DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
Panel:
Chairperson, RN
Member, RN
Public Representative
BETWEEN
COLLEGE OF NURSES OF ONTARIO Counsel for College of Nurses of Ontario
- and -
Jae-In Jane Park #70-4503-2
REASONS FOR DECISION
Counsel for Jae-In Jane Park, RN
Heard: May 13, 1999
A panel of the Discipline Committee of the College of Nurses of Ontario (“the College” or “CNO”) was convened to hear allegations against Jae-In Jane Park, RN, on May 13 1999. The allegations contained in the Notice of Hearing (Exhibit #1) are as follows:
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c.32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that on or about April, 1998 while working as a Registered Nurse at the Rehabilitation Institute of Toronto in the City of Toronto, in the Province of Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession with respect to your care and treatment of a client, and in particular you failed to initiate and/or perform the Code Blue and Cardio-Pulmonary Resuscitation; and/or
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c.32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that on or about April, 1998 while working as a Registered Nurse at the Rehabilitation Institute of Toronto in the City of Toronto, in the Province of Ontario, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional in that you failed to initiate and/or perform the Code Blue and Cardio-Pulmonary Resuscitation with respect to a client.
Ms. Park admitted Allegation #1. The College presented no evidence in regard to Allegation #2.
PLEA INQUIRY
Plea Inquiry
The Chair conducted a Plea Inquiry in order to ensure that Ms. Park’s admission of professional
misconduct as alleged was informed and voluntarily made.
AGREED STATEMENT OF FACTS
Agreed Statement of Facts
An Agreed Statement of Facts was received as Exhibit #2:
Jae-In Jane Park (the “Member”) has been registered as a Registered Nurse with the College of Nurses (the “College”) since 1970. She worked at Riverdale Hospital during most of the period from 1970 to 1998.
The Rehabilitation Institute of Toronto (the “Institute”) was formed by the amalgamation of The Queen Elizabeth Hospital and Hillcrest Hospital in 1997. The Institute has three locations in Toronto, one of which is on University Avenue.
Ms. Park began working as an RN at the Queen Elizabeth Hospital in October, 1989 and became an employee of the Institute at its University Avenue location upon the amalgamation. She was classified as a regular part-time RN. Initially she worked on Unit 9 East, which is a Long-Term Care Unit, until 1997 when the Unit was closed. She was then transferred to Unit 5 East (the “Unit”), which is a Stroke Rehabilitation Unit. It remained her base unit thereafter.
Unit 5 East consists of 24 client beds. It provides care to clients who have suffered hemorrhagic or infarct strokes.
In April, 1998, Ms Park was scheduled to work the night shift one night on Unit 5 East, from 11:00 p.m. that evening until 7:00 a.m. the next morning. She was assigned to be the Charge Nurse, with responsibility for care of clients and supervision of staff on the Unit. A Registered Practical Nurse was assigned to work with her. The RPN did not normally work on Unit 5 East, but had been reassigned to work with Ms. Park because of another nurse’s illness. No other nurses were assigned to work on Unit 5 East for the evening shift.
The client was on Unit 5 East on the day of the incident. The client, who was 72 years old, had been admitted to the Unit on a week earlier for post-stroke therapy. There was no “Do Not Resuscitate” order on the client’s health record. While the client was in the hospital Ms. Park was on duty on the Unit on two occasions prior to the day of the incident.
During the day shift the client was found to have a swollen left leg. He was sent to the Toronto Hospital for examination. He returned to the Institute just before 11:00 p.m. He had been diagnosed as having Deep Vein Thrombosis and Aspiration Pneumonia. Heparin was to be started. The client was on Unit 5 East when the night shift began.
The client became restless after his return to the Unit. As his behaviour was disruptive to other clients, he was brought into the lounge area next to the nursing station sometime between 12:30 and 12:45 a.m. He was put on oxygen via mask because he was having difficulty breathing.
After checking the client, Ms. Park told the RPN to take her break. At approximately 1:10 a.m., the RPN went elsewhere on the Unit to begin her break. Around 1:30 a.m. Ms. Park found the client without vital signs and apparently not breathing. She summoned the RPN to return from her break. She told the RPN that the client was not breathing and asked the RPN to look at him.
The RPN checked the client’s vital signs and found none. The client did not appear to be breathing. The RPN told Ms. Park this. Ms. Park went to call a physician while the RPN remained with the client. There was no physician on duty in the building at that time, but a physician was available by telephone. Ms. Park spoke to the physician by telephone and told her that she could not get any vital signs and did not know what to do. The physician told her to call a Code Blue immediately.
Rather than call a Code Blue, Ms. Park called “911” for assistance. An ambulance was dispatched at 1:54 a.m. and arrived at the Institute at 1:58 a.m. Ambulance personnel started CPR. The client was taken to the Toronto Hospital, where he died.
At no time did either Ms. Park or the RPN initiate CPR or call a Code Blue, nor did they discuss taking these actions.
It was the policy of the Institute that in the event of a client’s cardiac or respiratory arrest, nursing staff were to call a Code Blue and commence CPR. Ms. Park was aware of this protocol.
The Institute terminated Ms. Park’s employment on April 22, 1998, as a result of this incident. In February, 1999, Ms. Park began full-time employment at another facility.
Ms. Park admits the allegation set out in paragraph 1 of the Notice of Hearing.
The College tenders no evidence regarding the allegation set out in paragraph 2 of the Notice of Hearing.
Counsel made submissions highlighting the Agreed Statement of Facts.
FINDING OF PROFESSIONAL MISCONDUCT
Finding of Professional Misconduct
The panel deliberated and accepted the Agreed Statements of Facts and found Ms. Park to have committed professional misconduct as alleged in Allegation #1.
JOINT SUBMISSION ON PENALTY
Joint Submission on Penalty
A Joint Submission on Penalty was submitted as Exhibit #3 and is reproduced below:
- That pursuant to paragraph 51(2) 2 of the Health Professions Procedural Code (the “Code”), the panel should direct the College’s Executive Director to] suspend Ms. Park’s certificate of registration for a period of 4 months. This order shall be suspended on the following conditions:
a. Ms. Park appears before a panel of the Discipline Committee to be reprimanded;
b. Ms. Park provides the Director of Investigations and Hearings of the College with proof that she holds a current certificate in Cardio-Pulmonary Resuscitation (CPR);
c. [Ms. Park] provide the Director of Investigations and Hearings of the College with proof of her current Cardio-Pulmonary Resuscitation (CPR) Certification, for two consecutive years, commencing in 1999;
d. For a period of two years from the date of the hearing, Ms. Park provides the Director of Investigations & Hearings of the College with proof of her attendance at hospital sponsored updates on responsibilities in responding to Code Blue; and
e. Ms. Park meets with the College’s Nursing Practice Advisor to discuss the College’s standards of practice on resuscitation, within six months of the date of the hearing.
- [Pursuant to paragraph 23(1)(f) of the Code, the panel should] include the results of this disciplinary proceeding in the public portion of the Register of the College of Nurses of Ontario.
Both counsel supported the rationale for the Joint Submission on Penalty. After due consideration, the panel accepted the Joint Submission on Penalty.
RATIONALE
Rationale
In reviewing the Joint Submission on Penalty, the panel considered the following criteria: Public protection; and
Ms. Park’s capacity for rehabilitation.
The panel acknowledged the gravity of the incident as a serious breach of nursing practice standards.
Mitigating factors considered were the fact that Ms. Park has been a Member in good standing for many years with no allegations of professional misconduct and she cooperated with CNO during the investigation, voluntarily admitting the professional misconduct.
The panel agreed with the suspension of the suspension because:
the remedial aspects of the penalty were comprehensive and would serve to protect the public as
well as deter this behaviour in future;
this incident resulted in termination of her employment and the panel considered this a significant penalty in itself.
An oral reprimand was administered.
I, , RN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel as listed below:
, Chairperson Date Member, RN
Public Representative