to have a repeat colonoscopy within one year.  Further, although the gastroenterologist entered a note in the patient’s hospital chart on 10/6/2009 documenting the pathology findings, he failed to record the pathology findings in his office medical record, and he failed to obtain and/or maintain a copy of the pathology report in his office record.

The Board judged the gastroenterologist’s conduct to have fallen below the standard of care given failure to document that he advised the patient to have a repeat colonoscopy performed within one year of the date on which the original colonoscopy was performed and failure to have documented the pathology findings of adenocarcinoma in his office record.

The Board assessed a fine against the gastroenterologist with stipulations to complete courses in medical record keeping and medical ethics.

State: New Jersey


Date: March 3017


Specialty: Gastroenterology


Symptom: Blood in Stool, Abdominal Pain


Diagnosis: Colon Cancer


Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Neurology – Lack Of Documentation When Diagnosing Neuropathic Pain, RLS, and Carpal Tunnel Syndrome With Normal Neurological Examination



A 43-year-old male was referred by his primary care physician to a neurologist for multiple medical issues, including obesity, chronic post-operative pain following lumbar spine surgery, major depressive disorder, familial tremor, shoulder pain, excessive daytime sleepiness, congestive heart failure, and peripheral neuropathy.  The patient had been on Norco and was switched to Tramadol. The dose of Tramadol was 100 mg 4 times a day. Other medications were trazodone 100 mg h.s., zolpidem 10 mg h.s., HCTZ 25 mg, Lasix 40 mg, Flomax 0.5 mg, and topiramate 100 mg twice daily.

On 3/27/2014, the neurologist saw the patient for an office visit.  The patient complained of symptoms of foot pain, burning, and restless leg syndrome (RLS) symptoms.  The neurologist diagnosed neuropathic pain, RLS, obesity, carpal tunnel syndrome, low back pain, and tremor.  She planned to do B12 and ferritin levels, and she recommended an EMG/NCV of both upper and lower extremities.  The neurologist noted a normal neurological examination. Despite the normal neurological examination, the neurologist failed to keep adequate documentation to establish her multiple diagnoses.  She coded the visit as a level 5 new patient evaluation. The neurologist failed to document her 14-point review of systems and other required examinations to substantiate level 5 billing.

During a subsequent interview with the Medical Board, the neurologist initially stated that she had no recollection of the patient.  Her medical report timed the office visit at 9:15, and the encounter ended at 11:11 a.m., approximately 2 hours. She stated that she spent 40 minutes with him.  She could not account for the other time. She stated that “the rest was not me” and that she did not know what the time was “in between.” The patient claimed that she asked him only to stand and to try to stand on his heels and to squeeze her fingers.  When asked why she ordered the EMG, she answered, “For neuropathy versus radiculopathy versus carpal tunnel syndrome could have CDIP.” She did not know what a Controlled Substance Utilization Review and Evaluation System (CURES) report was.

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to keep accurate, timely, complete medical records to support her diagnoses, coded and billed for level 5 services not substantiated in her records, and was not aware of CURES reports and did not utilize it in her practice.

For this case and others, the Medical Board of California placed the neurologist on probation and ordered the neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California


Date: January 2018


Specialty: Neurology


Symptom: Extremity Pain, Back Pain, Joint Pain, Psychiatric Symptoms


Diagnosis: Neurological Disease


Medical Error: Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Interventional Radiology – Pain And Cold Foot After Arteriogram, Angioplasty, And Atherectomy



On 6/26/2015, a patient presented to an interventional radiologist’s outpatient clinic for a left lower extremity arteriogram and intervention for a thrombosed left lower extremity bypass graft, originally placed in 2007.  The patient had an extensive medical history including a renal transplant, diabetes, right leg amputation, and multiple revascularization procedures, including prior thrombectomies of the left lower extremity graft.

The patient reportedly had pain both at rest and with activity, and had a cold left leg prior to and immediately before the procedure.  In order to improve blood flow in the patient’s left leg, the interventional radiologist performed an arteriogram, angioplasty, tPA administration, atherectomy, and stent placement within the left lower extremity, including an attempt to revascularize the native superficial femoral artery.

Images show an initially thrombosed femoral artery to popliteal bypass graft and deep femoral artery.  Further images show balloons inflated in various parts of the graft and native arteries.  Final images show flow through a patent common femoral artery (CFA), bypass graft, and peroneal and anterior tibial arteries.  The deep femoral artery appeared occluded shortly beyond its origin.

After the procedure, a nurse noted the patient’s foot was cold.  The interventional radiologist also assessed the patient post-procedure and found the foot to be cold, both two (2) and four (4) hours post-procedure.  The interventional radiologist recommended to the patient that she travel to the emergency department of a university hospital.

The patient was then driven by her companion two hours to the emergency department, where she was assessed by an ED physician and a vascular surgeon.  She was taken to the operating room where she underwent surgery, which included a left leg above-the-knee amputation and a deep femoral artery thrombectomy.

The Board stated that the standard of care for an interventional radiologist when performing an intervention is to recognize complications and to take appropriate steps to manage them.  Although the patient’s foot was reportedly cold and painful immediately post-procedure, it can take some time for the foot to warm, and pain could be caused by reperfusion.  However, it is clear that two to four hours after the procedure, the interventional radiologist recognized that the patient’s leg had not improved and was worsening and that further care was needed.  Thus, when it became clear to the interventional radiologist that the foot was not improving, he recommended that the patient seek more treatment.

The records of the interventional radiologist’s care of the patient were inadequate in that they do not state whether the patient’s clinical status post-procedure was worse than before the procedure.  A post-procedure pulse examination was lacking which would have helped in determining the patient’s clinical status.

The patient reported to the ED physician that the pain began after the procedure and steadily worsened, which indicates that the patient rethrombosed her bypass graft and deep femoral artery (source of collateral flow) immediately.  This event should have been recognized by the interventional radiologist.

However, the interventional radiologist’s documentation for this patient was inadequate and sparse.  The medical records lacked documentation of the change in the patient’s status post-procedure, the discussion with the patient leading up to the discharge from his center, and the patient’s disposition.  The interventional radiologist discharged the patient to her own care directly from his clinic instead of calling Emergency Medical Services (EMS), which indicates that the interventional radiologist failed to recognize the gravity of what was occurring.

His conduct did not ensure that the patient would be attended continuously until definitive treatment was given.  The patient arrived at the emergency department at approximately 8:00 p.m., two hours after the patient was discharged from the interventional radiologist’s clinic.

Had the process of discharge and transfer occurred earlier, it is possible that the outcome could have been different.  The interventional radiologist failed to communicate with the ED physician ahead of the patient’s arrival.  The interventional radiologist gave the patient a CD of the procedure, a copy of the medical records, and his phone number, as an attempt of communicating with the emergency department personnel regarding the events that occurred at the interventional radiologist’s clinic.

However, the interventional radiologist failed to telephone the ED physicians at the emergency department to give a verbal report on the patient and to provide a more informative transition and preparation for continued care.  In expecting the practitioners at the emergency department to call the interventional radiologist to gain more information, the interventional radiologist improperly sought to shift his responsibility to provide needed information about the patient to the staff at the emergency department.

The interventional radiologist failed to maintain documentation regarding the change in the patient’s status post-procedure, the discussion leading up to the discharge from his center, and the patient’s disposition.  He stated that he was not sure if he documented these events, and if he did, he sent them with the patient.  Documentation sent with the patient has since been lost.  Documentation of a change in the patient’s clinical status was lacking.  The medical records lacked documentation of what was discussed regarding the patient’s disposition and where she was told to go for further care.

The Board judged the interventional radiologist’s conduct to have fallen below the standard of care for the following reasons:

1) The interventional radiologist failed to offer to transport the patient by ambulance or EMS services to ensure that she would be attended continuously until definitive treatment was given. His failure to do so indicates that he failed to understand the gravity of the situation which was occurring.

2) The interventional radiologist failed to adequately communicate with the emergency department, to call ahead of time to inform them that the patient was in transit, and to inform them of the circumstances.

3) The interventional radiologist failed to maintain adequate and accurate records.

The Board issued a public reprimand.

State: California


Date: December 2017


Specialty: Interventional Radiology, Vascular Surgery


Symptom: Extremity Pain


Diagnosis: Acute Ischemic Limb, Post-operative/Operative Complication


Medical Error: Diagnostic error, Delay in proper treatment, Underestimation of likelihood or severity, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Family Medicine – Treatment Of Elevated Blood Pressure And Headaches From Illicit Testosterone Injections



On 2/17/2014, a male patient in his early twenties presented to a family practitioner for medical assessment and/or treatment.

On 2/17/2014, the patient disclosed to the family practitioner that he was obtaining injectable testosterone from a source unknown to the family practitioner.  The patient indicated that he was utilizing the testosterone for bodybuilding purposes.

On 2/17/2014, the patient reported to the family practitioner that he was suffering from headaches and elevated blood pressure.

On 2/17/2014, the family practitioner surmised that the patient’s symptoms were likely the result of excess estrogen production secondary to the patient’s high-dose testosterone use.

On 2/17/2014, the family practitioner wrote the patient a prescription for Anastrozole, an estrogen-blocking substance.

On 2/20/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The family practitioner continued the patient on Anastrozole.

In February 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing excess estrogen production.  He also did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing excess estrogen production.

On 4/6/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The patient reported to the family practitioner that he was continuing to use testosterone, and that he was continuing to experience headaches.  The family practitioner surmised that the patient’s ongoing headaches were caused by elevated prolactin levels.  The family practitioner wrote the patient a prescription for Cabergoline, a prolactin-blocking substance.

On 4/10/2014, the patient presented to the family practitioner for medical assessment and/or treatment.  The family practitioner continued the patient on Cabergoline.

In April 2014, the family practitioner did not obtain or review any medical records establishing that the patient was experiencing elevated prolactin levels.  He did not obtain bloodwork or perform other diagnostic testing to confirm whether the patient was experiencing elevated prolactin levels.

On one or more occasions between 6/27/2014, and 1/9/2015, the family practitioner prescribed the following substances to the patient: clindamycin, Bactroban ointment, doxycycline, Zithromax, oral prednisone, Neurontin, and diazepam.  On one or more occasions in 2015, the family practitioner also prescribed the patient Anastrozole.

The family practitioner did not keep any contemporaneous medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 and 1/9/2015.

To the extent that the family practitioner had medical records regarding the medical assessment and/or treatment that he provided to the patient between 2/17/2014 to 1/9/2015, such records were all created in October 2015.

The Medical Board of Florida issued a letter of concern against the family practitioner’s license.  The Medical Board of Florida ordered that the family practitioner pay a fine of $8,000 and pay reimbursement costs for the case at a minimum of $1,457.57 and not to exceed $3,457.57.  The Medical Board of Florida ordered that the family practitioner complete a drug course, a medical records course, and five hours of continuing medical education in “risk management.”

State: Florida


Date: December 2017


Specialty: Family Medicine, Endocrinology, Internal Medicine


Symptom: Headache


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Failure to order appropriate diagnostic test, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Patient With Chest Pain Radiating To The Neck, Throat, And Back Discharged With Instructions To Follow up In 3-5 Days



On 11/15/2013, a patient complained of chest pain radiating to his neck, throat, and across his back.  The patient stated the onset of the pain was noted to be one hour prior to his arrival at the hospital while he was screwing something into the wall, and that the pain was exacerbated by movement.

An ED physician performed an initial EKG, labs, and a chest x-ray on the patient.

The ED physician initially treated the patient with nitroglycerin and a GI cocktail, and subsequently with diazepam, morphine, Toradol, and Dilaudid.

The ED physician’s final assessment of the patient noted that the patient was still complaining of left side neck pain and “trap pain.”

The ED physician discharged the patient with a diagnosis of “musculoskeletal chest pain” and prescribed naproxen, Norco, and diazepam, along with instructions to follow up with him in three to five days.

The patient returned to the hospital the following day in cardiac arrest and expired on 11/16/2013.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence given that he failed to perform a CT of the patient’s chest to evaluate for aortic dissection.  He also failed to adequately document bilateral pulses and/or blood pressures in the patient.  He failed to pursue other etiologies of the patient’s reported pain.  The ED physician failed to admit the patient for further observation.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: December 2017


Specialty: Emergency Medicine


Symptom: Chest Pain, Back Pain, Chest Pain, Head/Neck Pain


Diagnosis: Aneurysm


Medical Error: Failure to order appropriate diagnostic test, Delay in proper treatment, Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Anesthesiology – Wrong Site Procedure For A Transforaminal Epidural Steroid Injection



On 4/28/2015 an 80-year-old female, presented to an anesthesiologist for an initial consultation for possible epidural steroid injections.  On 4/28/2015, the patient had a history of left sided lower back pain and left lower extremity pain.

On 4/28/2015, the anesthesiologist scheduled the patient for a left transforaminal epidural steroid injection (TFESI) to be performed on 4/29/2015.

On 4/29/2015, the patient presented to the anesthesiologist at outpatient surgery and laser center for the planned left TFESI.  On 4/29/2015, the patient and anesthesiologist signed a consent form for a left TFESI.  After the patient was prepped for the procedure, the anesthesiologist performed a TFESI on the patient’s right side (the wrong site).  While the patient was still in the procedure room, the anesthesiologist was informed that he performed the TFESI on the incorrect side.  The anesthesiologist then performed a TFESI on the patient’s left side (the correct site).

The anesthesiologist’s procedure report on 4/29/2015 procedures did not accurately document the anesthesiologist’s performance of TFESI procedures on two different sides of the patient.

The Board ordered the anesthesiologist to pay a fine of $5,000 against his license.  Also, the Board ordered that the anesthesiologist pay reimbursement costs of $5,857.63.  The Board ordered that the anesthesiologist complete a medical records course.  The Board ordered that the anesthesiologist complete five hours of continuing medical education on “Risk Management.”  Also, the Board ordered the anesthesiologist to complete a one hour lecture on wrong site surgeries to medical staff at an approved site.

State: Florida


Date: December 2017


Specialty: Anesthesiology, Neurology


Symptom: Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Orthopedic Surgery – Documentation Error Of Laceration Of Flexor Pollicis Longus Leads To Wrong Site Surgery



On 5/16/2014, a patient presented to an orthopedic outpatient surgery center with a left-hand work-related injury.  During the visit, an orthopedic surgeon properly diagnosed the patient with a flexor pollicis longus (FPL) tendon laceration of her left thumb.

The FPL tendon laceration was confirmed by the MRI scan performed on the patient on 7/3/2014.

On 8/7/2014, during the follow-up visit, the orthopedic surgeon wrongly documented the patient’s injury as an extensor pollicis longus (EPL) tendon laceration in the patient’s medical records

Consequently, on 9/10/2014, the patient presented to the orthopedic surgeon at the center, for an EPL tendon surgery (the wrong site, and/or medically unnecessary procedure) of her left thumb.  During the EPL tendon surgery, the orthopedic surgeon realized that the FPL tendon laceration repair should have been performed on the patient instead.  On 10/10/2014, the orthopedic surgeon performed the FPL tendon laceration repair on the patient’s left thumb.

The Board ordered the orthopedic surgeon pay a fine of $3,000 to the Board. Also, the Board ordered the orthopedic surgeon pay a reimbursement cost of $4,670.40.  The Board ordered that the orthopedic surgeon complete five hours of continuing medical education in “Risk Management.”  The Board ordered that the orthopedic surgeon complete one hour of lecture on wrong site procedure.

State: Florida


Date: December 2017


Specialty: Orthopedic Surgery


Symptom: N/A


Diagnosis: Musculoskeletal Disease, Trauma Injury


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Obstetrics – Lack Of Maternal Serum Alpha-Fetoprotein Testing With Pregnancy Complications



On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/10/2014, 3/17/2014, 3/24/2014. 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms for the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and blood discharge, morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son, who was born with spina bifida/myelomeningocele.

The obstetrician failed to diagnose neural tube defect on imaging studies.

The obstetrician failed to order a maternal serum alpha-fetoprotein (MSAFP) test and did not maintain adequate legible documentation of ordering an MSAFP test.

The obstetrician failed to order an anatomical survey sonogram.

The Board ordered that the obstetrician pay a fine of $7000 against his license. The Board ordered that the obstetrician pay reimbursements costs of a minimum of $3,786.18 and not to exceed $5,786.18.  The Board also ordered that the obstetrician complete a course on “Quality Medical Record Keeping for Health Care Professionals” and that he  complete five hours of continuing medical education on “Risk Management.”

State: Florida


Date: December 2017


Specialty: Obstetrics


Symptom: Fever, Bleeding, Nausea Or Vomiting, Back Pain


Diagnosis: Obstetrical Complication, Spinal Injury Or Disorder


Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Family Medicine – Patient With Kidney Stone Started On Morphine Along With Fluoxetine And Promethazine



A 27-year-old female was a patient of a family practitioner.  On 2/11/2014, the patient started complaining to the family practitioner about a potential kidney stone.

The family practitioner had records indicating that the patient was being treated with tramadol, Percocet, fluoxetine, and promethazine.

On 5/12/2014, the family practitioner prescribed morphine 60 mg, extended release, to the patient, to be taken twice a day, but the family practitioner never adequately documented medical justification for the prescription.  The standard starting dose for morphine is 15 mg every eight to twelve hours.

The patient was also taking fluoxetine and promethazine and the family practitioner signed a CVS form indicating the patient could start morphine despite possible contraindications.

The family practitioner did not take additional precautions to monitor the patient, despite her taking fluoxetine and promethazine in combination with morphine.

At 5:25 p.m. on 5/14/2014, the patient’s husband found her unresponsive in the bedroom and 911 was called immediately.

The patient ultimately was transported to a hospital and diagnosed with poisoning by opiates and related narcotics.

The Board judged the family practitioners conduct to be below the minimum standard of competence given his failure to prescribe morphine for medically justified reasons.  The family practitioner failed to start with an initial dose of morphine at 15 mg every eight to twelve hours.  The family practitioner failed to take additional precautions regarding monitoring for central nervous system or respiratory depression when the morphine was prescribed with the fluoxetine and promethazine.  The Board judged that the family practitioner failed to adequately create or maintain medical records that justified the course of treatment for the patient.

The Board ordered that the family practitioner have a reprimand against his license.  The Board ordered that the family physician pay a fine against his license of $7,500 and that the family practitioner pay reimbursement costs for the case between a minimum of $820.04 and a maximum of $2,820.04.  The Board ordered that the family practitioner complete a drug prescribing course and a medical records course and that the family practitioner complete five hours of continuing medical education in nephrology.

State: Florida


Date: November 2017


Specialty: Family Medicine, Internal Medicine


Symptom: Abdominal Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal, Renal Disease


Medical Error: Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Family Medicine – Three Patients Seen At Once Without Proper Examination and Documentation



On 9/21/2012, Patient A, Patient B, and Patient C presented to a geriatric practitioner at the same time in his office.  The geriatric practitioner saw the patients for less than nine minutes total.  At no time were the patients separated for individual assessments.  The patients were an undercover detective and two informants, using pseudonyms.  The appointment was audiotaped and videotaped.

The geriatric practitioner failed to perform a physical examination on any of the three patients.  The geriatric practitioner failed to create a treatment plan for any of the three patients.  He also sent the three patients for x-rays without a physical examination.  Per the geriatric practitioner’s instructions, all three patients presented for x-rays;  however, only Patient A and Patient C actually had x-rays performed.  The geriatric practitioner failed to create or maintain documentation of referring the three patients for x-rays.

On 10/30/2012, the three patients presented to the geriatric practitioner for a follow-up visit.  At that time, the geriatric practitioner failed to review readily available medical records from the patients’ first visit, failed to inquire about x-ray results, failed to review physical therapy results, failed to perform physical examinations and/or failed to create treatment plans for all three patients.

The Board judged the geriatric practitioner’s actions to be below the minimum standard of competence given his failure to perform a physical examination, perform a complete individual physical examination for each patient prior to referral for x-rays, other diagnostic testing, or further treatment.  Also, the geriatric practitioner failed to review any medical records or results at a follow-up visit, including x-rays, from prior visits, and/or procedures and review and analyze the physical therapy progress of the patients, and create treatments plans for each patient.

The Board ordered that the geriatric practitioner pay a fine of $12,000 against his license and pay reimbursement costs for the case for a minimum of $37,421.80 and not to exceed $39,421.80.  The Board also ordered that the geriatric practitioner complete a medical records course and complete five hours of continuing medical education on “Risk Management.”  The Board put the geriatric practitioner’s license on probation and required that he have indirect supervision to practice by a Board-approved physician.

State: Florida


Date: November 2017


Specialty: Family Medicine


Symptom: N/A


Diagnosis: N/A


Medical Error: Failure to examine or evaluate patient properly, Ethics violation, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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