Maureen Pacheco, suffering back pain for years in the wake of a car accident, checked in to Wellington Regional Medical Center to get the bones in her lower back fused.

She left without one of her fully functioning kidneys after a surgeon mistook it for a cancerous tumor and called an audible in the operating room. Pacheco never had a say in the matter, according to a lawsuit settled in September.

And what is more, the doctor wasn’t even the one performing the back surgery on April 29, 2016. Pacheco met Dr. Ramon Vazquez shortly before being wheeled into the operating room. Vazquez’s job was to cut her open so her orthopedic surgeons could perform the delicate back operation.

“As you can imagine, when someone goes in for a back surgery, she would never expect to wake up and be told when she’s just waking up from anesthesia, that one of her kidney’s has been unnecessarily removed,” said Pacheco’s attorney, Donald J. Ward.

Florida’s Department of Health has now filed an administrative complaint against Vazquez. He could face a range of penalties from losing his medical license to simply paying a fine. He has served as chairman of surgery at Palm Beach Gardens Medical Center since January and has privileges at St. Mary’s and Good Samaritan medical centers as well as Bethesda Memorial Hospital.

“Few medical errors are as vivid and terrifying as those that involve patients who have undergone surgery on the wrong body part,” according to the federal Agency for Healthcare Research and Quality. Such mistakes are deemed “never events” — meaning they should never occur.

The agency has found that such errors occur in about 1 of 112,000 surgical procedures.

Vazquez had an unblemished disciplinary record until he faced a malpractice claim filed by Pacheco and the administrative complaint.

“The case was settled on his behalf for a nominal amount due to the uncertainty of litigation and in no way did Dr. Vazquez admit liability by agreeing to this settlement,” Vazquez’s attorney Mark Mittelmark said in an email. Vazquez does not carry malpractice insurance, according to the Health Department.

The malpractice insurers for her primary surgeons, Dr. John Britt and Dr. Jeffrey Kugler, settled for $250,000 apiece, according to the Department of Insurance Regulation.

Pacheco’s back surgery was being done through the front of her body, so Vazquez as a general surgeon was brought into expose the surgical site, a fairly common practice, Hall said.

Vazquez made a “presumptive diagnosis” when he noticed what he thought was a malignant pelvic mass once he prepped the patient’s lower back for the back surgery, according to the Health Department’s complaint.

He clipped it and removed what he thought was a tumor, but a month later a pathologist at Wellington Regional confirmed the mass removed was, in fact, an intact pelvic kidney.

Wellington Regional did not return phone calls for comment.

The Health Department complaint, filed in December, said the cancer diagnosis was not related to the patient’s medical condition and “therefore medically unnecessary.”

Pelvic kidneys are perfectly fine renal organs that did not ascend to the normal abdomen region during fetal development.

However, two MRIs performed prior to surgery clearly showed the kidney in Pacheco’s pelvic region, the lawsuit filed against Vazquez stated.

Vazquez failed to review the MRI and never got Pacheco’s consent to remove what he thought was a cancerous mass, the litigation claimed.

In a response to the lawsuit, Vazquez’s attorney put the blame on Wellington Regional for failing to inform him that the patient had a pelvic kidney.