XAVIER BECERRA Attorney General of California MATTHEW M. DAVIS - . FILED Supervising Deputy Attorney General STATE OF A LIFOR MARTIN HAGAN . - BOARD OF Deputy Attorney General gags; State Bar No. 155553 aw 20.18. 600 West Broadway, Suite 1800 NALYST San Diego, CA 92101 P. O. Box 85266 San Diego, CA 92186- 5266 Telephone: (619) 738- 9405 Facsimile: (619) 645-2061 Attorneys for Complainant BEFORE THE MEDICAL BOARD OF CALIFORNIA DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA In the Matter of the First Amended Accusation Case No. 800-2015-010978 Against: . FIRST AMENDED ACCUSATION VINCENT PAUL KATER, MD. 6719 Alvarado Road, Ste. 305 San Diego, California 92120 Physician?s and Surgeon?s Certi?cate No. 45851, Respondent. Complainant alleges: PARTIES 1. Kimberly Kirchmeyer (complainant) brings this First Amended Accusation solely in her of?cial capacity as the Executive Director of the Medical Board of California, Department of Consumer Affairs (Board). - 2. On or about August 12, 1981, the Board issued Physician?s and Surgeon?s Certi?cate No. 45851 to Vincent Paul Kater, MD. (respondent). The Physician?s and Surgeon?s Certi?cate was in full force and effect at all times relevant to the charges and allegations brought herein and will expire on April 30, 2019, unless renewed. 1 VINCENT PAUL KATER, M.D. - FIRST ANIENDED ACCUSATION NO. 800?2015-010978 28' JURISDICTION 3. This First Amended Accusation is brought before the Board, under the authority of the following laws. All section references are to the Business and Professions Code (Code) unless otherwise indicated. NH Section 2227 of the Code states: A licensee Whose matter has been heard by an administrative law judge of the Medical Quality Hearing Panel as designated in Section 11371 of the Government Code, or whose default has been entered," and, who is found guilty, or who has entered into a stipulation for disciplinary action with the board, may, in accordance with the provisions of this chapter: Have his or her license'revoked upon order of the board. Have his or her right to practice suspended for a period not to exceed one year upon order of the board. Be placed on probation and be required to pay the costs of probation monitoring upon order of the board. 1 Be publicly reprimanded by the board. The public reprimand may include a requirement that the-licensee complete relevant educational courses approved by the board. A Have any other action taken in relation to discipline as part of an order of probation, as the board or an administrative law judge may deem proper. - Any matter heard pursuant to subdivision except for warning letters, medical review or advisory conferences, professional competency examinations, continuing education activities, and cost reimbursement associated therewith that are agreed to with the board and successfully completed by the licensee, or other matters made confidential or privileged by existing law, is deemed public, and shall be made available to the public by the board pursuant to Section 803.1.? 2 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 DONONM-Section 2234?of the Code, states: ?The board shall take action against any licensee who is charged with unprofessional conduct. In addition to other provisions of this article, unprofessional conduct includes, but is not limited to, the following: Gross negligence. Repeated negligent acts. To be repeated, there must be two or more negligent acts or omissions. An initial negligent act or omission followed by aseparate and distinct departure from the applicable standard of care shall constitute repeated negligent acts. An initial negligent'diagnosis followed by an act or omission medically appropriate for that negligent diagnosis of the patient shall constitute a single negligent act. When the standard of care requires a change in the diagnosis, act, or omission that constitutes the negligent act deScribed in paragraph (1), including, but not limited to, a reevaluation of the diagnosis or a change in treatment, and the licensee?s conduct departs from the applicable standard of care, each departure constitutes a separate and distinct breach of the standard of care. 6? 95 I 6. Section '725 of the Code states: Repeated acts of clearly excessive prescribing, furnishing, dispensing, . or administering of drugs or treatment, repeated acts of clearly excessive use of diagnostic procedures, or repeated acts of clearly excessive use of diagnostic or treatment facilities as determined by the standard of the community of licensees is unprofessional conduct for a physician and surgeon, dentist, podiatrist, - physical therapist, chiropractor, optometrist, speech-language pathologist, or audiologist. Any person who engages in repeated acts'of clearly excessive prescribing or administering of drugs or treatment is guilty of a misdemeanor and shall be punished by a fine of not less than one hundred dollars ($100) nor more 3 VINCENT PAUL KATER, MD. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 uh bitthan six hundred dollars or by imprisonment for a term of not less than 60 . days nor more than 180 days, or by both that. ?ne and imprisonment. A practitioner who has a medical basis for prescribing, furnishing, dispensing, or'administering dangerous drugs or prescription controlled substances shall not be subject .to disciplinary action or prosecution under this section. No physician and surgeon shall be subject to disciplinary action pursuant to this section for treating intractable pain in compliance with Section 2241.5.? I 7. Section 2266 of the Code states: A ?The failure of a physician and surgeon to maintain adequate and accurate records relating to the provision of services to their patients constitutes unprofessional conduct.? FIRST CAUSE FOR DISCIPLINE (Gross Negligence) 8. Respondent is subject to disciplinary action under sections 2227 and 2234, as de?ned by section 2234, subdivision of the Code, in that he committed gross negligence in his care and treatment of patients more particularly alleged hereinafter: PATIENT A 9. According to respondent?s certi?ed medical and billing records, respondent ?rst started treating Patient A, a then?32-year old female, in approximately June 2003, for her primary health care needs.1 The patient?s prior medical history included anxiety, depression, post- traumatic stress disorder, arising from a prior abusive marriage, ?bromyalgia, systemic lupus, chronic migraine headaches, and complaints of pain. Respondent continued his- care and 1 treatment of Patient A and over time she was also seen by various other specialists. After awhile, patient A was tried on several different pain medications, including fentanyl, hydromorphone, 'hydrocodone, and oxycodone, mostly under the guidance of the pain management specialist. Beginning in at least 2005, respondent treated patient A?s mental with different medications including, but not limited to, Venlafaxine, Seroquel, Lyrica, Buspar and 1 Conduct occurring more than seven (7) years from the ?ling date of this First Amended Accusation is for informational purposes only and is not alleged as a basis for disciplinary action. 4 VINCENT PAUL KATER, MD. - FIRST AMENDED ACCUSATION NO. 800-2015?010978 Xanax. Starting in approximately 2006, respondent started prescribing Xanax on a near basis with the dosage being increased over time from-0.5 mg to 1.0 mg and the quantity being increased from #60 to #90. Respondent had hospital admissions on November 17,, 2008, for the treatment of ?uncontrollable pain involving diffuse muscles and joints, along with migraine on November 26, 2008, for back pain; and December 9, 2008, for weakness followed by abdominal pain, nausea and vomiting. 10. On or about January 6, 2009, respondent?s husband called to report that he was trying to get patient A into the Mayo Clinic in Scottsdale, Arizona, and.requested a copy of her medical records be faxed to the clinic. 11. On or about January 16, 2009, respondent received correspondence from Aetna, as part of their ?Aetna Rx Check drug utilization program [which] reviews patients? medication therapies and informs physicians of the potential misuse of certain medications,? which warned him that patient A, under her former name, was receiving prescriptions for alprazolam (Xanax)2 from other physicians. Respondent reviewed the correspondence and noted ?put in chart [right] side? .12.. On or about March 2, 2010, respondent received correspondence from Aetna, as part of their ?Aetna Rx Check drug utilization program,? which, once again, warned him that patient A was receiving prescriptions for alprazolam (Xanax) from other physicians. Respondent reviewed the correspondence and instructed his staff to ?put in her chart at the front.? Respondent continued to prescribe patient A alprazolam (Xanax) 13. On or about September 8, 2010, patient A called respondent?s of?ce and requested Xanax. According .to a chart note, patient A was ?crying and asking for her. meds? and she reported her ?anxiety is out of control desperately? and she'needed Xanax 2 Xanax? (alprazolam), a benzodiazepine, is a centrally acting hypnotic-sedative that is a Schedule IV controlled substance pursuant to Health and Safety Code section 11057, subdivision and a dangerous drug pursuant to Business and Professions Code section 4022. When properly prescribed and indicated, it is used for the management of anxiety disorders. Concomitant use of Xanax? with opioids ?may result in profound sedation, respiratory depression, coma, and death.? The Drug Enforcement Administration (DEA) has identi?ed benzodiazepines, such as Xanax?, as a drug of abuse. (Drugs of Abuse, DEA Resource Guide (2011 Edition), at p. 53.) - 5 VINCENT PAUL KATER, MD. - FIRST ANIENDED ACCUSATION NO. 800?2015-010978 LII about September 11, 2010, patient A was admitted to Alvarado BHS for severe anxiety and depression and for ?detoxi?cation.? Her admission diagnoses were listed as major depression, recurrent; anxiolytic dependence, opioid dependence, and anxiety disorder NOS (not otherwise speci?edj. Speci?c problems addressed during patient A?s admission to Alvarado BHS included, but were not limited to, ?out of contact with reality, alteration in mood/depressed, substance abuse, [and] chronic pain Patient A was stabilized and discharged on September 16, 2010, to an outpatient recovery treatment center. 15. On or about October 11, 2010, reSpond'ent received correspondence from Aetna, as part of their ?Aetna Rx Check drug utilization program,? which, once again, warned him that - patient A was receiving prescriptions for alprazolam (Xanax) from other physicians. 16. On or about October 21, 2010, respondent attempted to terminate his physician- patient relationship with patient A by sending her a certi?ed letter which stated, in pertinent part: ?There appears to be a breakdown in con?dence, trust and communication that is . essential for a physician patient relationship. This is due to you getting tranquilizers from several doctors. Accordingly, this letter is to advise you that I am terminating our relationship. I shall not be able to attend [to] you after November 5, 2010. I will be available during these 15 days for emergency treatment and for prescriptions requests. 66 99 l7. On or about December 8, 2010, respondent received a consultation report from Dr. . H.K., aboard certi?ed who diagnosed patient A as suffering from Attention De?cit Hyperactivity Disorder (ADHD) Combined Type, Obsessive Compulsive Disorder (OCD), Panic Disorder and Opiate Dependence. Among other things, Dr. H.K. recommended .. reducing and stopping Xanax and adjusting her Subutex and Lunesta, and possibly changing her Effexor, consider adding medicine for her Attention De?cit.? At or around this time, respondent stopped prescribing Xanax to patient A. 18. Beginning in November 2010, respondent began treating patient A again and continued to see her every few months. _1 9. On or aboutNoVember 29, 2011, patient A was admitted to Sharp Grossmont Hospital emergency department ?secondary to a suicidal attempt}? According to available 6 VINCENT PAUL KATER, M.D. FIRST AMENDED ACCUSATION NO. 800-2015-010978 1medical records, patient A?s estranged husband called the Sheriff 3 Department. after patient A texted him that she was going to overdose on XanaxI Subsequently, the estranged husband observed patient A take a handful of Xanax and patient A-admitted to a registered nurse at Sharp Grossmont Hospital that she had taken eight (8) Xanax. Patient A was transferred from the emergency department on November 30, 2011, to a ?behavioral?health unit facility for further management.? - A 20. On or about August 16, 2012, respondent resumed prescribing alprazolam (Xanax) 2 mg (#60)ito patient A. The chart note for this date indicates, among other things, ?Xanax 2/60 bid [2 tablets per day] agree for one month only.? I 21. According to respondent?s certi?ed medical records, respondent continued to prescribe Xanax to patient A after August 16, 2012, and increased the dosage of Xanax 2 mg from to on December 20, 2012. Respondent?s chart notes for December 20, 2012, indicate, in pertinent part, ?Xanax 2/90 while trying to stop smoking.? Respondent?s - handwritten chart notes during 2012 were generally cursory, lacked adequate detail, failed to set forth? goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. 22. During the period of anuary 1, 2013, to November 29, 2013, respondent had nine (9) visits with patient A. According to respondent?s chart notes, the visits took place on January 21, ?March 5, April 12, May 13, June 11, August 6, September 30, October 28 and November 25, 2013. According to respondent?s chart notes,'patient A?sproblems during 2013 generally included, but were not limited to, anxiety and depression with occasional references to chronic pain, ADD, lupus, fibromyalgia. Respondent?s handwritten chart notes during 2013 were generally cursory, lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate phySical examinations, and/or failed to provide a clear rationale?for medical decisions. According to the Controlled Substances Utilization and Evaluation System (CURES) report over this period of. time, patient A ?lled, among other things, twelve (12) prescriptions of alprazolam (Xanax) 2 mg issued by 7 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800?2015-010978 respondent and thirteen prescriptions of Lyrica primarily 300 mg at quantities that varied between 23.. On or about October 5, 2013, patient A was admitted to Sharp Grossmont Hospital after she overdosed on her pain medication, Opana. 24. -On or about November 30, 2013, patient-A was found dead in her bed from an . apparent suicide by overdose. The of?cial cause of death was listed as ?acute oxymorphone intoxication and acetaminophen intoxication.?_ 25. Respondent committed gross negligence in his care and treatment of patient A which included, but was not limited to, the following: i Respondent failed to appreciate the danger associated with the concomitant use of benzddiazepines and opiate medications and increased the risk of harm to respondent when he resumed his prescribing of alprazolam (Xanax) beginning in August 2012 until the time of her death; and Respondent continued to prescribe Lyrica to patient A despite the increased risk of suicide associated with Lyrica.? PATIENT I . 26. On or about December 9, 2005, respondent began treating patient B, a- then-57-year old male with a self-reported history which included, among other things, lower-back disc surgery in 1981, high blood pressure, arthritis and joint problems, back problems, emotional and problems, positive family history for ?emotional disorder? and a problem with alcohol in the past. .Patient indicted he was under the care of a for generalized anxiety disorder and attention de?cit disorder and listed his current medications as clonazepam (Klonopin), Cymbalta and Restoral. Following respondent?s ?rst visit, he prescribed patient B, 3 Lyrica? (pregabalin) is a Schedule controlled substance pursuant to Health and Safety Code section 11058, subdivision and a dangerous drug pursuant to Business and Professions Code section 4022. When properly prescribed and indicated, Lyrica? is used for, among other things, the treatment of neuropathic pain associated with spinal cord injury and/or the management of ?bromyalgia or seizures. Caution must be exercised when prescribing Lyrica? to patients with a history of depression, suicidal thoughts, drug and/or alcohol addiction. '8 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 OONONUIamong other things, Vicodin?. and Viagra. During the period of 2006 through 2010, respondent continued to treat patient and prescribed various controlled substances including, but not limited to, Vicodin, Adderall5 and clonazepam (Klonopin).6 27. During the period of on or about January 2011, to December 31, 2011, respondent had four visits with patient B. According to respondent?s chart notes, the visits took place on March 25, June 21, September 15, and December 5, 2011. According to respondent?s chart notes, patient B?s problems during 2011 generally included, but were not limited to, back pain, neck pain and attention de?cit disorder. Chart notes for lune 21, 2011, documented that a Von?s pharmacist reported patient wasacting erratically and angry, was accusing the pharmacy of 4 Hydrocodone APAP (Vicodin?, Lortab? and Norco?) is a hydrocodone combination of hydrocodone bitartrate and acetaminophen which was formerly a Schedule controlled substance pursuant to Health and Safety Code-section 11056, subdivision and a dangerous drug pursuant to BusineSs and Professions Code section 4022. On August 22, 2014, the DEA published a ?nal rule rescheduling hydrocodone combination products to schedule II of the Controlled Substances Act, which became effective October 6, 2014. Schedule II controlled substances are substances that have a currently accepted medical use in the United States, but also have a high potential for abuse, and the abuse of which may lead to severe or physical dependence. When properly prescribed and indicated, are used for the treatment of moderate to severe pain. In addition to the potential for and physical dependence there is also the risk of acute liver failure which has resulted in a black box warning being issued by the Federal Drug Administration (FDA). The FDA black box warning provides that ?[a]cetaminophen has been associated with cases of acute liver failure, at times resulting in liver transplant and death. Most of the cases of liver injury are associated with use of the acetaminophen at doses that exceed 4000 milligrams per day, and often involve more than one acetaminophen containing product.? . 5 Adderall?, a mixture of d?amphetamine and l?amphetamine salts in a ratio of 3:1, is a central nervous system stimulant of the amphetamine class, and is a Schedule II controlled substance pursuant to Health and Safety Code section 11055, subdivision and a dangerous drug pursuant to Business and Professions Code section-4022. When properly prescribed and indicated, it is used for attention-de?cit hyperactivity disorder and narcolepsy. According to the DEA, amphetamines, such as Adderall?, are considered a drug of abuse. ?The effects of amphetamines and methamphetamine are similar to cocaine, but their onset is Slower and their duration is longer.? (Drugs of Abuse A DEA Resource Guide (2011), at-p. 44.) Adderall and other stimulants are contraindicated for patients with a history of drug abuse. 6 Klonopin? (clonazepam), a benzodiazepine, is a centrally acting hypnotic-sedative that is a Schedule IV controlled substance pursuant to Health and Safety Code section 11057, subdivision and a dangerous drug pursuant to Business and Professions Code section 4022. When properly prescribed and indicated, it is used to treatseizure disorders and panic disorders. The maximum daily dose of Klonopin? is generally not to exceed 4 mg per day. Concomitant use of Klonopin? with opioids ?may result in profound sedation, respiratory depression, coma, and death.? The Drug Enforcement Administration (DEA) has identi?ed benzodiazepines, such as Klonopin?, as drug of abuse. (Drugs of Abuse, DEA Resource Guide (2011 Edition), at p. 53.) . 9 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800?2015-010978 ?shorting his meds,? and that he ?proceeded to curse at staff and was kicked out of store without having Rx refilled.? Respondent?s handwritten chart notes during 2011 were generally cursory, lacked? adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a . clear rationale for medical decisions. During 2011, respondent issued at least ?ve prescriptions of, among other things, clonazepam (Klonopin) 2 mg ?ve prescriptions of Vicodin 5/500 mg four prescriptions of MS Contin (morphine sulfate)7 60 mg and four prescriptions of Adderall XR 30 mg and four prescriptions of Adderall 10 mg 28. During the period of on or about January 1, 2012, to December 31, 2012, respondent . had four visits with patient 3: According to respondent?s chart notes, the visits took place on March 5, May 29, August 13, and November 5, 2012. On February 12, patient called requesting a prescription of MS Contin and stated that he just needed 3 pills because ?he will have Withdrawals if [respondent] does not give him today.? According to respondent?s chart- notes, patient B?s problems during 2012 generally included, but were not limited to, back pain, chronic pain and attention de?cit disorder. Respondent?s handwritten chart notes during 2012 were generally cursory, lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to documentappropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. During 2012, respondent issued at least four prescriptions of, among other things, clonazepam (Klonopin) 2 mg four prescriptions of Vicodin 5/500 mg four prescriptions of MS Contin (morphine sulfate) 60 7 MS Contin? (morphine sulfate), an opioid analgesic, is a Schedule controlled substance pursuant to Health and Safety Code section 11055, subdivision and a dangerous drug pursuant to Business and Professions Code section 4022. When properly prescribed and indicated, it is used for the management of pain that is severe enough to require daily, around-the- clock, long-term opioid treatment and for which alternative treatment options are inadequate. The Drug Enforcement Administration has identi?ed MS Contin?, as a drug of abuse. (Drugs of Abuse, A DEA Resource Guide (2011 Edition), at p. 39.) The Federal Drug Administration has- issued a black box warning for MS Contin? which warns about, among other things, addiction, abuse and misuse, and the possibility of life- threatening respiratory distress. The warning also cautions about the risks associated with concomitant use of MS Contin? with benzodiazepines or other central nervous system (CNS) depressants. '10 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800?2015-010978 four prescriptions of Adderall XR 30 mg and two prescriptions of Adderall 10 mg i 29. During the period of on or about January 1, 2013, to December 31, 2013, respondent had four visits with patient B. According to reSpondent?s'. chart notes, the visits took place on February 5, May 2, August 1, and October 31, 2013. .On May 13, a handwritten chart note indicated that patient B?s blood test results were all good with the exception of an issue with the patient?s' liver with respondent recommending that the patient ?drink less alcohol, avoid Tylenol and [re?check] in 3 months.? 8 A chart entry of October 311, 2013, indicated that patient fell off a ladder two weeks ago trimming a tree and went to the hospital. According to respondent?s chart notes, patient?st problems during 2013 generally included, but were not limited to, lower back pain, chronic pain and attention de?cit disorder. Respondent?s handwritten chart notes during 2013 were generally cursory, lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. During 2013, respondent iSSued at least four prescriptions of, among other things, clonazepam (Klonopin) 2 mg two prescriptions of Vicodin 5/500 mg four prescriptions of MS Contin (morphine sulfate) 60 mg two prescriptions ofNorco 5/325 mg (#150) [with no explanation in the chart notes as to why Vicodin was discontinued and Norco was started], four . prescriptions of Adderall XR 30 mg [with no explanation in the chart notes as to why the amount of Adderall was being reduced]. 30. During the period of on or about January 1, 2014, to December 31, 2014, respondent had six Visits with patient B. According to respondent?s chart notes, the visits took place on January 27, February 11, April 22, July 22, October 20, and December 5, 2014. On April 22, 2014, respondent?s chart notes indicate ?weaning Adderall down to 10 q.d. [10 mg per day] we discussed meds [and] ways to do it.? According to respondent?s chart notes, patient?B?s problems during 2014 generally included, but were not limited to, lower back pain, chronic pain, attention 8 On a personal history ?rm of December 9, 2005, patient self?reported that he previously had problems with alcohol and that he no longer drank alcohol. 11 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 de?cit disorder, with some cursory references to anxiety and fatigue. Respondent?s handwritten ,chart notes during 2014 were generally cursory, lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. During 2014, respondent issued at least four. prescriptions of, among other things, clonazepam (Klonopin) 2 mg two prescriptions of Vicodin 5/500 mg three to four prescriptions of (morphine sulfate) 60 mg four prescriptions of Norco 5/325 mg and three prescriptions of Adderall 10 mg I 31. During the period or? on or about January 1, 2015, to July 1, 2015, respondent had three (3) Visits with patient B. According to respondent?s chart notes, the visits took place on January 9, March 20, and June 16, 2015. According to respondent?s chart notes, patient B?s problems during 2015 generally included, but were not limited to, chronic pain, attention de?cit disorder, and anxiety. During 2015, respondent continued to wean patient off of the Adderall 10 mg with a chart note of June 16, 2015, indicating ?he plans of stoppingthis [Adderall 10 mg] altogether.? Respondent also charted on June 16, 2015, ?wean KlonOpin as able.? ReSpondent?s . handwritten chart notes during 2015 were generally cursory, lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. According to CURES, during the time frame of January 1, 2015, to July 1, 2015, - Patient filled the following prescriptions from respondent: three prescriptions of morphine sulfate 60 mg three prescriptions of hydrocodone/APAP (N orco)5/325 mg three prescriptions of Adderall 10 mg and four prescriptions of clonazepam (Klonopin) 2 mg . . 32. Respondent committed gross negligence in his care and treatment of patient Which included, but was not limited to, the following: Respondent primarily relied on opioids to treat patient B?s alleged pain and failed to adequately consider safer non-opioid based treatment options for the treatment of patient B?s alleged pain. 12' VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 \o'ooxioxumPATIENT .33. On or about January 18, 2005, respondent Started treating patient C, a then?45-year old female with a history of lumbar spine and cervical spine fusion surgery in 1999. As part of the initial visit, respondent obtained a release from patient for her medical records from Medical Clinic, which were received a few days later. Respondent conducted a physical examination and-ordered labs. According to respondent?s chart note for January 18, 2005, respondent?s assessment included, but was not limited neck and back pain, depression, gastroesophageal re?ux disease (GERD), and anemia. 34. During the period Of 2003 through 2010, patient was treated by reSpondent and seen by various other specialists. In late 2010, respondent referred patient to Dr. W.W., a pain management Specialist, for evaluation and consultation. At the time of her evaluation, patient C?s pain medications were listed as hydrocodone/APAP 10/325 mg (12' tablets a day) and OxyContin (oxycodone HCL) 80mg (3 tablets three times a day) for a combined morphine milligram equivalency (MME) dose of 1,200 mg per day. Dr. impression was left lumbar facet pain, left anterior thigh pain, possible radicular and possible analgesic hyperalgesia (increased pain or hypersensitivity associated with chronic use of opioids) and his recommendation was to maintain patient onthe'OxyContin 80 mg 3 tablets t.i.d. for two weeks, hydrocodone/APAP (Norco) 10/325 mg 6 tablets q.d. (per day), urine drug screen and consultation with another physicianVINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 about November 16, 2010, Dr. W.W., who had just seen patient C, for a pain management consultation, sent correSpondence torespondent which stated, as follows: ?Dear Dr. Kater: got a call from [patient on November 9 saying she didn?t want to see me, but would be getting her medications from you until she was seen elsewhere. I suspect she was unhappy with the fact that I referred her to Dr. who helps me sort out complex analgesic problems. [Patient as you know, is requiring very large doses over many years. She is also vague about her history and everything'on physical exam produced pain. One medical explanation for this is analgesic hyperalgesia, when pain meds are causing increased pain rather than giving pain relief. The more common explanation is some behavioral/drug issue. Dr. is very good at sorting out these issues and also very good at developing a working rapport with even (sic) patients, whatever the underlying problem. ?I?m writing to suggest caution with [patient and to suggest the kind of assistance I was seeking from Dr. - ?I?m sorry I couldn?t make any progress with her.? 36. During the period of on or about January 1, 2011, to December 31, 2011, respondent. had'thirteen visits with patient C. According to respondent?s chart notes, the visits took place on January 4, February 1, March 1, March 29, April 26, May 20, June 20, July 18, August 15, September 12, October 10, November 7 and December 1,2011. According to respondent?s chart notes, patient C?s problems during 2011 generally included, but were not limited to, and chronic pain. On February 4, 2011, patient was seen for a consultation with Dr. who was board certi?ed in physical medicine and rehabilitation and pain management who recommended that patient see another physician, Dr. N.T., who in her Opinion, was the ?most quali?ed to help her can offer additional pain management options.? Respondent?s chart nOtes of March 2, 2011, indicated, in pertinent part, referred to [Dr. [patient has been unable to get in to see [Dr. On April 15, patient reported ?her Norco got stolen out of her purse? and another prescription was approved for her. On April 28, a chart note indicated patient ?stated she would not be able to provide urine [sample] because she will be heading out of town? with a note from respondent stating ?next visit then.?9 On July 18, chart notes indicated the plan was to reduce OxyContin to eight per day. 'On May 13, 9 A urine sample was collected at the next visit of May 18, 2012, whichtested negative for 'hydrocodone/APAP (N orco) despite the fact that patient was being prescribed Norco. 14 VINCENT PAUL KATTER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 macaw 23' ._24 25 26' 27 28 a chart note documented an early re?ll. On?September 23, patient requested that a prescription of Ambien be called into the pharmacy and-she was provided with a prescription for Ambien 10 mg pm (as needed) for Insomnia. Respondent? handwritten chart notes during 2011 were generally cursory, lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. During 2011, respondent maintained patient. on, amongother things, prescriptions of hydrocodone/APAP (Norco) 10/325 (#180) mg and OxyContin 80 mg (#270) for a combined MME of 1,080 mg per day. 37. During the period of on or about January 1, 2012, to December 31, 2012, respondent had ?fteen visitsiwith patient C. According to respondent?s chart notes, the visits took place on January 20, February 2, February 24, March 22, April 19, May 18, June 14, July 12, August 7, September 4, September 17, October 2, October 29, November 26 and December 21, 2012. According to respondent?s chart notes, patient C?s problems during 2012 generally included, but were not limited to, chronic pain, occasional panic attacks and bronchitis. Chart notes of October 2, 2011, indicate ?we discussed [illegible] pain med [alternate] 8-9 OxyContin.? Chart notes of November 24, 2012, indicated ?[decrease] [medication] as Respondent?s handwritten'chart notes during 2012 were generally cursory, lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. During 2012, respondent maint?ained patient on, among other things, near prescriptions of hydrocodone/APAP (Norco) 10/325 (#180) mg and OxyContin 80 mg (#270) for a combined MME of 1,080 mg per day. According to CURES,.patient ?lled fourteen prescriptions of OxyContin 80 mg (#270) and 14 prescriptions of hydrocodone/APAP (Norco) 10/325 mg (#180) from respondent during 2012. 38. During the period of on or about January 1, 2013, to December 31, 2013, respondent had thirteen visits with patient C. According to respondent?s ?chart notes, the visits took place'on January 10, February 14 (seen by another physician), March 26, April 22, May 20, June 17, July 12, August 9, September 3, October 3, October 28, November 25, December 20 and December 15 VINCENT PAUL KATER, MD. - FIRST AMENDED ACCUSATION NO. 800?2015-010978 r" 23, 2013. According to respondent?s chart notes, patient C?s problems during 2013 generally included, but were not limited to, chronic pain, with some notations of bronchitis and depression/anxiety. On March 18, 2013; patient requested that a prescription of . Xanax be called in for her and respondent called in a prescription for Xanax 0.5 mg p.r.n. anxiety. Chart notes of March 26, 2013, indicate ?tomorrow for injections-in back Pain Management.? Chart notes of June 21, 2013, indicate ?Norco and Xanax not found in urine? despite the fact that respondent had been prescribing both of the controlled substances to patient Chart notes of August 9, 2013, indicate ?use of narcotics discussed.? On November 11, 2013, there was codeine found in patient C?s urine with chart notes indicating ?will [check] with patient next visit?? Respondent?s handwritten chart notes during 2013 were generally cursory, lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. During 2013, respondent maintained patient on, among I other things, near prescriptions of hydrocodone/APAP (Norco) 10/325 (#180) mg and OxyContin 80 mg (#270) for a combined MME of 1,080 mg per day; with occasional prescriptions of Xanax 0.5-mg.11 39. During the period of on or about January 1, 2014, to December 31., 2014, respondent had sixteen visits with patient C. According to respondent?s chart notes, the visits took place on January 17., February 11, March 6, April 4, April 25, May 19, June 13, July 15, August 8, September 8, October 2, October 27, November 18, November 23, December 11, and December 29, 2014. Chart notes of January 20 and 21, 2014, indicate patient was upset because respondent?s of?ce did not initiate price authorization for her OxyContin. According to respondent?s chart notes, patient C?s problems during 2014 generally included, but were not 10 A urine sample collected on October 28, 2013, detected an unexplained codeine analyte and failed to detect any sign of the Norco and Xanax that was being prescribed to patient C. 11 According to CURES, patient ?lled thirteen prescriptions of OxyContin 80 mg one prescription of OxyContin 80 mg nine prescriptions of hydrocodone/APAP (N orco) 10/325 mg (#180) and three prescriptions of hydroco?done/APAP (N orco) 10/325 mg from respondent during 2013. 16 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800?2015-010978 10limited to, chronic pain, depression, bronchitis, and occasional depression, anxiety and panic attacks. On January 31, 2014, patient called requesting codeine cough syrup with respondent documenting in his chart that ?already taking narcotics, extra codeine won?t help.? On February 1 1, 2014, patient requested early re?ll of her OxyContin because she was heading out of town.12 On June 16, 2014, respondent?s of?ce received a call from a CVS pharmacist advising respondent?s of?ce that patient was seekingi'early re?lls of Norco and OxyContin. Respondent?s handwritten chart notes during 2014 were generally cursory, lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. During 2014, respondent maintained patient on, among other things, near prescriptions of hydrocodone/APAP (Norco) 10/325 mg (#180) and OxyContin 80 mg (#270) for a combined MME of 1,080 mg per day; with occasional prescriptions of Xanax 0.5 mg.13 40. During the period of on or about January 1, 2015, to July 2015, respondent hadeleven visits with patient C. According to respondent?s chart notes,.the visits took place on January 22, I February 22, March 17, March 20, March 26, April 7, April 10, May 7, May 12, June 4, and June 16,2015. Accordingto respondent?s chart notes, patient C?s problems during 2015 generally I included, but were not limited to, chronic pain, GERD, hypothyroidism, and occasional .bronchitis. On January 26, 2015', respondent?s of?ce received a call from'a pharmacist advising that patient was requesting an early re?ll of Norc?o and OxyContin with respondent approving the early re?ll. Chart notes of May 15, 2015, indicate patient called and ?said she is allowed to have pain patch. . .not sure of which one to get? with respondent documenting to pick up RX how many days will she need it for?? A CURES entry for May 20, 2015, indicates a 12 Other chart notes of February 11,2014, indicate ?Spoke with pharmacist pharmacy He ok?d re?ll of Norco but said OxyContin 1s 11 days early and will not ?ll it barring some major DX [diagnosis] like cancer.? 13 According to CURES, patient ?lled fourteen prescriptions of OxyContin 80 mg (#270) and fourteen prescriptions of hydrocodone/APAP (N orco) 10/325 mg (#180) from respondent during 2014. 17 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 ?114th prescription was ?lled on that date for a Fentanyl patchI4 100 meg/hour for 72 hours. The addition of the fentanyl patch increased patient C?s morphine milligram equivalency (MME) from an already alarmingly high of approximately 1,080 mg per day to 1,380 mg per day. There is nothing documented in respondent?s chart notes as to the medical necessity for the Fentanyl patch. On June 4, 2015, patient told respondent she lost her OxyContin. The chart notes of June 4, 2014, indicate ?long discussion loss of_ [medication] last occurred 4 years ago. Dangers of narcotics against discussed. Need to wean as able.? On June 10, 2015, respondent received a written note from a third party advising him, in pertinent part, that ?I?m writing you to let you know that [patient has been selling pills for years. and that she had a ?side business._? Chart notes of June 11, 2015, indicate ?Ftold [patient I'can no longer give her narcotics as she was seen selling them-[-] will give her names of pain specialists [with a list of integrated pain management specialists] On June 16, 2015, respondenthad an of?ce visit with patientC who denied Selling her medications as reported. Chart notes of June 16, 2015, indicate ?1 will give her this one last refill to her time to ?nd a doctor to give her [medications].? Respondent?s handwritten chart notes during 2015 were generally curSOry, lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. According to CURES, patient ?lled seven prescriptions of OxyContin 80 mg six prescriptions of hydrocodone/APAP (N orco) 10/325 mg and one prescription of Fentanyl patch 100 meg/hour for 72 hours from anuary 1 through July 1, 2015. I 41. Respondent committed gross negligence in his care and treatment of patient which included, but was not limited to, the following: . 14 Fentanyl transdermal (Duragesic?) patches are a Schedule II controlled substance pursuant to Health and Safety Code section 11055, subdivision and a dangerous drug pursuant to Business and Professions Code section 4022. When properly prescribed and indicated fentanyl transdermal patches are indicated for the management of pain in opioid- tolerant patients, severe enough to require daily, around-the-clock, long term opioid treatment and for which alternative treatment options are inadequate. The FDA has issued several black box warnings about fentanyl transdermal- patches including, but not limited to, the risks of addictiOn, abuse and misuse; life threatening respiratOry depression; accidental exposure; neonatal opioid withdrawal and the risks associated with the concomitant use with benzodiazepines or other CNS depressants. - 18 VINCENT PAUL KATER, M.D. - FIRST AMENDED. ACCUSATION NO. 800-2015-010978 Respondent. failed to properly manage and/or monitor the opioids that were being prescribed to patient which included, but was not limited to, failing to recognize indications of misuse or diversion, failing to taper or rotate opioids as recommended and failing to prescribe opioid antidote. PATIENT 42. Onor about June 1,2007, respondent started treating patient D, a then-48-year old male with a self-reported history of high blood pressure, arthritis/j oint problems, back problems and adult Patient listed his current medications as including, but not limited to, Adderall 20 mg, OxyContin 80 mg Dilaudid 8 mg and Viagra. Chart notes for the initiallvisit indicate ADHD, (2) pain on [right side] 'due to injury [and] (3) re?lls? and - reference made to ?pain [management doctors] Kaiser stable, on regimen.? The chart notes for the initial visit fails to document any detailed physical examination. Respondent?s assessment was ADHD and back, knee, hip and leg pain. The plan, as documented in the chart notes, was to re?ll meds records [re-check. one month].? The chart notes for the next Visit, June 26, 2007, indicate ?[patient said he had sent away for records, 2 [weeks] ago.? There were no prior medical records located in the certi?ed medical records produced to the Medical Board by respondent. 43. [Onor about October 12, 2007, respondent?sof?ce receiyed a call from a pharmacy indicating that ?[patient ?lled prescription from you on October 9, 2007 for Oxycodone [and] brought in another Rx date 10/9/07 for same Rx today. Pharmacist wants to know if you wrote 2 Rx?s.? The chart notes for this date indicate that respondent spoke with the pharmacist and [patient and ?he is to get further re?lls at pain specialist no more re?lls from this of?ce.? i? Chart notes for December'3, 2007, indicate ?names given to pain specialist OKto re?lls meds.? On February'12, 2008, there were further discussions with patient?D about not following respondent?s prescribing schedule. NH 19 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 AWN _0r about December 10, 2009, respondent sent a letter to patient which advised him that he would no longer be writing him prescriptions for ?chronic narcotics.? The letter - stated, in pertinent part: will no longer write prescriptions for chronic narcotics. These medications can more appropriately be continued through a chronic pain clinic. Names, addresses, and phone numbers of several local pain specialists are attached 1n this letter. I can send a referral to specialist of your choice. Appointments should be made soon, as it often takes several weeks to initially see these doctors. I will continue to re?ll medications until you are seen by the pain specialist, but in no event will that continue beyond February 28, 2010. [11] 1 W111 continue to be available for all other medical' 1ssues.? . 45. Despite sending the letter of December 10, 2009, and indications of patient continuing to re?ll his medications early, respondent continued to re?ll patient D?s prescriptions including Oxycodone 30 mg (#360) which continued through October 25, 2010, at which point the prescriptions of Oxycodone 30 mg continued on a near basis but the quantity was decreased to (#120) for November 15, 2010, and then increased to (#240) for December 2010.15 . 46. During the period of on or about January 1, 2011, to December'31, 2011, respondent had sixteen visits with patient D. According to respondent?s chart notes, the Visits took place on. January 3, January 21, February 7, February 28, March 17, April 12, May 6, June l6,lJuly 7, July 20, August 19, September 21, October 20, Nevember 15, December 9, and December 2,9 2011. According to respondent?s chart notes, patient D?s problems during 2011 generally included, but were not limited to, chronic pain and ADD Chart notes of February 28,2011 state ?dangers of narcotics discussed continue to advocate for pain specialist continue to wean meds until he gets pain specialist.? Respondent?s handwritten-chart notes during 2011 were generally cursory, lacked adequate detail, failed to set forth goals of treatment includingef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. During 2011, respondent maintained patient on, among 15 Respondent?s chart notes for August 30, 2010, indicate ?moving to Israel, if not? to pain specialist OK to re?ll. 20 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 pother things, Oxycodo?ne 30 mg (#240 4 MME 360 nag/day) from January which was gradually tapered down to (#190 MME 285 mg/day) in September. On October 20, 2011, respondent began prescribing methadone 10 mg and reduced?the Oxycodone 30 mg to #150 which resulted in an increase of the MME from 285 mg/day to 465 mg/day. There was no explanation in respondent?s chart note of October 20,2011, for the addition of methadone which resulted in a siXty-three (63) percent increase in the MME for patient D. Moreover, the?introduction of methadone increased the risk for fatal cardiac with no apparent EKG monitoring taking place. 1 i 47. During the period of on or about January 1, 2012, to December 31, 2012, respondent had ?fteen visits with patient D. AcCording to respondent?s chart notes, the Visits took place on February 2, February 29, March 26, April 20, May 18, June 14, July 9, August 31, September '24, October 18, November 9, OCtober 18, November 9, November 30, and December 21, 2012. According to respondent?s chart notes, patient D?s problems during 2012 generally. included, but were not limited to, chronic pain (with indications of knee pain), HTN (hypertension), ADD,.and occasional'depression. Respondent?s handwritten chart notes during 2012 were generally 7 cursory,- lacked adequate detail, failed to set forth goals of treatment including ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. Respondent maintained patient on, among other things, Oxycodone 30mg (#150) and methadone 10 mg [combinedMME of 465 mg/day] from January 1, 2012, through November 29, 2012. On. November 30, 2012,16 respondent increased the Oxycodone 30 mg to (#180) and continued the methadOne 10 mg which increased the MME for patient from 465 mg/day to 510 mg/day. 48. During the period of on or about January 1, 2013, to December 31, 2013, respondent had fourteen (14) visits with patient D. According to reSpondent?s chart notes, the visits took place on January 17, February 11, March 8, April 2, April 23, May 16, June 13, July 11, August- 16 The chart notes for November 30, 2012, indicate that ?weather makes pain much worse. . . [treatment] options [and] need to control medications. . . [assessment] OA [osteoarthritis] knee [and] [plan] if pain continues severely, to pain [increase] oxycodone to 180 [six per day].? . 21 VINCENT PAUL KATER, M.D. - FIRST AMENDED 800-2015-010978 00 ?4 Lh_August 30, October 17, November 7, and December 2, December 30,2013. According to respondent?s chart notes, patient C?s problems during 2013 generally included, but were not limited to, alleged chronic pain, HTN, ADD, GERD, and occasional chest pain. On May 16, 2013, after experiencing repeated problems with early entered a chart note which stated ?warned re: last early re?ll will sign af?davit [illegible] visit re early re?ll next re?ll not before [June] 13.? ReSpondent?s handwritten chart notes during 2013 were ?7 generally cursory, lacked adequate detail, failed to set forth goals of treatmentincluding ef?cacy and functional improvement, failed to document appropriate physical examinations, and/or failed to provide a clear rationale for medical decisions. During 2013, according to respondent?s medical records, respondent maintained patient on, amOng other things, Oxycodone 30 mg on a . near basis, in ?uctuating quantities, 17 and methadone 10 The MME for patient at the end of 2013 was 510 mg/day. 49. During 2014, respondent had one visit with patient which took place on January 23, 2014. The chart notes for this visit indicate, among other things, ?last early re?ll? and will not give a re?ll prior to [February 21] under any circumstances.? On January 29, 2014, respondent received a telephone message from a SanDiego'Police Department detective regarding patient - and his girlfriend with a request to ?please call when yOu get in.? A handwritten note of the same date states, ?gave [message] to There are no chart notes as to the nature of the call, if any, between respondent and the detective. Chart notes of January 30, 2014, state ?Spoke with patient no further controlled substances will be given.? Respondent?s handwritten chart notes during 2015 were generally cursory, lacked adequate detail, failed to set forth goals of treatment including ef?caCy and functionalimprovement, failed to document appropriate physical - examinations, and/or failed to provide a clear rationale for mediCal decisions. 17 Respondent?s medication ?ow sheet lists the following quantities beginning in January 2013, through the end of the year: #180 (three sequential prescriptions), #160, #150, #160, #160, #100 (three sequential prescriptions), #160, #160, and #180 (four sequential prescriptions). 22 VINCENT PAUL KATER, M.D.. FIRST AMENDED ACCUSATION NO. 800-2015010978 1'26 27' .28 50. ReSpondent committed gross negligence in his care and treatment of patient which included, but was not limited to, the following: I I. Respondent increased the risk of harm to patient Drwhen he prescribed oxycodone 30 mg in combination with methadone 10 mg and failed to conduct adequate cardiac monitoring. PATIENT 51. On or about 2001, respondent began his care and treatment of patient E, a then-89- year-old-woman with a history of, among other things,-osteoarthritis, urinary incontinence, macular degeneration and mild cognitive impairment with probable Alzheimer?s disease. 52. On or about February 23, 2001, patient had foot bunion surgery (a bunionectomy) and was prescribed an opiate based pain medication'for management of her post-operative pain. 53. On or about February 25, 2001, patient suffered a loss of consciousness during. dinner with family and was observed not breathing. Family members performed CPR on patient and she was revived. The paramedics were called and transported patient to the hospital, where she was admitted for further observation. While at the hospital,'patient was examined by respondent, as her attending physician, who was aware of the incident she experienced after taking ?Vicodin at home.? Patient was discharged the next day in stable condition and? respondent continued to provide primary care to patient E, over which time patient E?s Alzheimer?s disease progressively worsened. I 54. . Beginning on or about April 2007, respondent treated patient on several occasions for shortness of breath and night-time breathing dif?culties (orthopnea) and leg edema. On January 19, 2009, respondent signed a California Department of Social Services? Physician?s Report for Residential Care Facilities for the Elderly (RCF E) form, as part of patient E?s transition into B.G., a residential care facility, which indicated, among other things, that patient was allergic to Vicodin and Penicillin. Patient E?s diagnoses at time of admission to the residential care facility on January 30, 2009, were listed as dementia and history of urinary tract infections. Respondent continued to provide primary care to patient while She was at the residential care facility. ?23 I VINCENT PAUL KATER, MD. - FIRST ANIENDED ACCUSATION NO. 800-2015-010978 about'December 14, .2010, respondent executed another California Department . of Social Services? Physician?s Report for Residential Care Facilities for the Elderly (RCFE) form which, once again, indicated that patient was allergic to Vicodin and Penicillin. 56. On or abOut February 19, 2014, respondent?s of?ce received a call from the residential care facility advising them that patient 1E had fallen. A request was made for pain medication to be called into the pharmacy for patient and for x-rays of patient E?s hip. ?57. On or about February 20, 2014, arrangements were made for x-rays of both hips and respondent, without reviewing patient E?s charts, 18 whiCh indicated patient was allergic to Vicodin, a hydrocodone/acetaminophen (APAP) product, called in a prescription for hydrocodone/APAP (N orco) 5/325 mg #30 every six hours as needed for pain. Patient E?s daughter picked up the prescription of Norco the same day and gave her mother, patient B, one tablet _of the Norco with her lunch at approximately noon and then left the residential care facility.- As approximately 12:20 pm, patient E?s daughter received a call from the residential care facility advising that her mother, patient E, was in distress. Patient E?s daughter pulled her car over and read the paperwork for the Norco prescription, at which point she realized that Norco had the same active ingredients as Vicodin, for which her mom had a known drug allergy. Patient E?s daughter immediately called respondent?s of?ce to report that her mom had an adverse I reaction to the Norco. The?chart notes for patient E, ?lled out by a staff member, indicate ?[patient] had a[n] adverse reaction to Norco, [patient] was vomiting and her eyes rolling According to patient E?s daughter, when she attempted to speak with respondent, a Staff member told her he was currently with patients. When patient E?s daughter explained the situation to the . 18 The certi?ed medical records for patient contain various references to patient being allergic to Vicodin, a hydrocodone/APAP product, which include, but are not limited to, the outside of respondent?s three volumes of medical records each containing a warning stamp indicating ?Drug Allergies[;] PCN [penicillin] [and] Vicoden [sic] stopped a type- written chart note dated April 24, 2007, prepared by K. D. a physician assistant student, and initialed by reSpondent, which states hives, Vicodin? apnea[, ?Medication [Schedule/Instructions? frOm patient E?s residential care facility indicating that patient had drug allergies which included penicillin and hydrocodone/APAP (Vicodin), some of which were initialed by respondent, and at least two California Department of Social Services? Physician?s Report for Residential Care Facilities for the Elderly (RCFE) forms, that were signed by_ respondent. 24 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015?010978 .27 28? \Osoo? 24' staff member, the staff member told her there was a notation on the outside of the chart indicating that Vicodin (a hydrocodone/APAP.product) could cause the patient to stop breathing. Upon being advised of patient E?s adverse reaction to the Norco, respondent discontinued the Norco and, called in a prescription for Tramadol, a different and less-pbtent pain reliever. The chart notes for February 20, 2014, include a handwritten notation from respondent indicating ?stop [N]orco [T]ramadol 50 #30 ?1?2 q.i.d. [four times a day] pm [as needed for] pain.? According to respondent?s chart notes, patient E?s daughter was advised that the Norcol was discontinued and a new prescription was called in for Tramadol. According to patient E?s daughter, and D. J., the - owner and administrator of the residential care facility, several calls were made to respondent . requesting to speak to him, but there was no call back from reSpondent and respondent did not personally check on patient at the residential care facility. 58. On or about February 21 2014, respondent?s of?ce received a call from patient E?s daughter reporting that her mother, patient E, was ?not doing well.? The residential care facility also called requesting ?hospice order asap [patient not doing well)" Patient passed away on February 21, 2014, at 11:50 am. When patient E?s daughter arrived home later that day, she retrieved a message from respondent that was left at 12:10 pm. that day with respondent indicating he hoped her mother was okay. 59. Respondent committed gross negligence in his care and treatment of patient which included, but was not limited to, the following: . Respondent prescribed hydrocodone/AFAP (Norco) to patient without reviewing patient E?s medical records which indicated patient was allergic to hydrocodone/APAP1controlled substances such as Vicodin and Norco; Respondent failed to use a non-opioid based ?rst line therapy,.such as acetaminophens and/or nOn-steroidal anti?in?ammatory drugs before prescribing patient which created a greater risk of harm. to patient. and NH 25 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800?2015-010978 (0) Respondent failed to respond in a timely and appropriate manner after receiving the report Of patient E?s adverse reaction to the hydrocodone/APAP (Norco) that Was prescribed to her. A SECOND CAUSE FOR DISCIPLINE - (Repeated Negligent Acts) I 60. Respondent is further subject to disciplinary action under sections 2227 and 2234, as de?ned by section. 223 4, subdivision (0), of the Code, in that he committed repeated negligent acts in his care and treatment of patients more particularly alleged herein. PATIENT A 61. Respondent committed repeated negligent in his care and treatment of patient A which included, but was not limited to,? the following: Paragraphs 9 through 25, above, are hereby incorporated by reference and realleged as if fully set forth herein; Respondent failed to appreciate the danger associated with the concomitant use of benzodiazepines and opiate medications and increased the risk of harm to respondent when he resumed his - preScribing of alprazolam (Xanax) beginning in August 2012 until the 'time of her death; Respondent continued to prescribe Lyrica to patient A despite the increased risk of suicide associated with Lyrica; and Respondent failed to maintain adequate and accurate medical records regarding his care and treatment of patient A, including the prescribing . of controlled substances. PATIENT 62. Respondent committed repeated negligent in his care and treatment of patient which included, but was not limited to, the following: Paragraphs 26 through 32, above, are hereby incorporated by reference and realleged as if fully set forth herein; 26 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 DJN (C) (6) Respondent primarily relied on opioids to treat patient B?s alleged pain and failed to adequately consider safer non-opioid based treatment options for the treatment of patient B?s alleged pain; Respondent failed to recognize patient B?s elevated addiction risks and failed to adequately monitor patient B?s; use of controlled substances, including the benzodiazepines and opioids that were being prescribed to him; i Respondent increased the risk of harm to patient in prescribing high doses of clonazepam (Klonopin) concurrently with opioids and, in failing to seek a consultation related to any medical indication for clonazepam (Klonopin); and Respondent failed to maintain adequate? and accurate medical records regarding his care and treatment of patient B, including the prescribing of controlled substances. PATIENT 63. Respondent committed repeated negligent in his care and treatment of patient which included, but was not limited to, the following: i (C) Paragraphs 33 through 41,. above, are hereby incorporated by reference and 'realleged as if fully set forth herein; Respondent failed to properly manage and/ormonitor the opioids that were being prescribed to patient which included, but was not limited to, failing to recognize indications of misuse or diversion, failing to. taper or rotate opioids as recommended and failing to prescribe opioid antidote; and Respondent failed to maintain adequate and accurate medical records . regarding his care and treatment of patient C, including the prescribing of controlled substances. 27 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 ?19 .20PATIENT 64. Respondent committed repeated negligent in his care and treatment of patient which included, but was not limited to, the following: - Paragraphs 42 through 50, above, are hereby. incorporated by reference and realleged as if fully set forth herein; Respondent increased. the risk of harm to patient when he prescribed oxycodone 30 ?mg in combination with methadone 10 mg and failed to conduct adequate cardiac monitoring; Respondent primarily relied on opioids to treat patient D?s alleged pain and failed to adequately consider safer non-opioid based treatment options for the. treatment of patient D?s alleged pain; and Respondent failed to maintain adequate and accurate medical records regarding his care and treatment of patient D, including the prescribing of controlled substances. - PATIENT - 65. Respondent committed repeated negligent in his-care and treatment of patient which included, but was not limited to, the following: Paragraphs 51 through 59, above, are hereby incorporated by reference and realleged as if fully Set forth herein; . Respondent prescribed hydrocodone/APAP (N orco) to patient without reviewing patient E?s medical records which indicated patient was allergic to hydrocodone/APAP controlled substances such as Vicodin and Norco; Respondent failed to use a non-opioid based first line therapy, such as acetaminophens and/or non?steroidal anti-in?ammatory drugs (N before prescribing patient hydrocodone/APAT? (N orco) which created a greater risk of harm to patient and NH '28 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978 LII Respondent failed to respond in a timely and appropriate manner after receiving the report of patient E?s adverse reaction to the hydrocodone/APAP (Norco) that was prescribed to her. THIRD CAUSE FOR DISCIPLINE (Repeated Acts of Clearly Excessive Prescribing) 66. RespOndent is further subject to disciplinary action under sections 2227 and 2234, as de?ned by section 725, of the Code, in that he has committed repeated acts of clearly excessive prescribing drugs or treatment to patients and D, as determined by the standard of the community?of physicians, as more particularly alleged in paragraphs 33 through 50, above, which are hereby incorporated by reference and realleged as if fully set forth, herein. FOURTH CAUSE FOR DISCIPLINE (Failure to Maintain Adequate and Accurate Records) 67. Respondent is further subject to disciplinary action under sections 2227 and 2234, as de?ned by section 2266, of the Code, in that reSpondent failed to maintain adequate and accurate records regarding his care and treatment of patients A, B, C, and D, as more particularly alleged in paragraphs 8 through 49, above, which are hereby incorporated by reference and realleged as if NH 29 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800?2015-010978 \PRAYER WHEREFORE, Complainant requests that a hearing be held on the matters herein alleged, and that following the hearing,? the Medical Board of California issue a decision: 1. Revoking or suspending Physician?s and Surgeon?s Certi?cate No. 45 85 1, issued to respondent Vincent Paul Kater, I 2. Revoking, suspending or denying approval of respondent Vincent Paul Kater, authority to? supervise physician assistants and advanced practice nurses; 3. Ordering respondent Vincent Paul Kater, M.D., if placed on probation, to pay the Board the costs of probation monitoring; and I 4. Taking such other'and further action as deemed necessary and proper. DATED: February 12, 2018 Executive Dir Medical Boar California Department of Consumer Affairs State of California Complainant SD2014708244 81931501.doc - 30 VINCENT PAUL KATER, M.D. - FIRST AMENDED ACCUSATION NO. 800-2015-010978