STATE OF FLORIDA BOARD OF DENTISTRY RESPONDENT. AMENDED ADMINISTRATIVE COMPLAINT. Petitioner, Department of Health, by and through its undersigned

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1 STATE OF FLORIDA BOARD OF DENTISTRY CLERK: DATE: FILED DEPARTMENT OF HEALTH DEPUTY CLERK Angel &widely DECO DEPARTMENT OF HEALTH, PETITIONER, v. CASE NO: VERONICA ANNE THOMPSON, D.D.S., RESPONDENT. AMENDED ADMINISTRATIVE COMPLAINT Petitioner, Department of Health, by and through its undersigned counsel, files this Amended Administrative Complaint before the Board of Dentistry against Respondent, Veronica Anne Thompson, D.D.S. In support, Petitioner alleges: 1. Petitioner is the state department charged with regulating the practice of dentistry pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 466, Florida Statutes. 2. At all times material to this Complaint, Respondent was a licensed dentist within the State of Florida, having been issued license number DN Respondent's address of record is 4530 Grand Boulevard, New Port Richey, Florida

2 4. Respondent's mailing address is 765 Maple Ridge Road, Palm Harbor, Florida Respondent holds a conscious sedation permit. 6. On or about September 24, 2014, Patient T.M. appointed with Respondent for dental treatment. 7. Patient T.M. was a thirty-nine year-old male with Down's Syndrome and severe mental impairment. He had a history of congenital heart disease, pulmonary regurgitation, pulmonary hypertension, gastric ulcer, tonsillectomy, and umbilical hernia repair. 8. Patient T.M. took 2 grams of Amoxicillin and 0.25 milligrams of Triazolam one hour prior to his appointment on. September 24, 2014, as prescribed by Respondent. 9. Patient T.M. was taken by wheelchair from the waiting room to the dental operatory because he was lethargic from the medication prescribed by Respondent. 10. Once in the operatory room, Respondent administered 10 mg of Midazolam, 100 micrograms of Fentanyl, and 50 mg of Benadryl.

3 11. The minimum standards of performance in diagnosis and treatment in the practice of dentistry require a dentist to consult with a Down's Syndrome patient's medical doctor before administering anesthesia. 12. Respondent failed to obtain a medical consultation from Patient T.M.'s doctor prior to administering anesthesia. 13. Rule 64B (7), Florida Administrative Code, which supplements Section (1)(gg), Florida Statutes, requires a dentist to perform a pre-anesthesia physical examination of the patient and maintain a record of the physical examination which includes airway evaluation and risk assessment. 14. Respondent failed to examine and record a physical examination, including airway evaluation or risk assessment prior to administering anesthesia. 15. The minimum standards of performance in diagnosis and treatment in the practice of dentistry require a dentist to administer the proper amount of anesthesia. 16. The instructions for Midazolam indicate that the initial intravenous dose for sedation in adult patients may be as little as 1 mg, but should not exceed 2.5 mg in a normal healthy adult. 3

4 17. Respondent administered 10 mg of Midazolam. 18. Additionally, lower doses are necessary in patients receiving any other drugs which depress the central nervous system. 19. Respondent administered 1.00 micrograms Fentanyl, which is schedule II narcotic that depresses the central nervous system, to Patient T. M. 20. Respondent administered 50 mg of Benadryl to Patient T.M. Benadryl is a drug that suppresses the central nervous system. Benadryl must be used with caution with other drugs that depress the central nervous system as Benadryl's effects can be synergistic. 21. Respondent failed to administer the proper amount of anesthesia to Patient T.M. 22. The minimum standards of performance in diagnosis and treatment in the practice of dentistry require a dentist to administer a sedative such as Midazolam in increments so as to assess a patient's response to the medication. This is known as titration. 23. The instructions for Midazolam state that the initial dose and subsequent doses should always be titnated slowly. DON v. Veronica Ann Thompson, D.D.S.

5 24. There is no indication that the medications Respondent administered to Patient T.M. were properly titrated to effect. 25. Patient T.M. suffered respiratory depression and cardiac arrest. 26. Rule 64B (7), Florida Administrative Code, which supplements Section (1)(gg), Florida Statutes, requires a dentist to continuously monitor vital signs and record them at a minimum of every five (5) minute intervals during the procedure. 27. Respondent failed to record Patient T.M.'s vital signs every five minutes. 28. Patient T.M. became unresponsive during the sedation and CPR was administered. 29. The minimum standards of performance in diagnosis and treatment in the practice of dentistry require a dentist to follow proper emergency protocols when respiratory and cardiac problems develop. 30. When a patient is in "asystole" there is a complete absence of demonstrable electrical and. mechanical cardiac activity. If this occurs, a clinician should administer 1 mg Epinephrine intravenously every three (3) to five (5) minutes. Case No

6 31. An oropharyngeal airway or nasopharyngeal airway should be inserted if needed to keep the airway open during bag-mask ventilation, and an advanced airway, such as an endotracheal tube or supraglottic airway, should be used if ventilation is inadequate. 32. Respondent failed to follow the proper emergency protocols when Patient T.M. became asystolic by not administering Epinephrine. 33. Respondent failed to use an oropharyngeal airway or nasopharyngeal airway to improve ventilation. 34. The minimum standards of performance in diagnosis and treatment in the practice of dentistry require a dentist who is administering anesthesia during which a patient encounters some respiratory distress, to systematically provide an appropriate diagnosis, of the problem and to adequately treat and/or address the problem. 35. This includes giving reversal agents for sedative drugs when a patient is experiencing cardiac problems. 36. Respondent administered Midazolam and Fentanyl to Patient T.M. which causes respiratory depression. Flumazenil and Naloxone are used to reverse the effects of Midazolam and Fentanyl.

7 37. Respondent failed to administer Flumazenil or Naloxone to Patient T.M. 38. Emergency Medical Service was contacted and Patient T.M. was taken to the North Bay Hospital. 39. Patient T.M. died two days later as a result of "complications of multidrug intoxication." 40. Rule (4), Florida Rules of Administrative Procedure, defines conscious sedation as, "a depressed level of consciousness...that retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal command." 41. Rule 64B (3), Florida Rules of Administrative Procedure, defines deep sedation as "a controlled state of depressed consciousness accompanied by partial loss of protective reflexes, including either or both the inability to continually maintain an airway independently or to respond appropriately to physical stimulation or verbal command..." 42. Respondent administered multiple sedative drugs to Patient T.M. which resulted in a level of deep sedation where he was unable to independently maintain his airway and respond to physical stimulation.

8 43. Rule 64B (1), Florida Administrative Code, which supplements Section (1)(gg), Florida Statutes, prohibits a Florida dentist from administering deep sedation until they have obtained a permit. 44. Respondent failed to obtain a deep sedation permit prior to administering deep sedation to Patient T.M. COUNT I 45. Petitioner re-alleges and incorporates paragraphs one (1) through forty-four (44) as if fully set forth herein. 46. Section (1)(x), Florida Statutes (2014), states that "[b]eing guilty of incompetence or negligence by failing to meet the minimum standards of performance in diagnosis and treatment when measured against generally prevailing peer performance[,]" shall constitute grounds for disciplinary action by the Board of Dentistry. 47. Respondent violated Section (1)(x), Florida Statutes, in one or more of the following ways: 1) By failing to obtain a medical consultation from Patient T.M.'s doctor prior to administering anesthesia; 2) By failing to conduct a pre-anesthesia examination including airway evaluation and risk assessment;

9 1 3) By failing to administer the proper amount of anesthesia to Patient T.M.; 4) By failing to properly titrate anesthesia medication to Patient T.M.; 5) By failing to follow the proper emergency protocols when Patient T.M. went into cardiac arrest by not administering Epinephrine; 6) By failing to use an oropharyngeal airway or nasopharyngeal airway to improve ventilation; or, 7) By failing to administer Flumazenil or Naloxone to Patient T.M. COUNT II 48. Petitioner re-alleges and incorporates paragraphs one (1) through forty-four (44), as if fully set forth herein. 49. Section (1)(gg), Florida Statutes (2014), provides discipline for "[a]dministering anesthesia in a manner which violates rules of the board..." 50. Rule 64B (7), Florida Administrative Code, states that "...the following records are required when conscious sedation is administered...physical examination including airway evaluation and risk 9

10 assessment (e,g. Mallampati Classification, Body Mass Index, and ASA Classification)." 51. By failing to examine and record the examination including airway and risk assessment, Respondent violated Rule 64B (7), Florida Administrative Code, thereby violating Section (1)(gg), Florida Statutes. COUNT III 52. Petitioner re-alleges and incorporates paragraphs one (1) through forty-four (44), as if fully set forth herein. 53. Section (1)(gg), Florida Statutes (2014), provides discipline for "[a]dministering anesthesia in a manner which violates rules of the board..." 54. Rule 64B (7)(d)(1), Florida Administrative Code, requires a dentist to continuously monitor vital signs and record them at a minimum of five (5) minute intervals during the procedure. 55. By failing to record Patient T.M.'s vital signs every five minutes Respondent violated Rule 64B (7)(d)(1), Florida Administrative Code, thereby violating Section (1)(gg), Florida Statutes (2014). 10

11 COUNT 11/ 55. Petitioner re-alleges and incorporates paragraphs one (1) through forty-four (44), as if fully set forth herein. 56. Section (1)(gg), Florida Statutes (2014), provides discipline for "[a]dministering anesthesia in a manner which violates rules of the board..." 57. Rule 64B (1), Florida Administrative Code, prohibits a Florida dentist from administering deep sedation until they have obtained a permit. 58. By failing to obtain a deep sedation permit prior to administering deep sedation to Patient T.M., Respondent violated Rule (1), Florida Administrative Code, thereby violating Section (1)(gg), Florida Statutes (2014). WHEREFORE, Petitioner respectfully requests that the Board of Dentistry enter an order imposing one or more of the following penalties: suspension, restriction of practice, imposition of an administrative fine, issuance of a reprimand, placement of Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate. 11

12 SIGNED this V4', day of 1)ece,--kqv Celeste Philip, M.D., M.P.H. Surgeon General and Secretary Tobey Schultz Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida Florida Bar # TEL: Express Mail Address: 2585 Merchants Row, Suite Original PCP: 2/5/16 Thomas, Britten & Fatmi Amended PCP: 12/5/17 Thomas, Morgan & Fatmi

13 NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section and , Florida Statutes, to be represented by counsel or other qualified representative, to present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. A request or petition for an administrative hearing must be in writing and must be received by the Department within 21 days from the day Respondent received the Administrative Complaint, pursuant to Rule (2), Florida Administrative Code. If Respondent fails to request a hearing within 21 days of receipt of this Administrative Complaint, Respondent waives the right to request a hearing on the facts alleged in this Administrative Complaint pursuant to Rule (4), Florida Administrative Code. Any request for an administrative proceeding to challenge or contest the material facts or charges contained in the Administrative Complaint must conform to Rule (5), Florida Administrative Code. Mediation under Section , Florida Statutes, is not available to resolve this Administrative Complaint. NOTICE REGARDING ASSESSMENT OF COSTS Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section (4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed. 13