College of Nurses of Ontario v. The Member, 2000 ONCNO 50767

DISCIPLINE COMMITTEE OF THE PRIVATE COLLEGE OF NURSES OF ONTARIO

Panel:

Chairperson, RN

Member, RN

Public Representative

Independent Legal Counsel

BETWEEN

COLLEGE OF NURSES OF ONTARIO

Megan Shortreed for College of Nurses of Ontario

• and -

The Member

Elizabeth McIntyre & Joan Boudreau for the Member

Heard: February 8, 2000

DECISION AND REASONS

NOTICE OF HEARING

The allegations against the "Member" contained in the Notice of Hearing (Exhibit #1) are as follows:

1. 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 January 21, 1999 while working as a Registered Nurse at [ ] Ontario, you contravened a standard of practice of the profession or failed to maintain the standards of practice of the profession with respect to the following incident:
   1. Your care and treatment of Client A on or about January 21, 1999 and in particular your conduct in inserting a rectal suppository into her vagina.
2. 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 January 21, 1999 while working as a Registered Nurse [ ] 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 with respect to the following incident:
   1. Your care and treatment of Client A on or about January 21, 1999 and in particular your conduct in inserting a rectal suppository into her vagina.

MEMBER'S PLEA

Through Defence counsel, the Member admitted to Allegation #1 as set out in the Notice of Hearing and denied Allegation #2.

THE EVIDENCE

CNO counsel presented the panel with an Agreed Statement of Fact (Exhibit #2), which provided as follows:

The Member

1. The Member graduated from St. James Hospital in Leeds, England as an RN in 1966, and as a midwife in 1967.
2. The Member has worked as a full-time RN at [ ] Ontario since 1968. She has worked on the Labour and Delivery Unit, the Psychiatry Unit and in the Operating Room (the OR). The Member has held her current position as a full-time RN in the OR since 1976.

The Facility

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4. The RNs rotate through various services, assisting with operations. At the time of the incident, The Member was assigned as the circulating nurse for the Otolaryngology Service. The clients in this service are mainly children and the procedures are relatively short, with many procedures scheduled throughout the day.

The Client

5. At the time of the incident, Client A was four and one-half years old. She underwent an adenoidectomy at the Centre in January 1999.

Allegation 1(a) - Contravention or failure to maintain the standards of practice

6. Client A was brought into the OR at 1100 hours, wearing pajamas and underwear which she wore throughout the procedure. The procedure was started at 1105 hours and completed at 1110 hours. A general anaesthetic was administered. The anaesthetist ordered a routine Tylenol 650 mg suppository be given to the child rectally while she was still in the supine position on the OR table under general anaesthetic.
7. The Member administered the Tylenol 650 mg suppository into the child's vagina rather than her rectum. The Member acknowledges that she did not adequately uncover the client's perineal and anal area or ensure that there was proper lighting of the area. As a result, she did not adequately visualize the child's anal opening and made the error of inserting the suppository into the child's vagina.
8. The charge nurse, Nurse A, noted that there was excessive lubricant on the front of the child's pubic area. The Member acknowledged to Nurse A. that she may have improperly administered the suppository. When the surgeon completed the surgical procedure, shortly after the insertion of the suppository, the Member checked the placement of the suppository and found that it had been inserted into the child's vagina. Nurse A noted blood coming from the vagina. It was spotty and mucousy as it was mixed with the lubricant that was used for inserting the suppository.
9. The surgeon, on being notified of the error, immediately unscrubbed and asked for a consultation from a gynecologist. The gynecologist noted the following:

"On examination, a fair amount of white discharge was noted from the vagina. There was also a superficial laceration near the fourchette, not involving the hymen. Using a syringe and warm normal saline, the suppository contents were washed out of the vagina. Using a nasal speculum, the vaginal shaft was inspected and noted to be unremarkable. Further treatment is not required and the very, very tiny mucousal laceration at the fourchette will heal on its own."

10. The following was noted on the client's Nursing Progress Notes for January 21, 1999:

"1345 Pt. up to BR. Voided. Pt. screamed during voiding b/c of burning. Mom reported that vagina is swollen. Pt. has blood on underwear - moderate amt... Mom is upset about vaginal bleeding and discomfort...

1515 ...Scant blood noted on underwear. Vagina reddened and blood noted...up around unit [with] mom. Little discomfort to walking due to vaginal discomfort...

1645 ...Scant blood noted on the underwear. Vagina reddened and blood noted. Area exposed by mom. Area painful to touch.

1700 Mom concerned about bleeding from the vagina. Pt. cried during voiding b/c of burning. Mom said there was blood on the toilet tissue when she wiped the patient.

1900 No bleeding from the vagina but it is reddened. ..."

The patient was then discharged.

11. The recommended positioning for administration of rectal medications is the left-lateral Sims' position. This position places the sigmoid colon lower than the rectum and reduces the risk of spontaneous expulsion of medication.
12. The Member admits that her conduct amounts to professional misconduct as set out in allegation 1(a) of the Notice of Hearing in that she contravened a standard of practice of the profession or failed to maintain the standard of the profession with respect to her care and treatment of client A.D. on or about January 21, 1999, and in particular her conduct in inserting a rectal suppository into the child's vagina.

Allegation 2(a) - Disgraceful, dishonourable and unprofessional conduct

13. The College tenders no evidence with respect to this allegation.

Defence counsel outlined that the Member had 30 years of nursing experience and had been an OR nurse since 1976. The subject of this hearing was an isolated incident in an otherwise unblemished nursing career. In addition, the working conditions (understaffed, fast pace of client changeover in the OR, perceived pressure from medical staff) did not support proper nursing practice. While the incident had caused upset in both the mother and child, the attending gynecologist's report indicated no injury to hymen. Finally, the Member feels deep remorse. Counsel argued that although it would be appropriate to find a breach of standards, this incident did not amount to disgraceful, dishonorable or unprofessional conduct.

The Chairperson conducted a Plea Inquiry to ensure that the Member's admission of professional misconduct was informed and voluntary.

DECISION

The panel deliberated, accepted the Agreed Statement of Fact and unanimously agreed that the Member had committed an act of professional misconduct. The Member had failed to meet a standard of practice of the profession by incorrectly administering a medication. While accidental, the fact that it involved not only a child, but an anesthetized patient made this incident more serious. No finding was made regarding Allegation #2 as College counsel tendered no evidence.

JOINT SUBMISSION ON PENALTY

The panel was provided with a Joint Submission on Penalty, Exhibit #3, as follows:

Whereas the Member has provided proof to the Director of Investigations and Hearings that she has met with a pediatric clinical nurse specialist to review the administration of suppositories;

The Member and the College jointly submit that the appropriate penalty in this case is for the Discipline Committee to make the following order:

1. Requiring the Member to appear before the panel of the Discipline Committee to be reprimanded, at a date to be arranged, but in any event within three months of the date the order becomes final.

College counsel stated that nurses must use diligence, care and skill at all times when administering medications, particularly so in an Operating Room setting and in dealing with small children. This particular incident, while showing that care had fallen below the standard of practice, called more for remediation than punishment.

Defence counsel indicated that the Member's practice had already been corrected as it relates to the administration of medications and suppositories. The Member has provided proof of this from a Pediatric Clinical Nurse Specialist. An oral reprimand would, therefore, satisfy remediation objectives.

Finally, defence counsel directed the panel to section 23 of the Health Professions Procedural Code which deals with the contents of the College's register. Under section 23(1)(f), a Discipline panel has the ability to specify information to be included. Further clarification can be found in 23(3)(ii) in that it is at the discretion of the panel to order publication. It was argued that this discretion should be exercised, that section 56 of the Code identifies oral reprimand as a possible exception to publication, and that publication should be reserved for more serious issues. College counsel stated that the College took no position on publication.

Defence counsel tendered as exhibits two documents. The first (Exhibit #4), a letter from an Orthopaedic Surgeon, was essentially a letter of reference for the Member. The second document (Exhibit #5) from an RN, dated January 21, 2000 certified that the member has completed an educational session, and follow-up testing regarding medication administration (including suppositories).

It was defence counsel's submission that the panel had been provided with evidence that the Member is a competent professional who made, recognized, and admitted an error and took immediate steps to remedy the error. She had admitted her error both to her employer and to the College, and had co-operated during the investigation and with the Agreed Statement of Fact and Joint Penalty.

PENALTY DECISION

After deliberating, the panel unanimously accepted the Joint Submission on Penalty with the following addition:

1. Direct that the results of this proceeding not be included in the public portion of the register.

REASON FOR PENALTY DECISION

The panel agreed that the penalty was appropriate in that it fulfills the objective of remediation in the Member's future practice. Mitigating factors the panel considered were: the Member was remorseful, had herself already taken steps to correct her practice, and had an otherwise unblemished nursing career. She had also cooperated during both the investigation and the Agreed Statement of Fact and had voluntarily admitted professional misconduct.

Finally, the publication of the hearing without the Member's name or identifying features is itself a general deterrent to the members of the profession, thereby serving the public interest.

At the conclusion of the hearing, the Member signed a Notice of Waiver tendered by her counsel. The oral reprimand was administered the same day.

I, [ ] , sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel [ ]