EXPANDED VERSION OF HOW THE NCVMB HANDLED OUR COMPLAINT
|1. Our Complaint||4. Monce Reprimand||7 Monce Rejection||10. Negotiations 2|
|2. Board Complaint||5. Questioned Issues||8. Negotiations 1||11. Consent Order|
|3. Jones Reprimand||6. 00048 Decision||9. Notice of Hearing|
Letter of Reprimand: Kevin A. Monce, DVM, Complaint 00006-1-1
REJECTED BY KEVIN MONCE ON NOVEMBER 6, 2001.
CONSENT ORDER EXECUTED ON APRIL 7, 2003.
- September 15, 2006
NORTH CAROLINA VETERINARY MEDICAL BOARD
P.O. BOX 12587
RALEIGH, NORTH CAROLINA 27605
OCTOBER 17, 2001
Return Receipt Requested
Letter of Reprimand
P. O. Box 15396
Wilmington, NC 28408
Re: File No. 00006-1-1
Nancy G. Deas and Edna E. Deas
Dear Dr. Monce:
I write on behalf of the North Veterinary Medical Board and its Committee on Investigations No. 1 to explain the decision of the Committee and the Board on the complaint by Nancy and Edna Deas (hereafter the "Deases") regarding your care and treatment of their dog Alex, a 14-year-old Manchester terrier. The complaint was filed against both you and Dr. Dana R. Jones of Raleigh. The decision with respect to Dr. Jones is set forth in a letter to him.
The Committee voted to issue you this letter of reprimand and to recommend to the Board that you should be assessed a civil monetary penalty of $3,000.00. The Board has agreed with the Committee's decision and recommendation. Please review the provisions of Board Rule .0601(h) and follow them if you choose to reject the reprimand and request a formal hearing. If you accept the reprimand, nothing further is required.
By copy of this letter, the Committee and the Board express their condolences to the Deases over the loss of Alex.
Board Investigative Procedure
The Veterinary Medical Board regulates veterinary medicine in the
State pursuant to the Veterinary Practice Act. Written complaints to
the Board are investigated by one of its three-member Committees on
Investigation (in this case, Committee No. 1), which reviews the materials
relevant to the complaint to determine whether there is probable cause
that the veterinarian complained of violated the statutes and/or administrative
rules governing veterinary medicine. A Committee follows Board
Rule .0601, copy enclosed, in conducting their investigation.
Several hundred pages of materials were reviewed by the Committee on this and the Board-initiated complaint, file no. 00048-2-1. The Committee also interviewed you, Dr. Jones and the Deases. A number of issues and questions were presented by the complaint, all of which have been considered by the Committee. The Committee has identified the relevant issues of this complaint, has made findings and decisions on the issues.
Summary of Chronology and Complaint Allegations
The chronology of complaint allegations is set forth in the letter of reprimand to Dr. Dana R. Jones, which letter is incorporated herein by reference. A copy of that letter is enclosed.
For the convenience of readers, the Summary of Chronology and Complaint Allegations set forth in the letter of reprimand to Dr. Dana R. Jones is copied here and
may also be viewed in the Letter of Reprimand to Dr. Jones.
The Deases allege that the medical care by you for Alex was negligent during the period of December 28, 1999 through January 3, 2000. Alex was presented to you with the Deases complaint of his not eating well, seeming to be weak and unsteady, and with possible weight loss. Blood was drawn and the following day you communicated to the Deases the results of the tests, the most remarkable which was elevated liver enzymes. You offered to discuss the case the next week with Dr. Kevin Monce from whom Alex had previously received veterinary medical treatment. Nancy Deas thereafter called Dr. Monce and described Alex's symptoms.
Alex's loss of interest in eating continued to increase on December 30. He was walking more slowly and unsteadily, occasionally bumping into objects. In responding to Nancy Deas' call that day, you indicated Alex might later need fluids. On December 31, Alex refused to eat but was drinking and urinating. The Deases presented Alex to you, and the Deases believed his behavior was more listless than several days previously during the ride to your facility, Durant Road Animal Hospital & Kennel, PLLC (the "Hospital").
You examined Alex and informed the Deases that Dr. Monce would perform a liver biopsy. This procedure would be performed in the place of an electrocardiogram the Deases has planned for January 12 with Dr. Bob English. You determined Alex had a "bad disc" and that he needed fluids. You advised the Deases not to let him jump down stairs. You took Alex into the laboratory while the Deases waited outside. The complaint alleges that when you returned Edna Deas noticed the dog's lower left canine tooth was missing. Nancy Deas later recalls she had noticed the tooth missing on December 28.
On January 2 by later morning Alex had refused all food except for three or four very small pieces of ham. He also refused to drink and had not urinated. His appetite was still weak the remainder of the day. This condition continued into January 2 and the Deases presented Alex to you shortly after 2:30 p.m. You administered fluids.
On January 3 Dr. Monce returned the Deases' call from the previous day and discussed their concerns. Nancy Deas asked whether there was an incident in the laboratory December 28 in which the dog may have been injured or jumped from the table while blood was being drawn. She asked in addition to the liver consultation that Dr. Monce "take charge and look Alex over to make sure that he is O.K."
At about 11:00 a.m. the Deases present Alex to your office. Dr. Monce was present with his trailer. He was assisted by Renee Dailey Daniel. You accompanied Nancy as she took Alex to the trailer. Ms. Dailey conducted an ultrasound test on Alex's abdomen. Prior to completion of the ultrasound, Dr. Monce informed the Deases he will need to sedate Alex. Dr. Monce differed from Nancy Deas in his assessment of Alex's weight: he estimated 16 pounds, Nancy responded that his usual weight is 12 but he had lost weight. Dr. Monce at Nancy's request listened to Alex's heart for approximately two to three minutes before administering the injection of anesthesia, which acts in fewer than 30 seconds. Ms. Dailey continued the ultrasound test and reported that the liver was enlarged and the edges rounded. Ms. Dailey found enlarged adrenal glands with a tumor in the left gland. Other findings of the ultrasound were a thickened gall bladder, and pleural effusion. The pancreas appeared normal.
Nancy Deas asked Dr. Monce whether it would not be "the kindest thing to euthanize Alex and not proceed (with the biopsy)?". Dr. Monce replied in the negative. Dr. Monce performed the needle biopsy, guided by Ms. Dailey's ultrasound image. Present in the trailer were Dr. Monce, Ms. Dailey, Nancy Deas, and for a period of time you. The biopsy of the spleen was placed on the slide. He obtained tissue and fluid samples and and performed a biopsy on Alex's liver. Dr. Monce said his first impression was hepatitis. Dr. Monce also obtained fluid from the area around the abdomen. Nancy carried Alex back into the Hospital.
Alex was placed on a table where Nancy believes the isoflurane was present, but she could not tell whether it was administered [NOTE: View polygraph of Nancy Deas on this issue submitted to the NCVMB]. You prepared to remove the tooth root and examine his mouth. You determined that the dog's jaw was broken. Dr. Monce examined it and said "that is is just cartilage" and pointed to the area at the center of the chin to show Nancy where he thought the problem was. Nancy's mother had said Alex had jumped off a chair, but Nancy told you that after further talking to her mother, Nancy believed Alex jumped 19.5; inches off of an upholstered chair and landed on his feet but did not fall flat down. Her mother could not be sure whether the dog hit his chin or not the the floors are wood and there is a mat in front of the chair. Dr. Jones removed the root and sutured the site. Dr. Hostetter cut Alex's nails and packed them with medicine.
The Deases allege that approximately 12:30 p.m. you checked Alex and reported he needs to swallow in order to "get the tube out." You found that his gums are "a little pale." At this point Nancy Deas alleges that she heard you say the word "curaine" to Dr. Monce and that he replied in the affirmative [NOTE: View polygraph of Nancy Deas on this issue submitted to the NCVMB]. This alarmed her because you and Dr. Monce had said that Dr. English would use the drug to paralyze the Deases' other dog, Gus, during the dog's cataract surgery the previous September.
Alex had difficulty awakening. You and Dr. Monce conferred and you administered an injection of dexamethasone, and drew blood for a CBC. You took Alex across the hall for radiographs, and then returned him to the table. At this point your colleague Dr. Jeannine M. Hostettler returned and showed Dr. Monce one to two pages of white paper which Nancy thought might be the CBC results. Ointment was placed in Alex's eyes. You determined the x-rays showed no disc problem. Nancy noticed Alex's eyes were partially open and staring, although she thought he was still asleep. She waited in the examination room for Alex to awaken.
At 2:00 p.m. you gave Nancy two pill containers and reviewed instructions about their administration A 4:30 p.m., although Alex was not awake, you informed her that she could take Alex home if she wished.
At home at approximately 5:00 p.m. Alex appeared asleep and his eyes were glazed, with ointment still in them. The Deases did not notice anything difficult about his breathing. At 10:30 p.m. Alex began rapid, labored breathing. The Deases called you, and you met them at the Hospital. You determined that Alex's condition was "dry". You gave Alex water and drew his blood for a PCV test the results of which were "not too bad." You administered fluids subcutaneously. You advised the Deases to keep Alex warm, and loaned them a heating pad.
The Deases attempted to keep Alex warm, but a few hours later, at 12:30 a.m. January 4 Nancy called Dr. Monce at home. She related to him your treatment earlier that evening and that Alex had not awakened, and was making "strange" barking-like sounds. Dr. Monce described a condition called "hepatic encephalopathy" and said the Deases need to administer an enema to the dog. He advised that they buy and administer one half of a Fleet brand enema or a comparable quantity of water with dish detergent.
The Deases called you and you reportedly heard Alex's barking sounds. They informed you of Dr. Monce's advice. You then advised them to take Alex to an emergency clinic. Although you thought they could not get into NCSU Veterinary Teaching Hospital, you gave them the telephone number. You asked that they call you back with a decision.
Nancy called Dr. Monce to inform him that you said Alex needed to be hospitalized. Dr. Monce asked if they gave the enema. Nancy alleges that Dr. Monce seemed to recommend their not gong to NCSU-VTH. He recommended that they go to Animal Emergency Clinic of Cary, and further recommended treatment for hepatic encephalopathy. Dr. Monce stated that Alex had liver disease and needed saline intravenously, as well as enemas. He says treatment could take two days. Nancy called the emergency clinic to inform them that they were bringing the dog there and provided Dr. Monce's home telephone number and asked that the staff call him. Nancy called to inform you they were going to Animal Emergency Clinic of Cary. You said if Dr. Ronald Feimster was on duty, to alert him about giving fluids, because Alex has already had them. You were concerned about oveloading Alex's heart. Alex had been given 275 ml of lactated ringers solution.
At the facility the Deases reviewed with Dr. Feimster Dr. Monce's recommendations, and gave him information about the quantity of fluids. Dr. Feimster then called Dr. Monce. Dr. Feimster then talked with the Deases about three possibilities: late abdominal bleeding from the biopsy; hepatic encephalopathy; and neurological problems. Dr. Feimster responded to Edna Deas that the prognosis was "end-stage". There were several questions and responses between Edna and Dr. Feimster about whether Alex was suffering and in pain. Eventually Dr. Feimster determined that Alex had severe acidosis. The Deases consented to Dr. Feimster trying sodium bicarbonate and later, to removing abdominal fluid. Dr. Feimster then calculated Alex's chances at "50-50 until morning." Dr. Feimster did not think Alex's problem was adrenal, but was a brain lesion. After more questioning and examination, Dr. Feimster determined that Alex was in renal failure.
Because of Alex's condition as determined by Dr. Feimster, and because of his physical condition, Nancy and Edna Deas consented to euthanization, which was accomplished at 3:30 a.m. Nancy left messages on your and Dr. Monce's respective business answering machines that the reason Alex was euthanized at 3:30 a.m. for renal failure.
General Complaint Issues as Determined by Committee No. 1
Attached to the Deases' complaint was an extensive list of approximately
39 questions, many with subparts. Committee 1 has organized the questions
into a series of issues. The following issues related to the complaint
1. Did you violate the Practice Act and Board Rules by delivering veterinary medical services to the Deases for Alex in a mobile facility not inspected or approved for such services by the Veterinary Medical Board?
2. Were you a primary veterinarian or only a consulting veterinarian in the treatment of Alex?
3. Did you comply with Board Rule .0207(b)(12) regarding minimum standards for recordkeeping in the treatment of Alex?
4. Did you provide competent veterinary medical diagnosis, care and treatment of Alex during the several days preceding January 4, 2000?
5. Did you violate the Practice Act by delivering veterinary medical services to Alex during this period through a business corporation known as "VetSound, Inc."?
Committee I addresses the foregoing issues with the following findings
and points. Some of the findings relate to more than one issue.
The Committee has found probable cause that you violated N.C. Gen. Stat.
§ 90-187.8(c)(6). Your diagnosis, care and treatment of Alex, as
described below, was not competent, and did not meet the minimum standard
of veterinary medical care. In lieu of sending this matter to a
formal hearing, the Committee has issued this letter of reprimand pursuant
to Board Rule .0601(h).
North Carolina General Statutes § 90-187.8(c)(6) provides the following:
(c) Grounds for disciplinary action [by the Board] shall include but not be limited to the following:
* * * *(6) Incompetence, gross negligence, or other malpractice in the practice of veterinary medicine.
* * * *
(15) All new veterinary facilities and all existing facilities changing ownership shall be inspected and approved by the Board prior to the practice of veterinary medicine within the facility.
You allowed Alex to be brought by Dr. Jones and Nancy Deas from
Durant Road Animal Hospital and Kennel, PLLC (the "Hospital") into your
trailer in the Hospital parking lot knowing that it was not inspected
and approved for the delivery of veterinary medical services.
While under your care in this facility you conducted invasive procedures
on Alex, including a biopsy of his liver and obtaining of other tissue
and fluid samples. Your acts and omissions constituted a blatant
disregard of the Veterinary Practice Act and Board Rule requirements.
Your conduct violated the minimum sanitary and practice requirements
of Board Rule .0207(b)(15). Further, your conduct in leading Dr. Jones,
Nancy and Edna Deas to believe that the facility was appropriate for
the delivery of veterinary medical services, when it was not, constituted
an act of misrepresentation in the veterinarian-client-patient relationship
in violation of G.S. § 90-187.8(c)(19). Your total conduct constituted
incompetence and malpractice in the practice of veterinary medicine
in violation of G.S. § 90-187.8(c)(6).
A related question on this issue is whether your treatment of Alex in this trailer caused or contributed to the deterioration of Alex's deteriorating health. The Committee does not find a causal connection.
2. Was your role that of a consultant or primary veterinarian? The Committee believes you were a primary veterinarian for Alex, often sharing this status with Dr. Jones. Although you have referred to your capacity as only that of a consultant, the facts show otherwise. You did a great deal more than merely consult. You had a history of treating Alex for several years, apparently long before you identified yourself as a consultant. Dr. Jones as well as the Deases contacted you in December, 1999 to provide opinions, diagnosis and care of Alex. You assumed the responsibility as a primary care giver. The Deases called you at home on at least three occasions during this period of time. On the evening of January 3 and the early morning hours of January 4 Nancy Deas called you and you gave her instructions and advice regarding treatment. The Deases looked to you as a primary care giver. Therefore, as a primary veterinarian, you should have provided more supportive care for Alex at the Hospital during the afternoon of January 3, as well as in the late evening of January 3 and early morning of January 4. These omissions are further discussed below.
3. Recordkeeping. The Committee finds you violated Board Rule .0207(b)(13) with respect to minimum standards for recordkeeping, which also constitutes a violation of the competency practice standards of G.S. § 90-187.8(6). Your recordkeeping was extremely poor, and you did not maintain a complete medical record for Alex. While you wished to deliver services in a consultive-type capacity, as noted above you were actually a primary veterinarian for Alex. Moreover, a facility providing limited veterinary services, even an approved one, is required by Board Rule .0208(b) to comply with the minimum standards of Board Rule .0207. Recordkeeping is one of these standards.
4. Care and Treatment of Alex. Your total care of Alex fell below the minimum competency standards of G. S. § 90-187.8(c)(6),especially in light of your status as diplomate of the American College of Veterinary Internal Medicine. You were at least a primary veterinarian for Alex from late December, 1999 through the early morning of January 4, 2000. You had treated Alex and the Deases' other dog, Gus, for several years. You were familiar with Alex's general condition and you knew his age. This 14-year old dog first needed precautionary support before, during and after your administration of anesthesia.
After Alex was transported from the trailer back to the Hospital following the biopsy procedure, you assisted Dr. Jones in further treatment and diagnosis. Shortly thereafter you left the facility before Alex had recovered. When Alex did not readily recover from the anesthesia, this was a second change for you to respond with supportive care, with fluids or otherwise. But you were not available. Perhaps because you incorrectly viewed your role as a consultant, you left the Hospital prior to Alex's discharge.
Was your treatment of Alex during the day of January 3 appropriate and
complete? The diagnostic procedures were appropriate, but you
erred in failing to provide treatment therapies readily available, such
as the administration of fluids, when Alex did not readily recover from
Did the recommendations that you made at or about 12:30 a.m. January
4 meet the minimum veterinary standard of care? No. There
appears to be little basis in the records for you to make a diagnosis
then that Alex had hepatic encephalopathy, when nothing else was mentioned
about that previously. You had not seen Alex for almost 12 hours.
The Committee believes there are risks associated with making that type
of diagnosis in this situation.
5. Practicing Through a Regular Business Corporation. Did you deliver veterinary medical services through the name of VetSound, the name of a business corporation, VetSound, Inc.? It appears that VetSound, Inc. owned the trailer, perhaps as co-owner with Renee Dailey Daniel, in which you treated Alex on or about January 3, 2000. A veterinarian is not permitted to deliver veterinary medical services through a regular business corporation. On this occasion it appeared that you were conducting a veterinary medical practice through the name VetSound. This violation is another aspect of your disregard of the statute and rules concerning veterinary medicine in this State.
Civil Monetary Penalty
Pursuant to N.C. Gen. Stat. § 90-187.8(b) and Board Rule .0601(m), the Veterinary Medical Board has voted to impose and collect from you a civil monetary penalty in the amount of $3000.00 for your violations of the Veterinary Practice Act and Board Rules, as discussed, which form the basis for this letter of reprimand. The amount of this civil penalty has been determined upon a finding by the Board of the following factors, only one of which is necessary to sustain the imposition of the penalty:
1. N.C. General Statute § 90-187(b)(2) [duration and gravity of violation]. You treated Alex in an uninspected facility, a serious violation.
2. N. C. General Statute § 90-187.8(b)(3) [willful or intention violation or one reflecting a continuing pattern]. Your treating Alex in an uninspected mobile facility was committed willfully and intentionally. It also appears to have reflected a continuing pattern. You disregarded the terms of the Practice Act and Board Rules.
3. N. C. General Statute § 90-187.8(b)(4) [a violation involving elements of fraud or deception to a client or to the Board]. Treating Alex in an uninspected mobile facility was an act of deception to Nancy and Edna Deas in the veterinarian-client-patient relationship, to the Veterinary Medical Board and to Dr. Dana Jones, your colleague.
4. N. C. General Statute § 90-187(b)(6) [profiting by violation]. The Board finds that you profited by charging for professional fees performed in the uninspected mobile facility.This concludes the decisions of Committee No. 1 with respect that portion of this complaint against you. The decision of Committee 1 has been reported to and accepted by the Veterinary Medical Board. Please be advised that if you elect a hearing, which is your right, the hearing panel is not limited to the disciplinary sanctions contained in this letter if the hearing panel finds a violation. In other words, the hearing panel can find no violation and impose no sanction, find the same violations and impose identical sanctions, or find violations and impose more severe discipline, both in terms of license discipline, civil monetary penalty, and recovery of costs. Please review Board Rule .0601(h).
If you or your attorney have any questions about this, please contact me or Mr. Mickey.
George G. Hearn
Attorney for the Board
cc: Nancy G. Deas
Edna E. Deas
Dana R. Jones, D.V.M.
Thomas M. Mickey, Executive Director
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