Opinion ID: 2543521
Heading Depth: 1
Heading Rank: 6

Heading: the board could reject the hearing officer's recommended order and make findings of fact

Text: Dr. Pearl argues that the Board inappropriately rejected the hearing officer's recommended order. She does not dispute that it is the Board, not the hearing officer, that is the ultimate fact finder in disciplinary actions or that the Board is not bound by a hearing officer's recommendations. The Board rejected the hearing officer's recommendations for the following reasons. The Board determined that the hearing officer's recommendations were contrary to the evidence presented, that the hearing officer inappropriately based his recommendations on his own experience as a military medic, that he gave more credibility to Dr. Pearl's witnesses than Dr. Wayment and Dr. Jonakin, who both testified to the standard of care in Rupert, Idaho. The Board also found that the hearing officer lost objectivity by filing a Hearing Officer's Response to the Board's Brief and Exceptions to the Recommended Order, and that the hearing officer had inappropriately consulted an outside physician regarding Count One of the complaint. The Board does not need to accept the hearing officer's factual determinations. E.g., Dep't of Health and Welfare v. Sandoval, 113 Idaho 186, 190, 742 P.2d 992, 996 (Ct.App.1987). This Court reviews the findings of the Board, not the hearing officer, although this Court gives the Board's decision greater scrutiny if the Board refuses to accept that hearing officer's recommendations. Dr. Pearl also contends that the Board violated her right to due process by basing its decisions on allegations not contained in the complaint, which she did not have an opportunity to defend. Dr. Pearl is entitled to due process safeguards in a disciplinary proceedings, H & V Engineering, Inc., v. Idaho State Board of Professional Engineers, 113 Idaho 646, 747 P.2d 55 (1987), which include the right to be fairly notified of the issues to be considered. Grindstone Butte Mut. Canal Co. v. Idaho Power Co., 98 Idaho 860, 574 P.2d 902 (1978). Where a decision is based on allegations of which the physician has not received notice, the decision should be overturned as a denial of due process. Krueger v. Board of Professional Discipline, 122 Idaho 577, 836 P.2d 523 (1992). Dr. Pearl also contends that the Board's decision is not supported by substantial and competent evidence. The seven counts that the Board found that Dr. Pearl had violated must be examined individually. A. Count One Count One of the complaint charges: Respondent provided medical care and treatment to Patient S.B. during the hospitalization which was below the standard of care. Psychiatric consultation would have been appropriate in a patient with behavioral abnormalities. The patient experienced iatrogenic barbiturate intoxication, consistent with the multiple doses of Phenobarbital administered. Phenobarbital administration appears to have been overly aggressive. The patient was also given Compazine for behavioral problems. This is a poor choice in a seizure patient, as phenothiazines lower the seizure threshold. The district court held that the Board's findings of fact deviated from the allegations contained in the complaint, and therefore held that Pearl's due process rights were violated. That decision is correct. The Board found that Dr. Pearl violated the standard of care by not monitoring Dilantin levels in the patient. The Board also found that her use of valium on the patient violated the standard of care. It is clear that Count One does not concern the administration of valium or the monitoring of Dilantin. Under Krueger, a physician must be given notice of the particular violations of the standard of care in order to have the opportunity to present evidence and gather witnesses. The Board based its decision in part on Dr. Pearl's administration of valium and monitoring of Dilantin levels. These violations were not contained in Count One. Therefore, the Board violated Dr. Pearl's due process rights by considering this evidence. B. Count Two Count Two of the complaint charges: On or about September 13, 1995, Patient A.D., a 19-year-old male, was admitted to the Minidoka Memorial Hospital emergency room in Rupert, Idaho, with a laceration to the top of the left foot. The laceration was described as 6 centimeters in length, 1 to 2 centimeters deep, and varied from 1 to 4 centimeters in width. Respondent provided medical care and treatment to Patient A.D. during his admission which was below the standard of care, in that Respondent failed to clean and anesthetize the wound prior to suturing. The Board found that Dr. Pearl violated the standard of care by failing to evaluate the extent of the injury and failing to clean and anesthetize the wound prior to suturing. Dr. Pearl argues that the failure to evaluate the injury was not alleged in the complaint. The Board responds that because the complaint alleged the size of the wound, there was notice that the extent of the injury was at issue. The Court will not review this count. The district court determined that there was not substantial and competent evidence to support the Board's findings. The Board has chosen not to dispute this determination. The record therefore establishes that the Board's decision on Count Two is not supported by substantial evidence and this Court does not need to reach the issue. C. Count Three Count Three of the complaint charges: On or about September 13, 1995, Patient O.N., a 52-year-old male, was admitted to the Minidoka Memorial Hospital emergency room in Rupert, Idaho, with a wound to the left hand. The wound was described as being located on the left third digit extending from the first distal knuckle to about the medial knuckle. Respondent provided medical care and treatment to patient O.N. during his admission which was below the standard of care, in the Respondent failed to clean the wound prior to suturing. The Board found that Pearl failed to obtain surgical consultation, failed to appropriately clean the wound, and delayed closing the extensive wound. The Board admits that Count Three does not allege failure to obtain surgical consultation or a delay in closing the wound but does allege that Pearl failed to properly clean the wound. The Board's decision is based in part, therefore, on allegations not alleged in the complaint. Dr. Pearl was only on notice of a cut that she failed to clean. D. Count Four Count Four of the complaint charges: On or about October 17, 1995, Patient M.P., a 9 year old male, was admitted to the Minidoka Memorial Hospital emergency room, in Rupert, Idaho, with intractable vomiting. Respondent provided medical care and treatment to Patient M.P. during his admission which was below the standard of care. The patient had signs and symptoms of dehydration and bilious vomiting. Multiple antiemetics were used prior to adequately discerning the cause of clinical symptoms (for example, rule out diabetic ketoacidosis, rule out intestinal obstruction). As rule out diabetes mellitus was included in the admission diagnosis, the use of D5½ NS is inappropriate. D5½ NS is not an appropriate intravenous rehydration fluid. The amount of potassium used in the intravenous fluid is inappropriate for a pediatric patient. After rehydration and potassium infusion, no laboratory analyzes were ordered. The Board found that Pearl had performed an inadequate workup to evaluate the cause of vomiting, used an inappropriate dose of potassium, ordered an improper IV solution containing dextrose and failed to order follow up lab work. Count Four clearly alleges these violationsit alleges that Pearl failed to discern the cause of the vomiting, inappropriately ordered an IV and failed to order a laboratory analysis. There was no due process violation regarding Count Four. Pearl also argues that the Board's decision is not supported by substantial and competent evidence. The basis for Pearl's argument, however, is basically that there was conflicting evidence. Dr. Pearl argues that each witness testified differently regarding the use of potassium and dehydration. The Board's decision is based on the testimony of Dr. Wayment and Dr. Jonakin. The Board noted that Pearl had ordered potassium because the patient was deficient in potassium, but admitted that lab work was not available to her at the time she ordered potassium. Dr. Wayment testified that if one suspects that a patient is diabetic, it is inappropriate to order an IV solution containing dextrose. Both Dr. Wayment and Dr. Jonakin testified that Pearl violated the standard of care by failing to order follow-up lab work when the treatment was completed. The Board noted that there is no documentation that Pearl examined the patient's abdomen when she should have. Dr. Jonakin testified that Pearl needed to determine the cause of vomiting, and that using multiple antiemetics, as Pearl did, can mask the cause of vomiting. Pearl argues that Dr. Wayment's treatment of this patient was substandard, and that the Board completely disregarded her own testimony. Dr. Pearl does defend her use of multiple antiemetics by testifying that she was concerned that the patient had been vomiting for so long that he could have a less common affliction, such as tears in the esophagus, and that the patient was given multiple drugs in small doses to try to stop the vomiting. However, Dr. Pearl does not refute the testimony that is in the record or relied upon by the Board. Dr. Wayment and Dr. Jonakin both testified that Dr. Pearl's care was below the standard of care for the community. Dr. Pearl has only presented evidence that there is some conflict of evidence in the record. The existence of conflicting evidence is not a basis to reverse the Board's determination. E. Count Five Count Five of the complaint charges: On or about November 1, 1995, Patient B.P., a 65-year-old female, was admitted to the Minidoka Memorial Hospital emergency room, in Rupert, Idaho, complaining of feeling a lump in her throat. Respondent provided medical care and treatment to patient B.P. during her admission which was below the standard of care. The patient's history is compatible with esophageal stricture. Most likely etiologies, given the patient's age, include hiatal hernia, reflux esophagitis, and neoplasm. There is no description of physical findings to support thrush. The Board found that Pearl failed to conduct an adequate examination to rule out common etiologies and diagnosed and treated thrush without laboratory confirmation. The allegation in Count Five is that Dr. Pearl did not have the findings necessary to support a diagnosis of thrush. This is what the Board found. As such, there is no due process violation with the Board's findings. Dr. Pearl also argues that the allegations in this Count are not supported by substantial and competent evidence. The Board noted that when the patient arrived, she complained that it felt like a blood pressure pill was stuck in her throat. Dr. Pearl's notes indicate that the pill was taken the night before and it felt like it was stuck in the patient's throat. Dr. Pearl diagnosed thrush, ordered medication, and instructed the patient to see Dr. Wayment several days later. The patient was discharged nine minutes after Dr. Pearl arrived. Dr. Wayment testified that Dr. Pearl violated the standard of care by diagnosing thrush without doing a culture and should have evaluated the patient for esophageal stricture. Dr. Wayment doubted that the patient had ever had thrush. Dr. Jonakin concurred with Dr. Wayment and testified that Dr. Pearl did not perform an adequate evaluation. Dr. Pearl argues that Dr. Jonakin testified that there could have been signs of thrush, but does not refute the allegations that thrush should not be diagnosed without performing a culture. The decision of the Board on this Count is supported by substantial and competent evidence. F. Count Six Count Six of the complaint charges: On or about September 28, 1995, Patient E.P., a 46-year-old female, was admitted to the Minidoka Memorial Hospital emergency room, in Rupert, Idaho, with a complaint of headache. Respondent provided medical care and treatment to Patient E.P. during her admission which was below the standard of care, in that patient E.P. was discharged from the emergency room by the Respondent without appropriate evaluation and treatment of hypoxemia. The Board found that on September 24, 25, 26, and 28, Pearl had failed to evaluate and address the patient's hypoxemia. The only date contained in Count Six is September 28. The Board admits the findings need to be restricted to the date of September 28. The Board's decision is based, at least in part, on matters not alleged in the complaint. This was a due process violation. G. Count Seven Count Seven of the complaint was dismissed by the Board. H. Count Eight Count Eight of the complaint charges: On or about October 27, 1995, Patient E.H., a 28-year-old female, was admitted to Minidoka Memorial Hospital in Rupert, Idaho, with a 28-week gestation pregnancy with right pyelonephritis. Respondent provided medical care and treatment to Patient E.H. during her admission which was below the standard of care. It is outside the usual scope of practice in emergency medical to provide inpatient care of a high risk pregnancy (28 week gestation, pyelonephritis, preterm labor). The Board found the care provided to this 28 year old pregnant female . . . to be below the standard of care and beyond the usual scope of emergency physicians to treat a high risk, 28 week gestation, pregnancy. Count Eight alleges that it was improper to provide inpatient care of such a pregnancy, and the Board found that it was outside the scope of emergency physicians to treat this type of pregnancy. Dr. Pearl's due process argument on this issue is that Count Eight does not allege a violation of the standard of care, but rather that her actions were outside the usual scope of emergency care. However, it is clear that she was on notice of what the claimed violation was. There was no due process violation regarding Count Eight. Pearl also argues that the Board's decision is not supported by substantial and competent evidence. The Board noted that Dr. Pearl was asked by Dr. Saurey to cover for him while he was gone. Dr. Pearl had no OB privileges in the hospital. That night, the patient began having contractions, and the nurse testified that the patient was going into premature labor. Dr. Pearl ordered valium, which the nurse refuted and refused to give, and Dr. Pearl administered the valium herself. The nurse testified that she called Dr. Wayment to advise him that Dr. Pearl had administered valium. Dr. Wayment testified that he got the call from the nurse, although Dr. Pearl testified that it was she who called Dr. Wayment. Dr. Wayment arrived and ordered magnesium sulfate to stop the premature labor. Dr. Wayment testified that it was a violation of the standard of care to treat premature labor with valium, and that it was a violation for Dr. Pearl to have taken over inpatient OB without obstetrical privileges. Dr. Pearl's argument concerns only her OB privileges and the fact that she was working at the request of Dr. Saurey. Dr. Pearl does not address the improper use of valium on the patient, which would constitute improper emergency care of a high risk pregnancy. Because there is evidence from Dr. Wayment that Dr. Pearl violated the standard of care, this decision of the Board is supported by substantial and competent evidence.