FAX to DOH concerning Investigation/ Medical Board Review based on Secret Records
Link to Medical Expert Opinion
October 16, 2003
Department of Health Prosecution Services Unit - Legal by fax 850-414-1991
Tallahassee, FL 32399-3265
Re: Case No. 2001-18695
a) Your response to my letter of September 30, 2003 dated October 1, 2003
b) Impeachment of the medical Expert or accusation of Fraudulent Medical Records
Dear Ms. Mary Denise O'Brien:
I thank you for supplying the requested information on Dr. Unaeze's hearing and promising to obtain the information as to the other three complaints.
Upon reviewing the expert opinion, I consider the opinion a falsification of facts in favor of the subject. In any civil case, his portrayal by omission of facts would be impeachable. This report appears to be a "selective choice" of review. It takes parts of records to support a "no find" of any medical omission. [nurse's notes alone, instead of looking at the actual orders in the case of the sonogram]. I call attention to what Dr. Dan McCanne, known fighter for universal healthcare, recently said:
"As we reform health care, it is essential that we understand the true nature of the problems. Presenting data that deliberately create false conclusions is really no different than lying.
"By carefully selecting data" from the records, this Florida state medical expert "deceive[s] readers" into believing "[t]he spurious conclusion." The true facts "totally refute this conclusion."
The other possibility is that the expert has received fraudulent medical records.
It appears that the age of the patient allows for not following the standard of care and justifies all "poor outcomes." A poor prognosis and advanced age of the patient may even justify an "impeachable" review. It appears old age justifies zero care for big bucks.
I understand this type of review is common among medical professionals today. This is one reason for the poor quality and high cost of medicine in America.
1. I take issue with the emboldened part of the statement:
"The patient had a history of CVA in January 1999 that required hospitalization until transfer to rehab on 2/2/99. "
It is correct is that the patient was hospitalized until 2/2/99 - medical necessity is still questioned, since the statements of Dr. Liskiewicz [the only known emergency department physician involved - somewhere a Dr. Silpa appears for Medicare billing] are in total contrast to what was necessary for the welfare of the patient.
There was not one procedure performed during her hospitalization according to my copy of the medical records [hospital attestation statement in my medical record copy] and to
my knowledge, which could not have been performed at home ----especially if the patient was in such bad condition to expect impending death.
As the patient's legally designated health surrogate, I should have been informed of the prognosis to allow for competent decision making for my mother. Dr. Unaeze only talked about effects from the 4-day-old fall.
I realize, "paper is patient." This was one of my mother's favorite expressions.
2. "she died on 2/13/99 after unsuccessful resuscitation." This is true. However, why did the doctor order resuscitation if her condition was terminal [see #12]? This was against the living will of the patient, which was on file.
If the patient has rights, didn't Dr. Unaeze violate them in ordering resuscitation of a lost cause without any prognosis of recovery?
Was the resuscitation 2 days after Dr. Unaeze was "on call for the treating physician" for the purpose of justifying his attempt to save her life? Whereby- - according to my records and knowledge--- he did absolutely nothing for either the pain or the low potassium value of the patient, which might have helped her to recover.
3. "the subject physician .... was not negligent in her care." "Based on the reports from the nurses' notes, the subject ordered appropriate xrays'(venous duplex ultrasound to rule out DVT .."
The statement above is found under #3. The statement is true, however, those same notes/orders as presented in my complaint state that this test to rule out DVT [ordered at 6:15 AM] was canceled before the test could be made at 6:45 AM. Since it was a telephone order, it should be implied that the physician had not examined the patient and had no access to her records at that time and no reason to stop this "appropriate x-ray."
Is not canceling the appropriate ordered test before it is done, negligence? The subject canceled the appropriate test himself as documented in my copy of the medical records and to my personal knowledge. I argued with him that the x-ray was unnecessary for this patient's bones. My knowledge of the patient appears to have been documented by the x-ray - only mild osteoarthritis [when considering the patient's age = nonexistent].
Please inform me if you have a record of the test having been performed as ordered!
I am aware of a fraudulent facility name having been used to bill Medicare [Heritage Park - a name discontinued by the owners in 1994 as documented by AHCA]. The investigation of Dr. Unaeze was not commenced until after the facility was taken over by a new management group and renamed "Heritage Park" in November 2002.
You have stated yourself, that the medical records used for this investigation are in the name "Heritage Park" although the patient was in fact at the facility "Integrated health Services of Bradenton" at the time in question.
I have received no itemized bill from the Rehab facility - against state and federal law. I was provided a peculiar ledger sheet. The ledger sheet shows the patient being discharged at 8:38 AM on 2/12/99, which is untrue. Another form [MDS] shows her dead on 2/12/99 - a day before death.
If this doctor actually states that the appropriate test was ordered, yet does not question, why the appropriate test was canceled by the same physician and never performed, his report is biased and worthless from a medical position.
See #10: "10. The sonogram ordered was appropriate to rule out DVT." --yet canceled and never done.
The x-ray order was a replacement/substitution order of the ultrasound test to rule out DVT!! The sonogram was never performed. This is an omission to the layman. Is it not to a medical professional? Or does old age excuse this omission?
4. "The subject managed the patient well with no evidence of negligence in care."" All appropriate care and monitoring were provided to the patient."
My questions were based on my physical presence at the time and Dr. Unaeze's documented lack of presence:
What care? What monitoring? There was no painkiller given, but the continued Darvocet-100 [a habit-forming aspirin, which was already prescribed by subject's partner [Dr. Sharma] on 2/11/99], which was documented by the nurses as not working [p.62].
According to the medical records, which I received on the day of my mother's death, absolutely no potassium was being given. My mother was not on an IV or any other special nourishment and she was only getting the antibiotic "Claforan" as prescribed by Dr. Sharma, although Dr. Hoban writes about the antibiotic" Cleocin" [p.46].
What care is shown in the subject records for the patient care?
No care is shown in mine other than monitoring her demise.
The potassium deficiency [level 3.1] is shown in the lab of 2/8/99 [p. 110], yet no effort at correction is shown in my set of records.
"Normal levels of these substances are essential for effective homeostasis of body systems. Potassium is especially essential for effective heart function." [fn1]
Granted, Dr. Unaeze did not take over until the morning of 2/12/99, and the patient's condition was allowed to worsen due to four days of potassium deficiency. However, a detailed evaluation on 2/12/99 should have revealed the old deficiency and corrective action could have been taken. In reality it was not. No chemical test was shown to be ordered by the subject.
Is this not negligence? Or is the heart function of the elderly [Zoe was 88.] not important anymore? Or, did this expert have other care/action fraudulently shown in subject's "Heritage Park" records?
5. "The patient's outcome was unfortunate but cannot be attributed to any acts of omission or commission by the subject."
Is the cancellation of the appropriate test {Ultrasound to rule out DVT} an act of omission?
Is the lack of prescribing potassium, when a deficiency is clearly documented as existing an act of omission?
To a layman both of the above are certainly acts of omission,
unless an 88 year old is supposed to die because the "prognosis is poor."
If this is the case, just why was the patient in an expensive facility, for care at taxpayer's expense, when the family was willing and able to take care of her in the environment, which the patient herself desired --at home?
If one gets no necessary care [painkiller or replacement of deficient minerals] is the facility/physician fulfilling their contractual responsibilities to the Medicare program or to the patient and patient's family?
6. "The subject's assessment of patient's complaints and symptoms was adequate; assessment was complete. A complete history and physical was documented."
What complete history and physical?
On page 46 of my IHS bate-stamped medical records is the only written entry by the subject -
12 lines including the date on the Physicians Progress Notes [PPN] form. This is the only visit documented to my knowledge. At this time, he spent not more than five minutes with the patient and signed a release for home health care [p.43], which he later canceled and never "signed off" on.
Could the assessment have been adequate if he ignored the low potassium value and ignored that the Darvocet, he ordered, had already been ordered by his partner and was not working. He only talks about a fall {although at 6:15 he was concerned about DVT, yet canceled the test himself before it could be performed}?
Could it have been adequate without results of the ultrasound/ sonogram? Could it have been adequate if subject talks about a four day old fall, when this medical expert talks about "a pending terminal event." {see #12}
7. Re: test results/ drugs prescribed:
See #9:
"9. The medical records maintained by the subject completely document and justify the course treatment utilized in the care of the patient. The history and examination are complete. The test results, records of drugs prescribed, dispensed or administered, and reports of consultation and/or hospitalization are included in the patient's medical records. The medical records are not deficient."
According to my set of medical records, no tests were ordered by Dr. Unaeze [other than the canceled Ultrasound and "STAT" hip x-ray [which took more than 5 hours to be performed, although the hospital is less than 5 minutes away] and the unnecessary CT-scan for a slipped disk [which may be missing in the expert's records].
In my set of records and in the Symphony Mobilex Report, the x-ray report is shown as having been ordered by Dr. Sharma and having been completed at a later hour than was true.
Only one medication was ordered {reordered since Dr. Sharma had ordered it the night before} - Darvocet-100. The drug record, I received, also does not show that subject Dr. Unaeze ordered Darvocet, but only orders by Dr. Sharma, who was called by phone and prescribed Darvocet by phone on 2/11/99.
The subject, Dr. Unaeze, is not shown as having ordered any medication other than in his Physician Progress Note [PPN] [p.46].
The medical records, I have show that Zoe was receiving Claforan, although Dr. Hoban mentions in his consultation report that she is on Cleocin in his progress note and consultation report.
Cleocin use after the 2/3/99 is not in my copy of the medical records other than in Hoban's entry on the same page with Dr. Unaeze's PPN entry [p.46].
What medications and tests were ordered by subject Dr. Unaeze in subject's records to be considered adequate and well-documented?
Furthermore, how can the medical expert determine if the records are "not deficient? " He was not with the patient, appears to have records from a [at the time] nonexistent facility and describes items, which cannot be from records created at the time of the incident.
I know, what the expert has documented is not true, and that other things documented are in error. At best, he can say, "it appears" that they are complete and accurate. The Florida system of forbidding the complainant to see the records upon which this "expert" bases his opinion is to allow crime to flourish.
8. The medical expert does not mention the CT-scan, which was performed in the evening of 2/12/99 and shown as having been ordered by Dr. Unaeze as a regular scheduled clinic test by Blake Medical Center. Page 43 of my bate-stamped medical records shows it having been ordered "stat CAT scan of lumbar sacreal spine." It was, however, not performed until about five hours later. One nurse notes erroneously, that the patient was being taken to Park South, when the patient was taken to the emergency room of Blake Medical Center. I was there with the patient, having accompanied her in the ambulance. I even signed an ABN form to get the test.
Is this test missing from the subject's records? In view of the patient's "pending terminal event." {see #12} is this not an inappropriate order?
This test was clearly an inappropriate and expensive test calculated to do nothing in the case of a recognized "pending terminal event."
Why does the expert not mention this part of the complaint? This may not have anything to do with the death of the patient, but it does have to do with violations of law, which forbids unnecessary testing?
In conclusion, either the medical expert has written a report to protect the subject doctor by selectively choosing notes or orders to document appropriate care without an objective overview of the genuine 'care" received, or he has different medical records, which would then be fraudulent and criminal.
As I have not been allowed to see the records for this investigation, I cannot be sure which has been performed. In any case, elderly patients must suffer under such circumstances. Affordable quality care will never be achieved as long as such methods of complaint investigation are allowed to be used.
9. Under # 5 "The subject's diagnosis of the patient's condition was appropriate..." I have found only one actual diagnosis associated w/ subject's name: 724.02 = "spinal stances". What appropriate diagnosis did this "expert" have? Is old age a diagnosis? If so how is age 88 differentiated from this particular patient's mother's age: 105? At what age does it start?
10. Please inform me under which statute[s], that I am not allowed to view the medical records used in an investigation of my personal complaint. Please explain, why I, the complainant and personal representative of the deceased patient, am not allowed to see the records. Being made "public" has to do with public information, but certainly not with the victim per se.
Please show me any federal regulation, which forbids the victim from seeing the investigative material, i.e. the patient's own Medical records as presented by the subject and the involved facilities. Please provide answers to my complaint about your expert opinion.
Any such "secrecy" regulation prohibits the patient/complainant and often witness[es] from controlling the truth or fraud of the medical records. Such a regulation would not be conducive to affordable quality health care and allows for fraud to hide medical conditions, which should be honestly evaluated for the benefit of society as a whole. It is not conducive to a proper objective investigation and sets apart victims of medical wrongs from all other crimes.
Very sincerely,
Carol Stronstorff, Former health surrogate and personal representative of Zoe E. Stronstorff
P.S. See attached expert opinion [used for Board decision on 9/12/03 with my comments line by line - six pages .
[fn1] Appleby, Kristin S., Medical Records Review- 3rd Edition, Aspen law & Business, 1999, p. 71 under § 2.3 Blood Tests, Electrolytes
ATTACHMENT (medical expert opinion for Florida AHCA/DOH physician complaint w/ detailed questions - statements by the witness and health surrogate of Zoe: Carol Stronstorff
Department of Health Medical Review
DOH Medical Review,
Physician Review Response Physician Reviewer:, . - , MD
Subject: Vitalis Unaeze, MD Case number: ME O1-18695 Date: June 2, 2003
Overview
This case is predicated on the receipt of a complaint regarding the subject's care of ZS an 88-year-old female. The subject was on call for the treating physician and treated the patient during her stay at a rehabilitation facility. The patient had a history of CVA in January 1999 that required hospitalization until transfer to rehab on 2/2/99. When the subject was on call for the treating physician, the patient's condition deteriorated and she died on 2/13/99 after unsuccessful resuscitation. It is alleged that the subject failed to provide proper care to the patient.
*** Subject [Dr. Unaeze was called on the morning [6:10 AM on 2/12/99 after a nurse documented a night of crying out in pain from a cramped leg - cold extremities]. My medical records show him reordering Darvocet-100, canceling the at 6:10 AM telephone-ordered "US to r/o DVT" at 6:45 AM before ever physically examining the patient. The "STAT" x-ray was not performed until after noon. He then ordered "IHS HomeCare" after seeing the patient for the first time in the facility. He then canceled this order by phone. He ordered a "STAT" CT-scan after 2:00 PM [not scheduled until after 6:00 PM as a "reg clinic" [according to Blake Hospital records].
On 2/9/99 the patient had had an operation - removal of a salivary stone operation {excision} and had a documented potassium deficiency. According to my copy of the medical records and my physical presence at the facility, nothing was being done to correct this deficiency..
See 12 below : if the "patient's deteriorating condition was consistent with a pending terminal event,", why was the patient then resuscitated against her living will on 2/13/99, yet not given any effective painkiller or potassium, which may have helped the patient recover from the cramps and survive.
Did one want the patient to die? At no time was the family told that this condition [pain and cramped leg was "terminal". She was being treated according to subject, Dr. Unaeze, for a 4-day old fall.
Questions
1. I do not know the subject.
2. I currently perform the examination/ test/procedure or prescribe the medications at issue. The lag time I performed/prescribed was 2003.
3. The subject does meet the applicable standard of care in his approach to this patient. According to the medical record, the subject treated the patient while on call for the regular treating physician. The patient's condition was such that at 88 years old and with multiple co-morbidities and a significant recent CVA, her prognosis was poor. The events that led to the patient's ultimate demise were related to her poor condition: the subject physician did not contribute to the patient's deteriorating condition and was not negligent in her care.
Based on the reports from the nurses' notes, the subject ordered appropriate x-rays (venous duplex ultrasound to rule out DVT and plain films to rule out hip fracture).
*** He ordered the ultrasound but canceled it within the 1/2 hour before the test was made - so he never had this test - See orders p.42 ***
The extent of the patient's infarct was such that there was little chance of long-term survival. The subject managed the patient well with no evidence of negligence in care. All appropriate care and monitoring were provided to the patient.
*** What care? What monitoring? There was
no painkiller given, but the continued
Darvocet-100 [habit-forming aspirin], which was not working !!!***
The patient's outcome was unfortunate but cannot be attributed to any acts of omission or commission by the subject.
*** What about the low value of potassium? No potassium was given ***
The family's concern is taken into consideration and it is regrettable that they lost their mother. However, the prognosis was poor for this patient.
The subject's assessment of patient's complaints and symptoms was adequate; assessment was complete. A complete history and physical was documented.
*** What complete history and physical was documented? I am only aware of one paragraph in the five minute visit after the x-ray, showing no broken bone or damaged tissue ***
5. The subject's diagnosis of the patient's condition was appropriate and adequate.
*** What was the diagnosis? For the canceled US , it was DVT
For the evening CT-scan it was "slipped disk" ***
6. The patient's complaints/condition did not call for the use of specialized consultations for diagnosis and/or treatment.
*** What about a painkiller? What about potassium supplementation? ***
7. The appropriate plan or treatment was pursued.
*** What plan? Let her die without going home or without an effective painkiller? ***
8. The subject did not prescribe medication excessively or inappropriately.
*** This is an understatement. He did not prescribe any medication according to my records --- only the already ordered Darvocet-100, which was not working [ordered by Dr. Sharma on 2/11/99 evening]. ***
9. The medical records maintained by the subject completely document and justify the course treatment utilized in the care of the patient. The history and examination are complete. The test results, records of drugs prescribed, dispensed or administered, and reports of consultation and/or hospitalization are included in the patient's medical records. The medical records are not deficient.
*** I would like to see these records of the "subject." I have only 3 orders
1) telephone order for US to rule out DVT - not done
2) telephone cancellation with order for STAT x-ray for 4-day old fall
3) note in physician progress notes - "full range of movement and "order" for already ordered Darvocet-100 - no review of potassium deficiency or any other order
4) order for home health care
5) telephone cancellation of taking the patient home on 2/12/99 --- no reason therefore given
6) unnecessary "regular clinic" order for CT-scan for slipped disk
10. The sonogram ordered was appropriate to rule out DVT.
*** Right on, an appropriate order, which subject canceled before patient got the test? Why did he cancel it if it was appropriate? Or do your records show the patient receiving it? ***
11. The plain x-rays were appropriate to rule out a hip fracture following a fall.
*** But there was no fall -- at least not since four days earlier, when no damage was determined by both the doctor [Sharma] and the nursing home staff. The patient's pain started in the chest and moved to the leg after she was stood up on 2/11/99 - the leg cramped painfully and was blanched white.
These symptoms are not "fall-related".
12. The patient's deteriorating condition was consistent with a pending terminal event. All efforts that were made were appropriate for the patient's condition.
*** What effort was made?
on 2/11/99, I wanted the doctor called because of the extreme pain of my mother, which started in the chest. I was told it was just a cramp by the nurses and pacified that she would be given an adequate painkiller -[Darvocet-100 prescribed and documented by the night nurse as not working].
on 2/12/99 - she was supposed to be taken to the hospital to get emergency care - Ultrasound to rule out DVT -- this was canceled and not done
we then waited for over five hours for an x-ray to come [I told the doctor, my mother had strong bones and I did not believe it was from such [broken bone- dislocation] --- the x-ray documented no problems!
the doctor visits the patient and does not review the records but leaves instantly without doing anything. He did not state that she was dying and they would do
nothing - He did not even give her a working painkiller- otherwise, we could have taken her home.
The CT-scan to rule out a slipped disk, which was ordered by subject is not mentioned by the "expert." This test was done as a regularly scheduled clinic according to my records, and must definitely be considered an inappropriate test, if nothing was being done because of the "pending terminal event." This test was billed to Medicare and the private insurance. In view of the earlier x-ray ruling out such damage, this was inappropriate testing - an adequate painkiller would have been cheaper and more beneficial to the patient.
It appears that no review of either the EKG or chemical tests [performed on and 2/8/99 -no other such tests are shown done before Zoe's death - five and 1/2 days later] was done.
Is doing absolutely nothing for a patient, who was sent to Rehab against her wishes the applicable standard of care? ***
Summary/Conclusion
The subject does meet the applicable standard of care in his approach to this patient.
*** Is doing nothing until death; then not signing the death certificate nor reporting his "care" as required by Medicare the applicable standard of care in Florida? ***
According to the medical record, the subject treated the patient while on call for the regular treating physician. The patient's condition was such that at 88 years old and with multiple co-morbidities and a significant recent CVA, her prognosis was poor. The events that led to the patient's ultimate demise were related to her poor condition: the subject physician did not contribute to the patient's deteriorating condition and was not negligent in her care.
*** He did not do a "GD" thing to relieve either pain or electrolyte deficiencies or to send her home to die or live with appropriate intervention. ***
The subject managed the patient well with no evidence of negligence in care. All appropriate care and monitoring were provided to the patient.
*** What care? No painkiller - no potassium? no appropriate tests? ***
The patient's outcome was unfortunate but cannot be attributed to any acts of omission or commission by the subject.
*** What about the subject not reporting the death, so that the medical examiner could have checked into the patient's death. The treating doctor did not sign the document for 3 days ["on call for the treating physician and treated the patient during her stay at a rehabilitation facility"] after the death and removal of the patient. ***
The family's concern is taken into consideration and it is regrettable that they lost their mother. However, the prognosis was poor for this patient.
*** What medical value does the concern of a family have in this "expert opinion"? What value does "regrettable" have in this opinion?
What good do my comments to this case do, when they are placed in a file to which the public has no access?
*** As Sarah Grim said, she could not find one doctor to say that a doctor was at fault. It was always the patient's age. What is wrong with doctors today?
See story of Sarah Grim, former head of the Missouri Peer Review program, who exposed Florida corruption in the ITN-affair involving former AHCA head Ruben King-Shaw, Jr.. <Http://spcpi.homestead.com/files/sarahgrimm.HTM >
I would appreciate a responsible answer to the questions raised by the review of this "expert opinion" and my detailed position in this attachment.
Why are we taxpayers paying for worthless investigations, which only contribute funds into worthless profit-making organizations and to irresponsible physicians, who protect their peers first and patients last?
Medical records used by complaint subject should not and cannot be kept secret from the complainant if any kind of effective investigation is to be made. Freedom of information is the only way to go. Health care professionals are allowed special rights. This is unconstitutional and against human rights everywhere.
These questionable privacy laws are being falsely used to protect healthcare special interests against the interests of the general public. Continuing this policy of closed records endangers responsible health care. You and your loved ones, too, may be sacrificed on the alter of unconscionable profits. www.spcp4u.org