1. law, govt and politics

presentation of the most common emergency room
situatïons .
Respondent's
physical
examinations and thought processes were sorely
inadequate . Respondent consistently exhibited
shotty Lsic) diagnoses and practices, along
with poor record keeping . Respondent also
demonstrated a serious lack of engagement with
hïs patients.
The Hearing Committee believes that Respondent
c/eates a threat to patient safety and he
cannot be allowed to return to practice
medicine in this State .
Prior to our consideration of this matterz we received a
submission
from
respondent dated
October
26, 2009, whereln
respondent advised the Board that he had filed an appeal of the New
York action with the Administrative Review Board . Respondent asked
this Board to review the submissions that he made in support of his
appeal of the New York action, and beseeched this Board not to take
adverse actâon against his New Jersey license while the New
York appeal was pending .
We decline to consider respondent's submissions ,
extent they seek to challenge the findings of fact or conclusions
of law that were made by the New York Board, and explicitly adopted
by this Board x
Makker has not supplied any documentation that
A small portion of Dr . Makker's written submissions can
more properly be categorized as beîng in the nature of mitigation .
We also declined to consider those submissions at this time, as
N .J .S .A . 45 :9-19.16a contemplates that the Board 's consideration of
relevant mitigation evidence, and/or oral arguments as to
discipline, is to be afforded after an Order of Immediate License
suspension is entered , and that , upon consideration of any
additional evâdence submitted or arguments made , a final
determination as to discipline is to be made within 60 days of the
would suggest that the Order of the New York Board revoking
lïcense is in any way stayed pendïng appealz and thus the findïnga
of fact made
effect.
the Nebq York proceeding are
full force and
clear that the New York findings were based,
part, on credibility determinations made following hearings in Nebq
York, and we explicitly reject
should conduct
Makker's suggestion
we
independent review of the New York Board's
fïndïngs, or otherwise substitute our judgment for that of :he body
which directly heard this matter.
Conclusions of Law
--
We conclude that
record before us fully supports
conclusion that respondent's continued practice in New Jersey would
endanger or pose risk to the public health , safety and welfare .
Based thereon , N .J.S .A . 45 :9-19.16a mandates that we presently
enter an Order immediately suspending the license of respondent Ram
swaroop Makker to practice medicine and surgery in the State of New
Jersey .
Furlher Proceedinqs to Consider Mïtïqation Evidence
N .J .S .A . 45:9-19 .16a provides that a physician who is the
subject
an order
immediate license suspension shall be
provided an t'opportunity to submit relevant evidence in mitigation
date of mailing of this Order. Accordingly , we will hereafter
afford Dr. Makker an opportunity to submi: relevant mitigation
evidence to the Board for review and/or to request an opportunity
to make oral arguments as to discipline, in accordance with the
procedures established below .
'
l
.
I PETNUMQBW WI
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G 91811 Q t7
4.
NE
STA
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YOR
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ARD
STAFTOR
E PROFESSDE
IONA
PAL
RME
TME
DG
G'OF
LCOND
HEAL
UTCT
H j,w:g-pg
i
i---
1N THE
cy- AIAT'I'ER
..aj COMMISSIONER'S
.
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o:
IW M SWAAOOPMAKKEX
1
l
C
M .D.
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(
I
ORDER Axo
NOTICE o F
FlsAspxo
TO: RAV SW AROOP M KKS.R.M.D.
RedactedA ddrevs
rhe undetsigoedrW éndy E.Saunderi.Executive Deputy Com m iksioner.for
Richard F.DaineskM .D.,Com missionerofHeao .atteran investkllion.upon m e
recom m endalion ofa Ceom m ittee on Ptofessi4nalM edicdlC ondud bftbe'Slate
Board for ProfessionâlMèdicalCondud ,and um n the Statem entofC haTges
attached hereto and m ade'a parthereof,has deterrftined thatthq continued pracrtice
ofmedscineitlllneState QfNew Yorkby'fG M SW AROOP MAKKER,M .b.,the
Respondent.conslitutes an im m lnentdanger to ttle health ofthe people ofm is stzle
.
lt1 therefore:
ORDCRED,pursuahtto N.Y.Pub.Health Law â23O.(12).thate'
O ttive
irnm ediatety RAM SW ARO OP MAKKER.M .D ..Respondent.shallnotpractice
m edicine in tlne State ofNew Yofk. Thls Ordershallfem ain in effectunl- s m e lfied
ofvae ted by tb/ C/m m issionerofHealth purstlantto N.Y.Pub..Healsh L1w
ï230(12).
PLEASS TM E NOTICE thata heàdng w lllbe beld pursuantto the provisions
ofN.Y.Pub.Hëallb Law :230.and N.
Y .Statl Admin.Proc.Ad 1 301-307 and 401 .
The hearing willbe conducted before a com m itlee on professionalcondud oi'tlne
State Bomrd for ProfessionalM edicealConduclon April30,2009,al10700 a.m ..at
the officaes oftlne New York Stale HealllnDeparlrnent,90 Church Street,4* Floor,
New York,NY 10007.and alsuch otheradjoumed dales,times and places as tbe
com m itlee m ay direct. The Respolzdentm ay file an answ erto the Statem entof
;
t
,
J
I
l
EX H IB IT
B
l4EW YORKSTATE
DEPARTM ENYOF HEALTB
STATE BOARD FOR PROFEZSIONAL MEDICAL CONDUCT
JN THK M ATTER
STATEMBNI
OF
OF
RAM SW ARSOP AIA K ZV:RAM .D4
CHARG E:
RAM S@ AROOP M AKKEASM .D.,the Responrenl,m s atlthorize: 1è
practice medicine in New York Stste on orsbot!tAugug 2:1993,by tNe issulnce
oflicense nurflber 193129 b# the N eiW York'Stàte Educltbn Dm art- lit.
:
FACTUAL ALLEB ATION.S
A.
Respondenttreafed Pati:otA (PàlléntA t flarriè iscontabed in the attached
Appendix)on November3.2006.AtMarylmm aculate Hospital.152-14 :91
*
Avenue,Jamaica,New York. Réspobdenl's managem enland têéztm eht
deparled from accepted sofjdards ofm edicalpracece iflthe folbwing
respecls:
Pztlent/ ardveu atthe fm pmencyAcofn via lmbutance wim
the chiefcomplaints c1Iethargy.respiratsry distresx and
hypoteàsion. Nespondentfailed to take and perform an
atjeqttste histo?y and phy< colexam ination.
2-
Respondentfalled to dtagnpse an4 treata slate ofaltered
m eotêlstatus,Jespiratory fafltlre and slnock.
3.
D espile knowing thatP atienlA was on m ethadone.R esgondent
failed to considsr 3nd treata disgriotis ofrnethadone ovee ose ,
4.
Respondentiflappropriately atttibtfted PalientA's critical
preseotation to sim pte gastreeateritis.
f
*
.
5.
.
'
Rèspondentfskled to intubate and apptopriately venflàte the
PâtieDt-
6.
'
'
RvspondentV ilëdto maintàjn : meùitalze ord To#.me j'
atient
w'
hjch accurately reitcl the evaluations he pxèkdedjibcltzdiog
properpatienlhistow ,phytiqsls
exdm inatibn.diapnoses.
f'
atîonsles fortestlngxtetm follbw-up and dischàrée hot4s.
B.
Resgondenïlreated'Patienté inMarch.2002.,alMary lm mpçldate Hospitaly
462-44 89* A'venqq.Jam aica,New York. Respqndent!s m anugem ëntand
tteatmentdepartbd from açcepted m andards offpede lpractte tn lhe
followlng rlspects:
ï.
PatlentB àrf'
iYed at e Em ergency Room via am bulance. She
com plàined qfabdom ln/lpainxw eakness and dtttenor/heà.
è
ksw ..<xckvu..w oq
h
vs-.
-sp-w,i'
l/*$'
%t
u
2.
Res'
pbnd4ntfailed t4 rake and perfotm an âöequate httory and
physidaleyam fnatiof).
)
Resporident fa/led to diagnbse and treat pn ed opic pregnancy.
'
-3v--* %
'
.#
4
.
p.
.
4.
Resgondentm àde an incorrectwbrkifjg diagnosis ofgaslroenieritis.
5
Respondensinappropriately otdered two abdom lnalxeays ofPatieof
.
:.
b-who waspregnant.
Respondenïfalfed to tim ely obtain a gynecology consufe tîon.
7.
Rcsponde ntta/ed 'to m ainlain a m tdlcalfecord.fo'
rth4 patienlwhlch
j
k.
acctlralely feflects tbe evaluations be provkled jinclvding proget
patienlhîstory,physicalexam inationcdiagnosesvrationales fortesting,
:
teslfolpow -up and consunations.
2
l
(
Responèentteated Patierd c t,n M ay t3,2007,atOurLaty o:Locrdes
.
Mospitqt Resptm de'
nt's manavementand treatm en! depàrted from accepted
.
''
.
x
.
sldndafdsofmedicplpracttcek)thefcllowingTespectst
.
PatientC,aocom paoiéd hy hi# pàrWntx,presented to thetEm ergency
Rbotncomplmininè cfleftàbdomlnalpainfollowinga spp'
l injury.
Respondeotfailed to 1kp azid pekrform ah àdeqtaate hYlory and
physicalea rininztbn.
RespotAd/ntfailed to orderan abdwminalCT scanto rule ou1s/lenic
injury.
3.
Respondentinapproprltqlypfdered Töraddl.a potenl'én4sgeslc.
Responderifirlapptopfjmety di/cbarged the patientw ith a diagooxkx of
V bdom inalpein s?p h1tw ith b/: own elbow '.
R/sponden'
tfaqed to m ainsaln a jiledftalrecord for4he pnttenfwhicl&
accuralety re:ec.
e 1he evaltlatunm he pttlvded,lncludlng propet
patietlt hltory.physica!ekaM inlfioù,diapnoses.rstb rlales fOT testing .
lestfollow-up and Ul
'
scharge ooles.
Respûndenttreated P atigntD pn Spptem bere.2095,11 St.Johffs Hosvltzl.
Oveerts,New York. R pspondenfs m ansq
reatm êntdepmrted
a em entênd t
from accepled slandards ofmediM lpraclic: in ll4e following reipècty:
Respond:ntfaged to tak: aad pedorm ln adequate hjstory and
physi
celexam inatkm .
Respondentfayed to ordera C T scan of abdom en and pejvis.
3.
Responöenl failed to consids: and m ake a dipgnosis of actlte
appendicitis.
Respondentfailed tô o.btoi
n 2 Stzf/icglconsullatiorj.
Responöentinappxopriœtely dischargsd the pstiemtw ith 1 diagnosis of
gaslroehterkis.
Respondentfàjed tp maihtain a m edicaltecotd Jor'the patieotw hfeh.
,
accktrate!yreflectpthex
evaluationsheprovzeéaincludklg'
pro/er
,
patien,Nstory.physe lexa> ilia'
tlon,diagrioses.ràfiobples.ftp tastklé,
testfollow-up and diàrhmrge noteé.
R@spondenltreeted PatientC on Jangal .
23.2:071ztOutLpdy ofLourdes
Hcspitâl. Regpofïdehps managem entand trpxtmenldepaded Jrorinatc/ptfd
standaràs ofmedlcalpraçtljlc,e'
ift1hefllloWlog r:spectr
Respondensfailed 1 take atld pedorm aq adeqtllte hktory 1nd
physicalexam inatb 2.
Relpondentigljoted and falled jo 1cttzpon im portantabnorm al1ab
values.
3.
R espondentfsiled to cpnsiderand m ake a rlisgnosis of acute liver
diselse.
4.
Rèsulls oflabotalory teyts and c low grlde lever suggeltèd the
5.
presence ifan îrdection. Responden!fsjlêd td address tbese fm
-dingsu
Rfspon:entm ade en îoporrectdiagnosis of biiajeralflahk pain.
Respondentfailed to considerhospitalizgtloo oftl)e pltientfot
evaluation and treatm entofacute alcoholic hepstltis and pùssiblp
fn/èction.
Respondentinappropriately ceferred PatieofE io a urobgielin M e
absetjc/ ofany urelogicalpathology.'
8.
Respondeolfailed to lnulude in his Uischafge instrtK tgons to PatientE
a w arning againstalcoholconsum ption.
Respondentlailed to m àintain a m edicgtrecrrd Jotthe palîentwhich
accurately rèflects the evàfuatiotlù be p'
rovided.including proper
patienthistofy-ph>sicalexarninaiiott.diagnöses,r'
àtvioro le: ft/rlestiog,
teslfollow-up and discharge rloles.
Xespondenttrealed Pm ieftF on Dem m ber5,2506:atM G lm m acbfate
Hof/ital. Respobdetlt': lntmhàtententand lreafmeotdeparted lrom zedepted'
M andards ofm edlcalprsctidé in ll7e löllöwing respecls:.
Respondqntfalled to lsks apd perform en edequate Niftöly atld'
physical.exaràination.
Respondentinappropriatèly N deted a head .
C T scan.
3.
Respondenlrriad:en inapprb/tivtéworking diâgnosis.ofméningitis
wbi'
ch dlsgnosis be also faile: to approp:ately ùkaluate and treyt.
4.
Retpvndentfafled to m ake a dl gùoslsoï vîtalsyndtom e.
5.
Respoadentfaiied to ozdetappropdate fluids to healthe gatlent-s
defiydràEon.
6,
Respcndentinapptopdately prd.ared tbd trapsferofPatleat F to a
tergary pedltrit re/erfalhèàpltll.StibneiderChildren's Holpitml.#or
the perform znce ofa lum bar punctufe.
Respondenffailed lo m aint4in e m edicalrecotd forthe palient w hich
aocurately reflecls the evaluationa he prcvidad,lcctuding proper
patient history,phyticalexam inalion,diagnoset. ratb nales for tesling.
testfollow-up and dxcharge notes.
Respondenttrem ed PgtientG on M atch 2-/-23.2097.atO u?Lady of
l.ourdes Hospitul. Respondznt's m anagem elntafld tTeatm ent deperled from
accepted slandards of m edicalpraclice in lbe fcllr?wjfng respects:
Respondentfailed to take '/nd perform artadequate history and
physicalexam ination.
Respondeotordered the adm'
inistre on öfPheoergan W hich is
conttaindhp ted klthlldren underthe age of- 0..
Respondentfailedto appropriatelymoëtorthe patièotfortecslratdfy
depresmbn,a knpwp complicltionofPhettetùan'.
Respondentinappröptialelydischargqd PatientG w im outcootfm in#
6
.
4.
*
.
llaatshe w a: adeqttately hydrated.
5.
Upon ditchqtpè,Ro pondentim propedy gake PàtiebtG '> mothera
prescriptioo forPlnerlergén.
Respondentprekare# an emergentydeppflrhentrepod whiO
contxfned iu ûcur
' zt inforrnétiœ concernyng whem et..ornotPatientG
had re- ived IV fltajd w bile in lhe lm spital.
Respondentfa7ed to m akrltlin 4 m edicalrècord O rlhe patientwhith
.
accurately feflects the evaluations he prcvided.incfuding proper
patignthistcfy,physioalexarninatlon,db gtnotyes,rationales fortestingx
testfolltjw-t.
ap and di&cijlrçe notes.
Respondenttreated PGtientH on December26.20016 a1O uCLady o/
J-ourdes Hospital. Respondeot's Mmnlpemetd and'freatm enfdepaded frofn
accepted Slaodatds öfmedicasp<actice in the fbllowlnq ,
respetts:
Respon4entfailed to take lfjd perform an ad&qtlite histol 'and
p'
hysic?fexgm ifo tibn.
R espondenlfailed lo otder an x-ray ofm e potiervl's right hip.
Responderd faiied to corfectly inferpretx-o ys ofthe patient's rightrtip.
w hich x-ray: a teclthician had independenfly perform ed. Responder!t
read them as negali
ve.they actuatly Ehow ed a ffacture.
Respendenlfafletj to consultw ith a fldiologi:twho w as avalfable at
fb
SECOND SPQCIFICATION
INCOM PETXNCE ON MORE THAN ONE OCCASION
Ru poridentis charged with cotnmië tlg pfofàssip% im iàconuuclas dêfine
in N.Y.Edlm.L'lw 56S39(5)bypfacte g theprofeM e cfm e iqinp wRh
fnconcgetencé on morq than one occal on asalleged in the ta* oftwo otajore of
.
2.
Paragraph A and il: àutlpa agrpphs,6 andvits subparagraphs,C
nnd ils subpdragraphsaD afè Xssubputagsaphl.E df)d 11
subparagfaphsvF and 11 subperagiaplu .G And its
sl
abpam gtaphs.andlotH and it;subparagfaphs.
11
1
.
TH l SPECIFICATION
FAIL R
'
.
'
.
gespondentis chatged Nvltllxrm mitting professlot'
p lm iscpnductas de:nêd
in NZY.Educ.Law : 6530132)byfàigrtg tomàinte a tecord foreach patientwhjèh
accurafely refle.
cl: the care ànd trèamnentpflhe patlent.aB afte'
ged in the facts of:
3. a tagraph A ànd A6sB and B/.C and f>,D and 56.E and E9,
F 1r143F7.G and G 7.artd/b/H and H7.
.
DATE:
Apn4.
a 7 .2009
New Ybfk,New Ycrk
RedactddSlgni
ltllre
DeputyCoupsel
B
ureau olProfessibnal M edicalConduct
tt
:
E X H IB I T
C
STAU M ENT OF CHARGCS
n eaccompangng StatementofChargè.salleged tbree(3)speciscationsofprofessional
m isconduck incltding allegationsofnegligence,incompetcnce and failureto maintain
medicalrecords.n echargesaremorem ecifcallysetforthin theStatementofchargrsdatedAplil
23,2009,acopy ofwhich isàttache,d hereto asApptndix 1and m ade apartofthlgDeterminstion
and Order. Rçspondentsle.d aazAns'wàrdatéd,April24.2009 a.
t)d denled a11allegationà.
SG TM ARY OF PX OCEEDINGV
Conam isswicmer'sOrder
April24x2009
NcticepfHe-qrlnjDàtd;
Aprit2y,2Ud#
M sw er
April24,2009
Fze-ltlearing Conference
April27.2X 9
Hearirg Dates:
Apdl3Q,20()9
M ay 5. 200.
9
June2,2009
June 11,2009
Cotnm issioner'slntetim Order:
June24,2009
D eliberqtion Date:
July 23,2009
W ITNE SSES
ForthePetitioner:
M azk S.Silbezm ân,M .D.
M otherofPatism C
FortheRespondent:
11
Rarp Swamoop M akker,M .D.
2
FIN DING S OF FAG
ThefollowingFindlngsofVactwerçmadeaûerareview ofthectirerecordavailabletothe
Hee ngCorhmitteeinthistltatter. n eseFindihgsrt.
ptetehtdocum entary bvidenceand testim ony
found petw asiveby theHeaing Comm itte-e. W he/etherewasconflicting :videncethe Heszing
Committeùctmssdered:11ofthcevidencepresentedatldi'ejectedwhutwn notrelw o tsbeliçvable.
prcrediblein favorofthecited evidenct. '
l'hePetitioner,which hastheburden ofprocl was
retjuirod to prove îts cas: by a preponduraoce of the evidence. The H ezring C om m ittee
unanimöuslyapeedond11Findings,anda11Finding,swereestablishedbyatleastape ondctance
oft'
he evidence.
1.
Ram Vwatoop V %lrt-et,M .D.,theReépondent,wasauthorizrdtopracticemedicineizjNew
York Statèön orabcutAugust2,1993,by thèissuM ceofliccnsenumber 193129 by the
Nev YorkStateBduca:én Dl attntent.
PATIEN T A
2.
PatientA,a40ycar-oldwomM withahistoryofsickltcellanernia,wasbroughtto tàeM aty
lrnm acalatc H cspitalEm ergency D epar% entby am bulance on l1/3/06. 80t,
h B asic Life
Stpport('%LS'')andAdvancedLifçStpport(%W 1.
zS'')tmitsresponded tothecallwith a
complaintofdiffcultybreathing.(T.25-26)1 n e B'
l.,
s reportnoted thatshehzd been
dischzrged scm tt
heED thepreviousday with sîcklecellanernia- Shewasfound covered
in diarzhea,vvith altered m ental status,semi-ree ènsjve,with low blcod pzessure a'
nd
j
difficulty breathing. H ervitalsignsw ereunMable,with a pulse of 110,blood pressure of
60/40,and a respiratory ratc of40. The A LS unitnoted thatPatientA w a: lethargic but
' NumbersinparenthesesrefertoHrarîngtrangcrfptpayes(T.)).
3
'
verballym m onsive.They CUI'tI)G noted shortnejgofbreath with thallow zrapid breathîng
amd abdorninzl breathing. M ultiple IV placement attempts by the M .S unit were
unsuccessfu1-('
Pet-Ekx2a.pgz.13-16/.
.
3.
Th:EmergencyDepxrtment(*fED3 tfia:enote:wetedocumented ét9:44 a-m.n echief
compb intwgsltnrespopslvcnesswith dlfficulty breatlûng slnèe :'
.40 a.m . 'rhé En tHage
vital sir s revealed a pulse öf 119y.blèod pressure of 119/91, respirations of 24, a
temperatureof99.2,andanoxygensntllrnt
g'bn of99% despitesnapjleinentaloxygen.Past
historyofsizklecelidlse%ewasnoted,aswerethepAtient'shomemedications,m ethadone
and albuterol. Furthernutsing notes Ydicate lethatgyyfecalsoiling.allover,and thatthe
patientwasmoxning,attimesin'
rtmtmsetopxin.(Pd.Ex.2a,pgs.20,25-28).
4.
Respomdentdbcumèntzd hià évàluation ofthe patientwith anote timed at9:55 a-m . Jle
redorded dhiefcom plaln
ztsofunrem cnsivenes:'ezith sbortrzesbofbruatlk acdthatthepatient
hadbeenfotmdathomewithamethadon:bottle,letiargic
',hypotensiyeytacchypheic,and
covered with dîarrhea. (7n t'xnminatioû,R:splmdem notes no G denct oftraum axwith
zlcurologicalexlmination demonstp ting unres/onsivenèàsorm llmblizig.Hefurthernotes
asuppleneckandnormalheartexamination.Exam inationsofthepupils,thelungsand the
abdom ed w err not docum ented. Rem ondent': clinical'im pression w as recorded as
gastroenttritfs.f.Pet.Ex.2a,pgs.21-23'
,(T.34).
5.
'
I'h: nurses had diffculty placing an 7 7aàd obtaining blood for analysis,butRespondent
obtained blood samples W a azterialpuncture at 10:30 a.m . Theblood w assentfor CBC,
CM P,CK,troponin,amylaseylipaseand coagulation testing..An JV linewatestablïshed,
' Rc$erstoexhibitsinevidencesubrritzdbyicNt
r.
vYorkStateDegacmentofHcahh(Prt.E,
x.)orbyI7r.Makkcr
tResp.5;
4.).
t
4
andRespopdentordereda500rkllv,normalsvlinebolus,follow edbyaconEnuousinfusion
at250 ml/holm Supplem entaloxygen.a chestx-ray,head CT and E'K.
G were ordered.
Cardiac and oxygen saturation molzitoring were ordered,as wellâs houtly neurological
statusmonitoring.(Pet.Ex.24
Laboratory studies revealed hyperkalemia (5.0,renalinm fficîency,alld ekidence of
htmolysis typicalforsickle cellàpemia- The CBC demonstrated anemia(146 of 7.5),
leukocytqsis(WBC of1:.9),andthzk
ombocytosis.M ezialbloodpetsanalysiswasnotàble
forsir lhclmtxacuterespiratpryacidods,witlzpll7.22.pCU2 of7U.$,and apO2 of169.6.
n elabcratorycalledtonotifytheED oft1)e.
x criticalvalues.lP:tEz.2a,p> .206-9).
Over the nextfew hours,PatientA remained tachycatdic. At2:00 p.mwhervitalsipns
clzanged,withabloodprebstltedropto8,
4/54andanoxygG sattzratîojzdropto92% otl100%
oxygen.At3:07 p.m .'
thepatiO tbecainebrédycarditàn'
d w > tinte aoystoliccr diéc àrrett.
Respondentattempttdendottachealintubationtwicewithoutstccett,@ etwEà.2a,pg,24).
Orotracheàlintubation was then successfttlly perform ed by anesthegia at3:12 p-m . The
*
+
patienlwassuccessfullyresuscîtated withiptubàtionrepinephppe,atopineànddopsrnine-
Shehad arcttzm cfspontaneouscirculation with ablood presgm'
eof45/28 docum ented at
3:25p.m .By 3:35p.m -ytl:ebloodprrszureinp roved to 105/43 on thecontirmtm sdopam ine
infasion.(Pet.Bx.2a.pgs.27-29).
Postresuscitation,physicians from the criticalcare tearn becam e invclved with the care of
thePatient.Theyplaced acentralvenöuscàtheterin the rightfem oralvein and obtained an
AB G at3:45p.m -revealing aPH of6.97,pC O2 of99,and pO2 of419 ortventilatorsettings
a
ofCM V 12 tidalvolume5O0m),and 100% oxygen'.Tlleynotedthatthepatientwmsfolmd
w it.
h an em pty bottle ofm ethadone in herhom e. TheCCU team 's clinicalim pression was
5
respiratoryfiluresecondarytomethadoneoverdosçwithencephalopath#,'Fhepaéentwas
subsm uentlyadmittedtotheclidcalcaretmit.(Pd.Ex.2a).
ln theICU,thepatientrernal
'ned intùbated andcpm gtose.Herurinetöxiçologyscm en was
positive for opiates and benendiazm ines. SubsequentCT oftlw brain showed tliffuse
cerôbzaledeotàctmtistentwithzztöxizencephfopaiy.n rPatient:utteredgtneralîzed
seizures and ceptkal ftvep a: high as 19$ degtùès. Pàtierit A evehtuàlly s'ufferkd
cardiovascularcollapseandwmspronoundeddeàdoh 11/9/06.A'
n amopl wasperform çd,
contsrmingthecaugeofdeathtobeanoxiceàcèphalopathyanddnzgoverdose.(Pet.Ex.2+
pg.27;Pet-Ex.2c).
T)w prhnary goalofan em ergencyroom physician isto identifyserioustiurata to life. Once
azneme/gencyroom (!*2R')physician rulesoutalllife-threateningcondltions,heorshemay
uothavethegoalofreach-ingadcfm-'
ltiveconclusion.Tl
wt'job canbe
. lefttoaplimarycare
doctororothermedalist.(T.23).
17.
'
'l''
he ctitioalissueà to be adthessed in thi: casewere the alteration in m entalsutussthe
hypotension and taclnycardia noted by EM Sy and the rem iratdry disttess. lnidal
considcratitmsby theER physician should hav: incltjded methédone ovetdosethatcould
cause abnorm alitie: in blood pressure,respiraEons and depresued m entalstats. Other
approprizte considerations would have included an zcute ischem ic stoke or hem orrhage,
volumodepletion,acutepneumorziaandpossiblesepsis.(T.39,.44,48and95).
Respondent'sassesonentwascxtrcm cly lim ited.H e fàiled to exam inc fhepatient'spapils,
aplzysîcalfindîngthatcouidhavesupportedoverdosefrom methadonc.(T.47).Hefailed
to exam ine thispatient'slungsdespitehcrrem iratory distress,and he failed to cxam ineher
abdom en despiteseverediarrhea.Hisclinicalim pression ofgastroentmV s,wlnilepossibly
6
a secondarydiar osis,oompletelyfailed to adtlre:sherciticaland tm stableneurological,
respizatory,andczrdiovascularcondîtîcn.(T.24-99).
Respondentfailed to address PaEçntA's severely depresged m entalMatus with a high
likelihoodofopidtûoverdosm Cf.47).
n e blood gms analysis thatw as chrawn by Rto opdent revealed hypovèntilation and
reoiratoryacidosis,c'riécalsir sofrespiratory'
instabilis'andim/e dinkrespitatthryfailure
due to opiateoverdöèe. Theblùod gasresultswere called to the ED,butthey were never
recordedinResponikàt'snot4soraddressedbyReo ondent.(Tk42-43).
n e patientrequircd eitherà 1 :14f)'V Nlrcarl.orlntabâticn wifh Z'
eSPJIJOZ'
/support,oz
.:
bctllin an attempttorcveOe th: reàpH tory dl rezsion duetö the opiateovetdose. She
received noneofthesecliticaltreatm eritsand insteadw assimply observe,d overthecoutse
ofhuurs as hercondititm sloqzzly det:riorated. No interventîons were inptïtm ed forher
cziticallyunstableairwrayandpoorrespiratorystatus.(T.89).
PatqentA wasdocum cnted to behypotensivew ith detatw aion at2)00p.m .Thisw orsening
ofthe patient's condition should have tziggered Respondentto reevaluate thè patient's
clinicalstztus. She * as not retvaluated, and no further treatm cnt or intervention was
provided.A t3:07 p.z/1e,PatientA suffercd bardycardia,follow ed by cardiac arres-t. Atthïs
point, Respondem undertook tw o failed attem pts to secure the patient's aizw ay w it.h
fntubation.Shenurseanesthetfstwassunmncmedahdsuccessfullysecuredtlaeainvayon the
firstattempt(T.51-53).
18.
Rsspnndentfaïledtorecognizejusthow sickPatfe'
ntA was.ThefailurepersistedSthouraser
hf
nurafterhouz''when addltionalc/ticalinforrnation cam ebtxck indicating thatPatientA
wasve.
ryi1landinalift-threatenïngcircumstànce.(T.54)
7
19.
Sarcanand/orintubationwouldhâvèreversed'therèspiratotyacïdosisthatshewas sùffering
had theybeen provided earliefinthetour:eofRem ondent'streaa entPatio tA'stardiac
arres'twiththes'ubsm uenlanoxicbraininjuryanddeathcouldhaveeuilybeenprevented.
(T.57)
20.
PatientA wasnotintubateduntilaftershesufered acardiacarrest.Thisoc-can'
ed afterthe
cardiacarrestteam tookoversometimebetwéefl3:00pm and4100pm.(T
,.53)
21.
n ere wmsenough tim: étRemtmdent's initialevàluatioh,excn in the abso ce ofother
findings.toclearlyindicatethatPatientA wasèriticallyllland atriskforverybadoutcotneà
unlessRespondenttookagpessivcadiontomanagethesittlàtion.(T.98)
J.
2.
Respondent'sm edicalrecord fôrPatirntA did notm eetm inim ally acceptable s-taudards.
-
(T.58)
.
PatlenfB
23.
On 3/4/02,at 9:02 à.m ., Patient é, a 37 ycar-old woman,was brought to tbe M ary
Imm aculateHospitalBD byEM S.Shereportedacuteonsetofzbdominalpain with nausea-
EMSfoundherproneinthchàllwàyandnotedht'
rtohavùpalectmjuntfvx withsweating,
wexkness ahd near syncope. Upon sîttihk.the Ehl-f was tmable to palpate her blood
prcssure.Herlowem bloodpress'urereecordedbyEM Swas64bypalpaùon.Theynotedthat
herlastmenstrualpe/odhadbeçn6weeksearlier,on %0/02.(Pet.Ex.3,pg.15).
24.
Jn triage,PatientB'svitalsignshad im proved,w ith a pulse of80 and a blood pressure of
114/94.The triagcnursenoled abdom inalpain w ith naustabutno vom ftingand tenderness
ontherïghtside.(Tet.Ex.3,pgs.22-3).At9:30a.m.,Respondentevaluated thepatient,
again notingtheabdominalpain and nausez,aswellasthelastmrnstrualpetiod 6 weeks
earlier.He noted difft
zseabdom inaltendem esson exam ination.Respondcntorderedblood,
8
urinalysis,urinepregnancytesting,aswellU IV nonnalsàline,Reglanahdpepcid.(Pet.Ex.
3,pgs.16-14.
25.
At9:30 am,thenursenoted theuHnepregnancytçstto bepositive,and the 1ab w ork was
srnl.At1:0Q p.m .,nuuingnoteàthâtthepatîentwasawaiting apelviculoasolmd.At3:!O
'
JXm-r asertzm HCG wasrunxwitharesulto/3J55.(Pet.Ex.3,
pg.78).Arozmd5:00p-1u.,
theGYN consultwasnodfed.n einitialhe oglobirkdranrljinthemdmljwas11.0and
a repeatdone at5:52 p.m .was8.3. At6:00 p-m.thepatientwentftjrpeld cultrasoundo
whichrevealedanemptyutenzsandariglk adnexz cyst(Pet.Ex+3,pg.101).
26.
n ewotkimgdiar osiswasruptuted ectopicprçgnancy.Thepaéentwentto theOR whdre
anexploratorylaparotomyr> ealedarupturedtctopicprer ancy intherightfallopian mbe
withactivebleedinéandhe opetitonemn.(T.137).
27.
PatientB underqze tapartialrightsalping4ctomyatdevacuationofthehea
m atoma.Shewas
transfused tw o lml'
tspfblood azld m ade an tm evefltfulrecovery. Shew as discllarged from
thehospitalon3/7/02.(Pet Ex.3).
28.
Given thisconstellkiioà ofsndingsofthelatepeHod,diffpjeabdom inalpain thatcameon
suddenlyandhypotensipnin theseldbyEM S,anectopicpregnancywouldhavebeen atthe
topofthediffrentialdiar osis.(T.106z108).
29.
n estandard ofcarein thisshuation callsforan immediatepelviccxam ination and urgent
gymccologicalconsultation.The patientwith a rupmred tctopic pzegnartcy is atrisk for
ongoingbleedingorshock ifdiar osisandàeatmentazedelayed.(T.107-108;116-117).
PatientC
30.
PatientC,a 15 a
year-old boy,cazneto the LourdesH ospitalED on 5/13/07w ith :com plaint
of abdom inalpain afterhaazing his elbow stabbed into the leftside ofhis abdom eo w hile
I
l
9
plagngsoccer.Hisvitalsighswcenornjal;tpecifkally,hisbloodpressurewaà112/84altd
hispulsewas72.HeTated17ispain 1/10.Thetziagt nursenoted a softabdom en Avïth left
side.dtendemess.(Pd,Ex.4a,pp 5).
Respondentevaluatedthepatient,again notin:thatthepatient'selbow struck hisabdom en
whilepla/ngsoccer,rcsultinginabdorninalpain.Remondent'shistoryindicatesthattlae
paininitiallyresolved,soPatienlC startedplayingàocceragain:tzatersthzpsdnreturned altd
hisparentsbroughthïm totla:2D-(Pet.Ex.4+ pgs.1,3t4).
Respondent'sphysicalLxarnination wastmr- arkable. Specifkv y,Rem ondentnoted a
soû abdom vnwithoutpzardingùrrebtmnd.Reo ondentprescribçd Totadol60mgN .The
Patientw ms discbarged fröm the ED apm oxim ately onà hour a.
f* prey= tationyw ith the
nursenotingthatthcPatientwaj ingoödçondition,withoutpain.eet.Ex.4aypg.5).
A thom e.afew hcurslater,tlne abdom inalppân incteased w ith Tadiztion jo the leftshoulder.
PûtientC dtvelopcd dizzinessand nearsyncppe. He wastaken to thrW ilson M cm urial
RegionalM edicalCenteywherehewasfotmd tohaveabdozninaltendemezswithrebound
and guazding.Hehad aW scan done,revealing aruptured spleen with hem operitoneum .
Hewasgiven 1'V tluidsandhisvitalsignsremaine,d stable.He wustakento theOR where
heunderwenta splenectomy. PatientC recovere,
d uneventfully and laterretmmed to full
activitiesandsports.(Pet.Ex.4b).
GiventhatRespondentevaluatedthepatientaboutthreehpursafterhisinjvzy,itislikelythat
there w ould have betn sipnifcant blood in the peritoneal cavity at tl
w tim e of his
examfnatfon. Duetotheseverityofthesplertfcfnjurythatwasfdentïfedatsurgery,and
gixen the am ountofblood thatw as seen on CT scan atW ilson M em orialHospital,itis
highjy likely thata proper abdom inal exam ination w ould have dem onstzated peritoneal
l0
*
fiadings.(T.148-150)PatientC'smotherqzntedthàtRep ondent'sentireexaminewasconductedwhile PatientC
Tvzsfullyclothed.(T.772).
Respondentshouldhaveordere,
d aCT scartoftheabdomenfoTtranmak(T.157).
Resptm dent's adm inistraticn of Toradol,a gotentppl
'n killer,w as inconsistent w ith the
absenceofflding,shemad:inlïisphysicalexnmlnadon.(T.15O.
Respondent'smedicalrecordfotPatientC lacksinternaloonsistencybecause izis Ending:
donotjustifywhyheadtniztisteredToradol.(R*.159).
ltwasinappropriateforReqxmdentt: dischargvPatlentC with adiàr osisoft'abdom ina)
pain stattlsposthitwithhisownelbow.''(T.159)-
Batiem D,apteviouslyhcaltlty3gyear-oldmznzpresentedt:theSt.Jbhn'sQtl:ènsHospital
F73on9AI0t vvithacomplaintofabdominalpairlforoneday,withotztvomie gordiarrhea.
Histriagetemperature was99.2 and hisothervitalsignswere tmrem arkable. n etriage
nursenoteddiffttscabdominaltendemessandpallor.(Pet,Ex.5a.pg.13).
Reypondc t evaluated thé padent,noting a history of rnid-abdom inalpain for one day,
getting worse over tim ek H e 1111t14e1-rmtèed that tltis w as the ûrst tim e the palient had
experienccd abdom inz pain,and thatalthough PatientD feltnauseatH ,there h?d beer nû
vom iting ordiazrhea. On exazninaïon,Respondentfound m id-abdom inalperi-umbilièal
pain withvoluntaryguarding.(Pet.Ex.5a,p
'g.14).
Respondent ordered blood w ork fncluding a CBC, chem isrry,xm yla<e, lfpasc,PT and
urinalysis.H e ordered chestand abdom inalx-rays.Thepatientw asgi'
fvn IV ncrm alsaline
and wasm edicated w ith IV Pe.
pcid,Reglan and Toradol.Thcx-raysw erencnnal.The1ab
11
work wasnotablefora'
W BC of9-4Mdth aleA shift,andwasothe- iseunremvkable.(Pet.
Exxsa,pt
gs.l5,!,6,2-4).
Responclentre% sesse: PatientD anddischargedxirnwithadiar osisofabdominalpain and
gastzoenteritis.H ewasgjvenpmscziptionsforReklan andPepcidvwâsadvisedto follow up
nithhisprimarycarrphysicianin3to4days.andtorehmtto theED ffneeded.(Pet.Ex.
5a).
n efollowilgday,thepatientccntinuedtohave ongoingpain and wenttc éeehisprim ary
Physician.'J'hedoctorreferred11111:totheED atM t Sinql
'HopîtalofQueensto ruleout
aculeap/endicitit.Onexnminaticn,hewasfoundtohaveabdomfnultend= ess,intluding
rightlow erquadranttenderness,andbewassemtforaCT scan.TheCT demonstrated acute
appendicitîs and hew astaken to the OR foran appendectom y. H = recovered uneventfully
:ndwasdischargédhometlx fol3owingday.(Pd.Ex,5b)
PatientD had aprespatdtion thatw asvery strongly suggeMive ofacute appc dicitiz based
onRespondent'sinitialhistoryandphysi4altxmn.Hispzin wasmid-abdom inal,steady ànd
w crsening overtim e. He had notsuffer:d tllispain in t:e pastand there w asno vom iting
ordiarrhea.(T.188).
ltw asa departtlre fzom the standr d ofcaretodischazgePatientD withoutdoinga CT scan
oftheabdomenandpelvistolookforsi> sofacuteappendicitis.(T.190-191).
n e characteristîd of the pain cxhibited by PatientD is notconsistentvith Rep ondent's
diar osisofgastroenteritis.(T.200).
% stzrgicalconsnltationshouldhavebeenorderedforPatientD,(T.190).
,
PatientD'sredorddoesnotindicatethatRespcndcntreassessedthepatientbefozedischarge.
tTL18,
5).
12
PatientE
5O.
PatientE,a35year-oldmanzpresentedtotlltLourdzsHospitalED triagenurseon 01/23/07
conp laining ofbilateral kidney pain of two days duration,light greater than I'
eft. He
rnentioned feelingburning on and off,asw ellas lethargy. Vitalsigns w ete a tem peram re
of99.7 and elevated blood pressureof1> /114,w 1:1norm alpulse,respira:ons,and oxygen
saturat/n.Pzinwasreportedasmïld,1/10.P et.Ex.6)
51.
RespondentevaluatedPatientE,againnothg arm ortofbilatpralkidneypm'nwitllbum ing,
notrelated to arination. Review tfsystem sw M negative fornausew vèm itinp fever,and
chills. The patientreported no signifiè-antpastmexlicalhistory,and socialhistory was
notablefûralcoholabuse.(PetEX.69pg.1).
52.
A phricalexaminztionbyRespondeninotedtheelevatedtriagebloodpressme,butwas
otberwdsenormal,includinganormàlabdom inalandflnnkexamination.Laboratorkstudïes
.
wereordered,includitgaCBU,comprehensivem etabolicpanel,colgulztionstttdies,cardiac
troponin,amd urinalysis.Basic CBC res-ultsw erenorm al,including awhitebloodcelltount
of6.5,buttherewas anotable bundem ia of 1924; B asic chem istriesw e cnorm al,butliver
functions studies were notable foralbum in 5.0,AST 246,A LT 271,alkaline phosphatase
of97,and abilirubin of3,1.Am ylu eand lipasew erenorm al.Tht coagulation sm dïesw ere
nozm dl. Udnalysis dem onstrated a specific gravity of 1.005,ïvit.
h 1+ ketones,b'
utwas
otberwise nonnal. A 12-1ead EKG tracing w as norm alvand cardîac troponin w as also
nonnal. A renalscnogram w asperfonned,and the lddmeysw e'
rcnoted to be nonnal. tPet.
Ex.6).
53.
R epratblood pressure prior to discharge w as 158/84.Patient E wlts discharged w ith a
diaguosïsofbilateralflartkpzinandwasadvisedtofollcuvupwithaurologist.(Pet.Ex.6).
13
Remondent'shistènrisverybzief n erewasnodescniption ofwherethepainw ayorw hat
iswaslîk:orit:duration.(T.218).ThereisnodocmnentationintherecordthatRespohdent
formulated orcons-idered a differentialdiagnosi.softhepatient'scom plaints.R espondent
remainedfocusedon theksdneysçven aftc:laboratcryaridim agin:dataindicated thattlnere
wa.snôproblem withthekidneys-,l'
nfacttlm patienthadacutetiverdisease.(.
T.222).
AlthoughRespondentordm-edafulllaboratoryworl/upphefailodtotzkenoteofsi> ftdant
results. His dlctated reportm entionsanormalC'BC,buthefailstonote signiscantbands
of19% .Healsomentiorisanorm alm etabollcpanel,ir oringthesir iscantlyelevatedliver
transam inasesandbilirubin thàtwc'
r:reported on tbatmetabolicpanel. These laboratory
abnonnalitiesgzveintportabtinfohnaticn aboutietruenatlzreo/tlw Patient'saoutoillress
beingrtlatedtoalzohplis'm andlikerdizeise,andunrelate-dto thekidneys.(T.219-222).
Bandcmia of 19% is ahigh mlmbcrthatsuggeststhepossîbilîty ofa seriousinfection or
inflamrnatotycondition.(T.220,:40)'
.
n e nursenotesthatRep cmdentTeviewed thelab dataand ordered arenalsonop-am . A
renalsonov am isreasonableto perform in apatientwith bilateralkidneypàin. However,'
based on the abnonnzlliverfunction tests,a cornplete abdom inalultasound should have
beenperformed atthe sarfletimeto nzleoutabnormalitieschftlw liverrgallbladder,biliury
ductsorotherintra-abdominalorgans.Respondentfailedtoappropriatelyorderthecorrect
ultrasoundstudy.(T.222-3).
Respondentdischazged PatientE with a diao osisofbilateralflankpain and zefcrred him
to aurologist,despitethe factthathisuroloscalwork-up wasnormaland tberewasno
i
z7dication ofaneed forfurfhertgologicalevaluation.H ow tver,itw asim portantforpatient
E to follow-up with aprim ary carephysician to furtbérevaluale theelevatcd liver function
14
testsarldelevztelbloodpressuzereadingys9()17:theED .Respondm:tfailedto appropriately
rcferhim forfollow-upofthtseabnormallndingsrelatedto amzteliverdismase.Respondent
alsofaîledtogiveapptopziatbinstructionsabbutalcoholcozzumption.(T.223-5).
On 12/5/06#atientF,a9year-oldohild,wasbroughttotlleM ârylmmadulateHospitalED
fcrevaluakon.n etriagenur'
ses'
poketoaparent andnotedcbmjlldnt.
soffever,backpain
and a sote thrvat. The tziage tv eraM e was 99.6,blood presspre 140/69,pulse 159,
respîrations22andtAygchzaturàtiim 99%.(Pet.Ex.7a,pg.5).
Respondentevaluatedthepatient,notiàgapreviouslyheàlthy child with areportoffevcrtö
104tbçpziornigM vv'
ithneck stie essbutnopinonm ovem entandnoheadacbe.Hz noted
thatthepatienthadreceiked lbuprbfen withoutrelief Physîcalexarninatfön w :.
snotable for
haryngealcrytàemaand goodmobllityoftlaeneck wiloutpain. n er= ainderefthe
P
exnminationwasnonnal.(Pet.Ex.7a,pg.14-15).
Extensivo ancillary studiesw ere ordered,revealing a norm alwhiteblood èellcountof 9.5
vvith 84% neutrcphild. Chernistry studiosw ere unzem arkable. A chestx-ray w as clear. A
head CT scanwmsdoneandwas.nonmal.Repeatvitalsignsrevealedatemperatureof1* .2
and a pulse of 130. Respondent's clinicalimpression was fever and neck pain wfth
tonsill.
itïs.(Pet-Ex-7a,pgs-4.14).
Respondem ordere)d 175 and l/3 norm alsalîne at65 m lA our,H e also prescribed lgr'
am of
j'kl ccftriaxone. Respondent m ade fuMher arrangem ent: to tzansfer the patient to the
specialtychildrcn'shospîtalbyambulanceforfurtherevaluationtoruleoutmeningitis.(
'Pet-
Ex.7).
The patfezltw as evaluated atthe Schncider Children's H ospital. The pediatricians there
15
noted thathe waànoti11appeafing. Upon taking am oredetailedhistory,they no4ed that
therewasnoheadachu)nophotophobia and noneck stie ess.Physicalexam ination w as
notable /oran absence ofm eningismus prrash. Pharyngeàlerythema was noted. '
Fhe
patîentwasdiar oscdw'ith aviralsyndromebase,
d on Mshistozyandphp icalexam ination.
Hewasdiséhm-gedhom:irtgoodconditicnwithoutfurtherwork-up.Tet-Ex.7-b)
Respondentdccum etitednèpasthistdtyandhisphysicalexnm inationnoyed thatthepgtie.
nt
ccm plained ofa stiffneck buthad no paih tm tnovem elt.Therew'
a:no hm dache undc.rthe
rcdew ofsystemsandnoexxmiààtionoftheeyezfèrphotophobia-(T.242,2667.
A 9 yearo1d with acutem ezzingitiswouldbehighly febrile,with atoxîcappearr ce. The
patientwouldbehûldinghishead with severepsin :134 exhibiting signsofstiffpessofthe
neckandmeningealpainupontestingbythephyxician.(T.245).
Patient F had no headache and had norm ai m obiiity of tJ): neck withöm pa
dn.Hîs
tenp eruturehad com edowm to 99.6 dcgreesand thepatientwâsdescdbed by thenurse as
awellappeazingchïld.ltBrasmostlikelytllatthepatienthadacutephmyngitid.(T.245).
n epropertesttoconfrm gdiagnosisofmeningitisi:todo aspinaltap.A CAT scanofthe
bralnhasnoutilityinJ'
nakingadiagnosisofmeninstisandisreservedforacllildsvithan
abnonnalnetlrologicalfmdingèrsevcrehcadache,Itshouldnotbeusedwhennotindicated
becauseitcan exposechildrentoinappropriatedosesofradiétion.(T,244).
Dehydrationisaconcernin apatientwith an elevated hearrateandacutepharyngitis.W hile
Resptmdentordered m aintenance fluidshedid notordôrappropriate fluids forrehydzatîon.
irleboluswasrcquï.
rtdtoreztorevolume.(T.246-7).
A.norderforanormalsal
a .
Rcspondeot's ozder to transferPatientF te a pcdfatric hospita)foran evaluation ofacute
m cnfngitiswas inappropriate, The paùentdid notçxhibitsip )s ofserious acutcîllnesà and
16
wasinappropziatelyworkedupwithaCAT scan.(T.247-248).
7O. n cstandardofcateforachildt'
hatpresentswithaconcem tbracutemetaihstisisto very
quïckly evaluatv the patient w1t.
14 blood culttu'es atad an imniediate ltuhbar ptmctttre.
ëntibioticsshtmldbeadministetedvvltiléawaitizigtbesetèstrestllt:.(T.261-262).
.
71.
Resyondent's tecèrds fôrPatientF were imad4quate to supperta working diagnosis of
rtpnin/tià.(T.264-165).
PatientG
72.
PatientG,an 8-m onth o1d child,was brought tö the ED at 8:30 p.m .on 3/27/07 w fth a
lzistozy ofvornitingand diarrheaforapproximately24 hours,'
w ithm ucou:in 1hesteoland
poot oral intake. She had no prior m edical hiàtory. V ital sqgns w ere norm al, w ith a
lymperatureof98.7,rdspirationsof22,pulseof157andoxygensàtttration of100%.(Pet.
Bx.8a,pg.5).
73.
Ryspondemtevalkated the baby,again noting a history ofvpmiting w1t144 episodq: of
vomiting in the ED,diazrhew as wcll a: a report of low-grade fevez. His physical
exaznination was norm al. He ordered a chest x-zay, a CBC arld a m etubollc panel.
RespondcntalsoorderedPhenergan 12.5m gasarectalsuppository,whichwasdocllm ented
asgivenat12:50a.m.(Pet.Ex.8a,pg.1).
74.
Flttid orders were ylso writtem by Rem ondent,with 160 mlspecified as a saliue bolus,
t
foilowed by 5% dextzosewfth !
,
4nonnalsalineat32m l/
hotlr.JtwasnotNvzittenontlaeorder
sheethow this crystalloid fluid was to be given,by IV or othenvise. How ever,on his
dictated repozl,R espondentspecifiedthattheintza-rectalroutehad been used to delïvctthià
fluid.There isno notation in the record by a nurse thatthcse ordersfor fluid w erecarlied
out.(Pet.Ex.8a,pg.1).
17
indicatethatPatientG hadboertre-hydratedpriortodischarge.(T.267-271,751).
79. Respondent's medicaltecord does notmeett'
ht standard o/ care because it cofltains
discre.
pr ciesthatazeun6xplaihedàndcoltftlting.(T.281).
PatientH
80.
PatientH,an 88yem old woman wit.
h m oderatedemcsntiaandm ultiplemedicalproblemz,
suffered a fallin her narsing hom e. She was tranm orted by xm bulance to th: Lourdes
Hospital ED on 12./26/06 forevaluation 0 e1-the fall. She was àoted to have an 02
satuzation of8!% inG age.Respondentnoted hercom plaintoftighthip andzib pain.He
pcgfonued a generalphysicaleknm ination and docum ented aflirrègular heartb'
eâ.
tW ith à
m urmur.(7n exeemity exnm ination he fbundgùod ro geofm otiön M d no tendem essofthe
pelvisorllipJcint.(Pet.Ex.9:,pg.2,4).
81.
Respondent order:d blo4d work, an I77
* G, and radiop aphs. n e radiographs that
Respondentspecisèd ontheprdersheetweretheleftfoot,pelvis,chestandlightribs. The
radicgraphsthatwtredonewerediffc entthanthtorders.Thechestandrightlibsstudiès
wereperfonmed,aswasazigz
hthipsezics* th 7vfews.(Pd.Bx.9a,pp 2)k
82.
Respondent'srecordstatedthatt''theleftfoot,pelvicbone,zightribseriesandchesf'show e,d
'tno lacturexdislocation,or acute inûltraEonw'' eet.Ex.9a,pg-4).ThePatie.
ntwas
discharged back to the nursing hom e on 12/26/06 at9:10 p.m . The radiologistdictated his
reportofthe righthJp flm s at9:29 pem .thatsam e day,noting an im pacted rightfem oral
nçckfracmre,(Pet.Ex.9a).
83.
lt rem ainsuncleaz when orhow ghe discrepancy in the reading ofthe righthip film sw a.
s
2
discovered,butPatientH remm ed to the hospitalED the follow ing day,approxinlately 21
hours later, for tzeatm ent of the Hght hip g actuz'
e. She w as adm itted to the hospital.
19
*
underwcntrighthip surgeryyand wasdischarged back to the nursing hom con 1/4/07.(T.
316).
4.
n elderlypatiéntwhosuffersafallrtmstbeevaluatednotonly forpossibletrauznaxbutalso
fcrpossible medicealproble sthatm zy havecontributed to thefall. Rem tmderttdid not
mentionposslblemedicalptoblemsthathlayhakecontributèd10PatièntH7sfall.(T.301302),
Respondentnevo-addressed tllepatient'slow oxygen satuzation or the abnermalEKG.
Gfven the1ow oxygen saturation andtlw abnormalcardiacexnm inatitmyxespohdentshoold
have considered the pâtient'spulm onary stattzs and addressed w hetherornotthere w as à
cofnponentofheartfailure.(T.302).
n erewasacliscrepancybetweentheordcr!thàtRespbndentlrroteandtheadualfilhnstllàt
wereperfonned.Rem ondtntordered apelklcx-rà#ybutno x-nayofthepatîent'sriga
hthip.
n e x-ray teclm ologisthoiràver perfbrm ed é fttllzight hip series- A pelvic x-ray only
pzovideàasinglevïew ofthehip in oneplaneanddoesnotprovide multïpleviçws. ltîsa
lesssensitivetesttolèokfcrahip IJ'
I
ZJ'
J'.(T.300,304).
n c 3 view s ofthe hip x-ray indicate a change of allp unent. O ne can clearly see thzt1he
anglebetweenthefemoralneck andthefemoralheadisabnormal.(Pet.Ex.9b);(1n.305306).
RespondentdischargedPatientH bctween 9:00pm artd I0:00pm .Shortly,within mimutes
a11m-thepatientwasdischargcd,theradiologistdidan offcialûnalreadingofthefilm a'
nd
diar osedanimpactedfemoralneckgacture.('
Pet.Ex.9b);(T.3074.
4J:y ED ,w here non-radiologists rcad x-rays,m ust have a system in place to idzntify
,
discrepanciesbetvvecn theED physfcian aod theradiozogistso thatapproprfatefcllow -upcan
20
-
bearranged.(T.315).
Despitetheradiologist'sreadingthatocclzrredwithi:minutesofPétientH 'sdischarge,it's
highly likelythattheradiologistwaàunawârebfRçspondc t'snègàtivcre ding ofthe film
bxausetllepaticntdidnotretàlrntotheED forAlmost21or22hourtlater.(T.316).
Respondent'sreferende in his reportthathtreviewed lcftfootand pelWc bone x-rays is
inaccurafebecausetltc'r:isnoeviderfcethatthesetestswerepcformed../et.Ex.9a,p.4);
(T.318).
Rcspondeat'sm edicalrecord.forPatfent11did notMeetgezlerally aczept:d standard: of
medicalrecordkeeping.(T.319).
CONCLUSIONS O FLAW
Respondentischargedwithtlu'ee(3)s'peèifcationsalle/ngprofessionàlmisconduct
withintheJ'
neaningofBdùcationLaw 96530. Thijstattltesetsforth flamerousformàof
conductwhich constituteproftssionalmisconductv%utdo notprovidedefinitionsofthe
vazioustypesofmisconduct Dudng the course ofitsdeliberationson thesechurges,the
Heazing Comm itlee consulted am cmorandum prepared by the GeneralCotmselfor the
Departm entofH ealth. Thisdocum ent,entitled f'Detsrtitions ofProfessionalM iscönduct
UndertheN cw York Education L,
aw '',sdsforth suggesled desnikonsfor p ossnegligence,
ncgligence,p ossincompetence,incompetcnceandthefzaudulentprzcticeofmedicine.
'
Fhe following definitions werc utilized by the Hearing Com zpittee duling its
delfberations:
Negligenceisfailureto exercise thecarethatwould beexerciscd by areasonably prudent
licensee underthe circum stances.
21
*
Jmcompetenceisalackoftlneskillorkmowledgenecessm'ytoprkcticetlnepr4fession.
Usingtheabove-referenceddefnitionasai- eworkforitsdelîberations,t'
heHearing
comml
'ueeconcluded,byapreponderanceèftheevidence,tlzatal1thre.
c(3) specifyations
of profcxssional m isctmduct shcittld be ststàined. 'I'hç rationale for the Conunitlee's
conclusionsregardingeach spuciscation pfmisgonduptissetforthbelow .
+kttheoutsd ofdeliberatlons,theHearingCommitteemadeàzetmm ination asto the
credibilityofve ouswitnessespresente;dbytbeparties.M ark V.Vilberman,M .D..testifed
fortheDepartm ent-Dr.Silbennan isboa d cerliûed in intem alxpùlntonary,critic-alcareand
emergencym edicine.Heiscmx ntlyon thefàcultyatCèlllmbiaunivùrsityM edicalCenter
wherehepracticu mnergencymedidineândteachesintErnalandpulm onatym e-diçint. Dr.
silberm r is a part-tim e director of em ergency m edicine at the Com m unity Hospîtal in
DobbsFtrry.(Pet,Ex.11);(T,20-21),Thellee gConunitteefox
andW zSilben'
nantobe
a'
rzim pressiv:and thöm ugh w itno s.A ltbough ltew assom etim esacadem ic and rigid,they
found lA
-i:testim ony to be very credible. The D m azm zentalso ofïbreed thetestim ony ofthe
motlnerofPaticntC.TheHeAringCom mitteefoundherttstimonytobefairlymeasm'
ed and
credible.n eybelieveherstatementthatRespondentdid nottmdressPatientC duzing his
exam ination.
Rem ondenttestiâed on his ow n behalf n eH earing Com m ittee found R espondent's
testim ony to be consistentwith inconsistenciesthalhe failed orrefùsed to acknowledge.
TheHcazinjcomnlitteebelievesthatRespondentlied totheHeadng Comrnitteein several
instances. n e Heazing Com m ittee dors notbelfeve thatR espondcntexamined PatientC
lhree differenttimes and that the paticnt was undressed. The H çaring Com m ittze aiso
believes thatRespondentlied abouthisre'view ofthe x-raysforPaticntH. TheHeazing
22
CornmitteefoundRespondent'scveralltesémony asnotcredible.
M TV NT A
n cttzxlA llegatitm s A,A.1yA.2,.Y.3sA .4,.
<.5 aud A .6 : SU STA IN ED
'
l'he Hearirg Cornm ittee concurs wifh t.
144 oyinion ofDr.Sïlberman and Snds that
Respondent'gfàilul'etfjpzoperlydiar dls:% dleat/atiensA conàtitutesaserîousdevixtion
from thestandardofcare. Noneofthe interventitmsdiàtcouldhaveprexentedPutie tA 's
crdiacatrestwereundertak= .n eHeazipgCommitt- tejectsRçspondeht'sexplanation
thathedidnotadminlsterNarcanbecauseofitssideuffmts.(T.384-385).'l'
huHearing
com mittoeconclvdesthattherewasnodownsideto uzingNarcan in tltiàinstance.Patïent
A 'sdeathwasfullypreventablehadRespondentacted within thestandard ofcgre.
PATIE NT B
FactualallegationsB and B.1,B-2 à.4 B.6 andB.# :SUSTM NED '
B.3:W ithdrawn by Departm tnt
B.5:NO'r S'OSTM NED
n eHearingComnnitjeerejew
otslkelpohdct'seNplanationthathedidnotperfontlapelvic
exam becausehedidnotwanttocausetznnecessarydiscomforttoPatient:.(T.518).The
Heming Comnlittee concars with Dr.Silberm an that attlne tim e of Rep ondent's iuïtial
examïnation,itwasurgentto tstablish tbcdiagnosisofectopicprer ancy and to'trx tthe
patientbeforefurtherheznon-hageoccurred.(T.116). Respondentmip lacedhisfocuson
aGlproblem,when thepaticnthadobviou,
qslzmptomsofan ectopicpregnancy.Respondent
placed PatïentB atgrave risk duzing the tnany hoursthatshe w ajtm derhiscare.
n e H eazing Com m ittee doesnctsustain ChazgeB .5 because Respondentcancelled the
23
abdomînalx-raysafterbereceived positivepter ancy restzlts.
PA-IXENT C
FactualallegationsC and C.1,C.2,C.3sC.4 and C.5)SUST
D
TheHearin:Cbznm ittee concurswith Dr.Silbennan thatifResmondenthad perform ed
amadequatephydcalexamînation,theseriousnessoftheinjprywouldhavebeenindicated.
n îsîs evidentfrorzjthe initialdnding oftendernessby th: triagenursecoupled +41.
17tlte
subsm uentfihdingsatW llson HospitalthâtPatientC'sabdolneh wasfullofblood with a
spleenfhatwasnotasubcapàularhematomalmtseVerelyfractured-(T.17$. TheHeàrlg
Cnmm ittee furtherbelievestiz testimony ofPatientC'4 motherthatRespopdentdid not
perform aheadtotoeexwninationdespitehlsnotations.TheHearing ComnGtteeconcludcs
thatRespöndentnevcr entertained a diagnosis ofa Faclured spl:en and isrep onsïble for
dèlaying appropriatetreatm enttoPatienlC.
PATIENT D
Factualallegatltm s D and D.1,D .2,D w3yD .4,D .S aud D.6: SU STA TN ED
TheHee ng Ccnunhteeconcurswith Dr.Silberm an thatPatientD presented v.
/111:a
classicccsefotearlyappendicitis.(T.188).Thepatient'sunexplainv pzinrequitedâtCT
scan and surgicalconsult. n e Healing Committee finds thatRespondo t's testïm ony
regarding thc assessinentof the patientdem onstratesthathisunderstanding ofthe disease
proccssisdeficient.(T.550-560).
PATIEN T E
FactualallegationsE and E.1,E.2,E.3,E.4,E.5,E.7,E.8,E.9: SUSTM NED
E.6: NO T SUSTM NED
The H cazing Cornnnittee again ccncttrs with the D epartlmenles'expert n e H cadng
24
cornm ittee notest'
hatRespondent'sw%ltands on zxzm ination''ofthé patio twas inadequate
and heseem edtold PatiehtE makehisowndiàplosi:ofldtlneypnin even when therew as
no evidenye thatthe'patienthad troùble voidiàg.(T.617,622 -625). The Rearing
Committee alsö doesnotbelievethatRo ondentadvised thepadenton seeking treatltyrit
fnralcoholism and obsm esthatitisnotdocumented in therecord. Chatge E-6 isnot
sustainedbecauseDr.Silbermanindicatedthathospitaliàatîohwbuldhav:beenajudn ent
call.(T.223).
PATTE N'
.
VF
FactxalallegationsF lnd *.1,F.2,F.3yF.5,F.6 and F.7: SUSTATNED
F.4: NO T SU STM N ED
Charge F.4 i:notsùstained. n 6 actuàldiar osis w as tonsilitisw hïch can be bacterial
orviralandtheHearin: Committeesndsitfû benotrelevant.The remai/ ng allegations
are sustained. 'l'heHearin: Committeç is èoncem ed thatmzen ifRespondem 's working
dlagnosisofmeningitishaàbeencorrect,Respondentwastedlifesavingtimcinordetinga
CAT scan. Respondent initially saw this paticnt at 7:40 a.m and did not crder the
administrationofantibiolicsuntil11:û0a.
m i(T.264).
PATIENT G
Factualallegadoo G.1 :W ithdrawu by Departm ent
Factualallegations GsG .2,G.3,G.4,G .5 and G .7:SUSTAINED
Factuulallegation G.6 :NOT SUSTM NED
l
.
The H eahng Cornmittee is deeply troubled by Respondent,s answ ers concenùng his
adzninistrationofphenergan.R ep ondenttestifed thatthentzrse toldhim thatTiganw asnot
available when thehopital'sPyxissystem clearly indicated thatitwas.(Pet-Ex-8b);
'
25
(T,699).RepondentsîtedthathewasawareoftheBlackBoxwainingforPhenerganbut
theHeadngComrnitteedoesnotbelievehim .W hen Rem ondentgavethePhenezgan,the
dosewas50percentmoreth* tlw appropriatedose.(T.273). Thef-learingComznitteeis
also disturbed aboutRespondtnttsexplanaion t1)a1havingthenurseortlleirlfant'sm other
keep ant'Eyeonthepatient''waàsufficicttomonitorfôrfespiratorydeptegsion.(T.704,
753-755).n eHeari'
ngCzfjratzidO beli> esitwasveryfottunatethattl1:cn'
orwés'caught
by tlaephnrmacy audthatPe entG did notrée iveany ftntherdosesofPlleùdgan.
n eHenn'mgCom mitteedaesnotsustain ChvgeG.6betauxèbnceihefluidsare ordow d,
thephysùciazlisnotrl ponsible fort11* adm izziskation.
PATIENT H
FactualallegntlonsH and H.1a11.2,H .3,11.4,H.# and H.7: SUSTM NED
Fuctualallegatlon H.6: NuT SIJSYAINED
TheHeaùngCommitteehasseriousconc= saboutRespondent'sc'redibilityin thi:case.
Regpondentesrecord documents resultz fl'
oï'
n leû footand pelvic slms when there is no
evidencethatthes:testswereeverperformed. Sete-stifseed théthesaw thepelvicx-raybut
theH eazing Com m ittee doesnotbelieke him .n eH earing Corm nitt:e furtlw rbelieves that
the hip x-l'
ay w asavailable forRespcmdent'sreviyw but17eneverbothered to read it. The
Hearing Comm ittee concludes that it w as a serious vïolatïon of the s'tandard of care to
disclnaz'
ge PatîentH beforea11x-raysw erereviewed.
Charge 1-1.6 is notsustained bzcause there isno evidencein therecord to supportit
NEG LIGEN CE ON M O RE THA N O NE O C CA SION
The H earing Com rztittte sustàîns allchttrgesofnegligcncc againstRespondenland tlaus
sustains the FirstSpeciscabon.
26
INCOM PETENCE ON V ORE THAN ONE OCCASION
'
TheHeazingComm ittte àus-tainsa1lohargzàèfincompetenceagainstRespondentand
thussustnl
'nKthe Second SpecifcationFA ILU R E TO M A TNTA W R EC O R DS
n eHearingCom mitteeGndsthatRee ondent'srecordsin a11instr ceswcrelnadequate
and they Sustaintherl7ur
'd Specificatiorl.
DETEM NATION Aà TO PENALW
The Heazing Ccm mittee,parsmanttô the Findinp ofFéctand Contlutionâ of Law set
forthabovedetennined byauhanimousvotethatRem ondent'slioensetopractiçem edicine
inNew YorkStateshouldberevdked.Thisdeterm inationwasreacbedondueconsideration
of the full spectrum of penalties available punnzant to statute, including revècation,
sum ension and/orprobation,censure and repdm apdz theim position ofm onutarypenulties
and dismissalintheinterestsofjustice.
The Hearing Cornm ittee voted, for revocation of R espöndent's licenà: because
Respondentfailed to ensure patientsafetyin eightcaàeswhich repres= tav:ry clwqtcut
pru entation of the m ost comm on em ergcncy roona situations. Respond= t's physical
cxanainations and thoughtprocesses were sorely inadequate.
Respcndent consistently
cxhibited shotly diagnosesand practices,alcng with poorrecord keoping. Respondentalso
dem onstrated aseriouslack ofengagementwith hispatients.
M osttroubling to the Com m ittee is thatRespondent lied,expressed no rem orse and
blarned others forhiim istikes.Thisisa pezsonality traitwhich czmnotbecorrected by
retraining. Even ifallow ed to practice in a supenzised settingx the H eM ng Cornm îttee is
27
concerned + atResponderttcould falsify êecordsorstate thathe perftnrmed exsm lnations
when he(lid not. '
rheHearing committee beli
.evesthatResptmdentcreates a threat
patientsafety and he csnnotbe allowed to retmn to practice medicine i.
n tllisStatek
Heating Conunitteebeliev4àand concludesthatrevtjiettioà istheappropriatepenalty und
iscorrunenstzratevzïthtl)yleqzelandnatm'eofRee ondent'sprof> siopalmisconduct.
28
Makker , M .D .
'R:m
Liceswaroo
nse //M/05
9872
ADDENDUM
Anylicenseewhoisthe subjectofan orderofthe Boardsuspending,revokingorotherwise
.
conditioning the license,shallprovide the following inform ation atthe tim e thatthe order
is signed,ifitis entered by consent,orim m ediately afterservice ofa fully executed order
entered aftera hearing. The inform ation required here is necessary forthe Board to ful5ll
its reporting obligations:
SocialSectlrity Ntlm berl: '
Listthe Name and Address ofany and aIIHea1th Care Facilities with which you are
affiliated:
Listthe Names and Address ofany and allHealth M aintenance O rganizations with which
you are am liated:
Provide the names and addresses ofevery person w ith whom you are associated in your
professionalpractice:(Youmayattachablanksheetofstationerybearingthisinformation).
Pursuantto 45 CFR Subtiile A Section 61.7 and45 CFR Subtitle A
Section 60.8,the Board is required to obtain yourSocialSecurity Num berand/orfederal
taxpayeridentification num berin orderto discharge its responsibility to reportadverse
actions to the NationalPractitionerData Bank and the HlP Data Bank.
DIRECTIVES APPLICABLE TO ANY M EDICAL BO ARD LICENSEE
W HO IS DISCIPLINED OR W HO SE SURRENDER O F LICENSURE
HAS BEEN ACCEPTED
APPROVED BY THE BOARD ON MAY 10, 2000
AlIIicensees who are the subjectofa di
sciplinary orderofthe Board are required to
provide the information required on the addendum to these directives
. The i
nform ation
provided willbe maintained separatelyand willnotbepad ofthe p
the Bo
ublicdocumentfiledwith
ard. Failure to provide the information required m ay resulti
action forf
n ftldherdisciplinary
ailing to cooperate with the Board,
Paragraphs 1through 4 below shallapply when
asarequi
red byN.J.A.C.13:45C-1etseo.
Ilcense is suspended orrevok
perm anently surrendefed,
ed or
withorwithoutprejudice.Paragraphsappliesto licenseeswho
ar
e
t
he
s
ub
j
ec
t
of
an
or
der
whi
ch,e ilepermittingcontinuedpractice, containsa probation
ormonitoring require
m ent.
Docum entReturn and Agency Notification
The Iicensee shallprom ptly forward to the Board office atPostOffice Box 183
Fropt Street, 2nd floor'
, 140 East
,Trenton, New Jersey 08625-0183 the originallicense
,
' cur
biennialregistration and, ifapplicable,the originalCDS registration
rent
licensee holds a Drug EnforcementAgen
ln addition,ifthe
c
y
(
DEA)
r
egi
s
t
r
a
t
i
on
,
he
or
s
he
shallpromptly
advise the DEA ofthe Iicensure action (W i
th respectto suspensionsofa finite term , at
the conclusion ofthe term
.
.
he licensee may contactthe Board office forthe ret
,t
docum ents previously surrenderedt
urn ofthe
o the Board.ln addition, atthe conclusion ofthe term
,
the Iicensee should contact the DEA to advise ofthe resum
asced
ption of practice and to
ain the im pactofthatchange upon his/herDEA registration
)
.
2.
Practice Cessation
The licensee shallcease and desistfrom engagingin the practice ofm edicine in thi
This prohibition notonly ba
sState.
rs a licensee from rendering professionalsea ices
from providing an opinion as t
, butal
so
o professionalpractice orits application,
hinvherselfas being eligible to practi
orrepresenting
ce. (Although the Iicensee need notaffirmatively
advise patients orothers ofthe revocation
, suspensi
on orsurrender, the Iicensee must
truthfullydisclose his/h
erlicensurestatus in response to inquiry
isalso prohibited f
)ThediscipljnedIicensee
rom occupying,sharing orusing office space in which anotherlic
provideshealihcareservices The disciplined Iicensee m ay contraztFor,
eqsee
from anotherIicensee fororre
acceptpaym ent
ntatfairmarketvalue office prem ises and/orequipm
ln no case m ay the disciplined licensee
ent.
authorize,allow orcondone the use ofhis/her
providernum berby any h
.
.
-
ealthcare practice orany otherIicensee orhealth ca
(1nsituationswheretheIicenseehasbeensuspended forlessthan one year reprovider.
m ay accept paym entfrom
,t
he licensee
anotherprofessionalwho is using his/heroffice durin
period thatthe Iicensee is suspend
g the
ed,forthe paymentofsalariesforopice staffem pl
atthe tim e ofthe Board action.
oyed
)
A Iicensee Fhose license has bqen revoked
,
permanently surrendered m ust rem ove signs
sus
pended forone (1) yearormore or
and take affirm ative
advertisem entsby which his/hereligibilit
action to stop
y
t
o
pr
act
i
ce
i
s
r
epr
esent
ed
also take steps to remove hi
The Iicensee must
s/hernam e frgm professfonallistings, telephone dfrectories
,
jrofessionalstationery,orbillings.Ifthe Iicensee'snameisutilized i
tltle,itshallbe deleted. Prescriptionpads
n a group practice
beqringthelfcensee'sna'
m eshallbedestroyed.
A destruction repod form obtained from the Office
befiled. Ifno otherIicensee isproviding services at
of
thDrug control(973-504-6558)must
e Iocation, allmedications m ustbe
rem oved and retum ed t
o the manufacturer, ifpossible,destroyed orsafeguarded
.
situationswhere aIicense has been suspended forIesstha
(In
and medica'
tions need not be d
n one year,prescription pads
estroyed but must be secured in a Iocked
Safekeeping.)
place for
.
.
.
3.
Practice Incom e Prohibitions/Divestiture
S
of Equity lnterest in Professional
ervice Corporations and Lim ited Liabllity Com
panies
A Iicensee shallnotcharge, receive orshare in anyfee forprofessionalservic
by him/herselfor others while barred from
es rendered
engagi
ng
i
n
t
he
pr
of
essi
onal
pr
act
ice. The
Iicensee may be compensated forthe reason
ablevalue ofservices lawfully rendered a
disbursem ents incurred on a patient's behalfprio
nd
rto the effective date ofthe Board action
A Iicenseewhois a shareholderifla professional
sew i
cecorporationorganizedtoengage
in z e professiona,practiee, wsose license is rev
o
ed'
term ofonet:lyearormoressalrbedeemedtobedk surrendered orsuspenyed o ra
is
meaningoftueprofessionalsew fcecor----.-- - zua
,lifiedfromtsepractiqewitsintse
Y'W '' - .
Iicensee shalldivest him/herself of al
el'
-f'
i'Wn n o ZI
W';'
lC-'
1'S'A'14A:17-1i).Adisqualified
.
n
- '= ' '
'
jk
)o'lstintheprofessionalsewice
corporatfon pursuantto N .J.
s.A.:4A:1z-:aJc
b.A-h 4W
l;o 0
''
?
2W
liability company organized pursuantto N .J'
s.
.
.
:1
financialinterest. such divestiture shaIIoccurwithin 90
days foll
o og o a ujo ooyyy ojsjo
o * 6UO OYPCiD9tbe licensee disquaIfffed to pa
rticipate intheapplicabIe form ojowooyss s
uROn divestiture, a Iicensee slnaIlforward to the Board a cop
to the Secreta@ ofstate, comm ercialReporting Division yofdocum en tatjos yom s otoy
, demonst
rating o atuja jns rost
bYs been term inated. Ifthe licensee is the sole sharehol
deri
corporation th'
n a professo sajsow joo
e corporation must be dissolved
disqualificat,ion.
within 9o days of the Iicensee's
14=
C,s
Whball'
S2membefOfalimi
ted
li
vsstbim/herSelfofafl
4.
M:dicalRecords
If,as a resultofthe Board's action, a practice is closed ortransferred to anotherI
the Iicensee shallensurethatduring the th
ocation,
ofthe disciplinary order
ree (3)monthperiodfollowingthceffectivedate
, a m essage wi
llbe delivered to patients calling the for
prem ises, advising where records may be obtained
m eroffice
of the
Tha message should inform patients
.
names and telephone numbers ofthe ticensee (orhis/heratt
cu'
stodyofthe records The same information shallalso be dissem i orney) assumîng
notice to be published atle
nated by m eans ofa
astonce permonth forthree (3)months in a newspaper'
of
.
generalcirculation in the geographicvicinity in which the practice
conducted
end of the three m onth period the licensee shallfile with the was
Board the na Atthe
,
telephone numberofthe contactperson who willh
me and
pati
ave access to m edicalrecordsofformer
ents. Any change in thatindividualorhis/hertelephone numb
repoded to the B
ershallbe promptly
oard.W hen a patientorhis/herrepresentative requestsa
medicalrecord or asks th
copy ofhis/her
at record be forwarded to another health care provide
Iicensee shallpromptly prokide the
r,the
record withoutcharge to the patient
.
.
5.
Probation/M onitoring Conditions
W ith respecttoanylicenseewhoisthesubjectofanyOrderimposinj a probationo
m onitoring requirem entora stày ofan active suspension
r
n whole orIn part, which is
,i
conditioned upon com plianc
e with a probation ormonitoring requirem ent the licensee
shallfully cooperat
,
e
wi
t
h
t
he
Boar
d
and
i
t
s
desi
gnat
ed
r
epr
esent
at
i
ves
EnforcementBureau
ncluding the
, i
ofthe Di
Iicen j
' vision ofConsumerAffairs, in ongoing monitoring ofthe
see sstatus and practice. Such m onitoring shallbe atthe em ense ofthe di
practitioner.
.
'
'
sciplined
(a)
Monitoringofpracticeconditionsmayincludev butisnotlim ited to inspection
,
(confidentialityofpati
andInspectionandcopyinjofpatientrecords
entidentityshallbeprotectedbytheBoard)toveflfycompliancewith
ofthe professionalp
rem isesandequipm ent,
the Board Orderand accepted standards ofpractice.
Monitoringofstatusconditionsforanimpaired practitionermay i
is not I(
ib
m)ited to
nclude,but
, pr
actitioner cooperation in providing releases perm itting unrest
accessto recordsand othe
ricted
rinform ationto the extentpermitted by law from anytreat
facility, othertreating practitioner
m ent
, suppor
tgroup orotherindividual/facility involved in the
education,treatm ent, m onitoring or oversight of the practitioner
rehabilitation
. or m ai
ntained by a
program forimpaired practitioners. Ifbodilysubstance monitoring hasbeen
ordered,the practitionershallfullycooperate by respondingt
o a dem and forbreath. blood,
urine orothersample in
a tim ely m ahnerand providing the designated sample.
NOTICE OF RePORTING PRAGTJGQ.
S OF BOARD
REGARDING DISCIPLINARX ACTIONS
-
Pursuantto N .J.S.A.52:14B-3(3).al
lordersoftheNew JerseyStateBoard ofMedicalExaminersare
available forpublic inspection. Should any inquiry be m ade concerning the status ofa li
inquirerwillbe inform ed ofthe gxistence ofth
censee,the
evidentiary hearings,prœ eedings on motionseoror
d
e
r
a
n
d
a
c
o
j
y
wi
l
l
b
e
pr
o
v
i
d
e
d
i
f
r
e
q
uested.AII
otherapplicabons which are conducted as p
hearinqsandtherecord. includingthe transcriptand dx ument marked in evidence
ublic
public Inspection
. are avai
lable tor
, upon r
eqtlest.
-
Pursuan
tto 45 CFR Subtitle A 60.8,the Board is obligated to repod to the N ationalPractitioners Data
Bank
any
action relating to a physician which isbased on reasons relating to prqfessionalcom p
Orprofessionalconduct:
etec e
'
'
(1)
(2)
(3)
.
W hichrevokesorsuspends(orotherwiserestricts)aIicense
W hichcensures,reprimandsorélace-sonprobation
,
UnderwhichaIi
censeissurrendered
,
.
.
Pursuantto 45 G FR Section 61.7, the Board is obligated to rm ortto the Healthcare lntegrity and
Pr
on (HlP)Data Bank,any formalorofficialactions, such as revœ ation or suspension ofa
I
i otecti
çen
set
andtheIengthofanysuchsuàpension),reprimand, censure orprobationoranyotherIossof
li
cense orthe rightto applyfor,orrenew ,a Iicense ofthe provider.supplier,orpracc oner,whetherby
oper
ation
f
inding
byofIaw ,voluntary surrender, non-renewability,orotherw ise, orany other negative action or
such FederalorState agency thatis publicly available inform ation.
Purstlantto N.J.S.A.45:9-19. 13.ifthe Board refuses to issue, suspends,revokesorotherw ise places
conditions on a Iicense orperm it, itis obligated to notify each Iicensed health care facility and health
m aintenance organization w ith which a licensee is affiliated and everyotherboard lic
withwhom he Orshe isdirectly assx iated in private m edicalpractice
ensee inthisstâte
.
I
n
accor
dance
wiith an agreem entw ith the Federati
on ofState M edicalBoards ofthe United Statesva
li
st
ofaII
discipl
naryordersare provided to thatorganizationona monthlybasis.
W ithin the m onth follow ing entry ofan oqder, a sum m ary ofthe orderwillappearon the public agenda
forthe nextm onthlyBoard m eeting and is forwarded to those m embersofthe publi
c
ln addition, the sam e sum m aryw illappearin the m inutes ofthatBoard m eeting requesting acopy.
a
ch are also m ade
, whi
vqilable to those requesting a copy
.
W
Diithin the m onth tollowing entry of an order, a sum m ary of the order willappear in a M onthly
sciplinary Action Listing which is m ade available to those m em bers ofthe public requ
esting a copy.
O n a periodic basis the Board dissem inates to its Iicensees a newslette
d
r w hi
ch includes a brief
-' - ' -*
escription ofalIofthe orders entered by the Board.
From tim e to tim e,the Press Office ofthe Division ofConsum erAffairs m ay is
the summaries ofthe contentofpublic orders
-
sue rdeasesincluding
.
Nothing herein is intended in any way to Iim itthe Board, the Division orthe Attorney Generalfrom
disclosing anypublic docum ent.