A patient went in for a standard back surgery. She awoke one kidney short.

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Maureen Pacheco who, at 51, went to Wellington Regional Medical Center in April 2016 to get the bones in her lower back fused because she was suffering pain from a car accident years earlier.

She left the hospital one kidney short.

According to a complaint filed in December by the Florida Department of Health against Dr. Ramon Vazquez, a West Palm Beach doctor, Vazquez unnecessarily removed her pelvic kidney from her left side.

Vazquez, according to the complaint, “noted a pelvic mass and provided a presumptive diagnosis of a gynecologic malignancy, lymphoma,and/or other metastatic disease.”

He proceeded to remove the “mass” in its entirety, without a preliminary biopsy to determine malignancy. But the mass wasn’t a mass —it was Pacheco’s kidney.

And Vazquez wasn’t even her surgeon.

Rather, he was there “to cut her open so that her orthopedic surgeons could perform the delicate back operation,” The Palm Beach Post reported. She’d only just met him shortly before she was wheeled into the operating room.

Pacheco’s lawsuit was settled in September for “a nominal amount,” Vazquez’s lawyer, Michael Mittelmark, told The Washington Post. Mittelmark added that Vazquez “did not admit liability and does not think he did anything wrong.

The confusion arose because Pacheco had a somewhat rare condition called “pelvic kidney,” which occurs during fetal development., when it fails to ascend to its normal position.

So her kidney was not in the usual upper abdominal area but was “fully functioning,” despite being in the pelvic region, The Washington Post reported. If there are no associated symptoms, like obstruction or reflux, no treatment is necessary so many patients simply live with the abnormality, according to the Ann & Robert H. Lurie Children’s Hospital of Chicago.

Two MRIs prior to Pacheco’s surgery showed she had a pelvic kidney, according to her lawsuit, the Palm Beach Post reported.

Vazquez is a general surgeon in West Palm Beach. According to the state’s Board of Medicine, he has an active license with no record of discipline on file. But as a result of this incident, the health department has now requested that the medical board consider suspending or revoking Vazquez’’s medical license, put him on probation or impose an administrative fine, among other “corrective” actions.

A spokesperson at Wellington Regional Medical Center said in a statement to Inside Edition: “Dr. Vazquez is not and has never been an employee of Wellington Regional Medical Center. Dr. Vazquez was an independent physician with medical staff privileges at Wellington Regional as well as other hospitals in Palm Beach County.”

Vazquez, the statement continued, is “no longer on the medical staff of Wellington Regional.” and that the hospital, which is located at 10101 Forest Hill Blvd., “took all necessary and appropriate steps to review the circumstances of this most unfortunate incident. In the over 30 year history of Wellington Regional Medical Center, an incident of this nature has never occurred before or since.”

Vazquez earned his medical degree at New York’s Albert Einstein College of Medicine of Yeshiva University, according to U.S. News and World Report. According to Florida’s Board of Medicine, Vazquez “has an active license with no record of discipline on file,” the Washington Post reported.

A 2006 AHRQ-sponsored study on wrong-site surgery evaluated nearly 3 million operations between 1985 and 2004 and found a rate of 1 in 112,994 cases of wrong-site surgery. The study’s authors “suggested that the average large hospital may be involved in such an event every five to 10 years, a rate 10 times less frequent than retained foreign bodies.”

“Few medical errors are as vivid and terrifying as those that involve patients who have undergone surgery on the wrong body part,” the Agency for Healthcare Research and Quality says on its website.

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