College of Nurses of Ontario v. The Member, 2000 ONCNO 50768

Discipline Committee of the College of Nurses of Ontario

Panel: Chairperson, RPN Member, RN Member, RN Public Representative Public Representative

Between: College of Nurses of Ontario Counsel for College of Nurses of Ontario

• and -

The Member Counsel for The Member

Heard: August 22, 2000

Reasons for Decision

A panel of the Discipline Committee of the College of Nurses of Ontario convened on August 22, 2000 to hear the following allegations at the College of Nurses of Ontario 101 Davenport Road, Toronto Ontario.

Notice of Hearing

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 or about April 1999 while working as a Registered Nurse at Sunnybrook Health Sciences Centre in Toronto, 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 the Client.

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(7) of Ontario Regulation 799/93, in that on or about April 1999 while working as a Registered Nurse at Sunnybrook Health Sciences Centre in Toronto, Ontario, you physically abused a client with respect to the following incident:

   1. Your care and treatment of the Client, and;

3. 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 1999 while working as a Registered Nurse at Sunnybrook Health Sciences Centre in Toronto, Ontario, you engaged in conduct or performed an act, relevant to the practice of nursing that, having regard to all of the circumstances would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional with respect to the following incidents:

   1. Your care and treatment of the Client.

The College counsel advised the panel that they would hear evidence with respect to allegation #1 but the College would provide no evidence on allegations #2 and #3.

Plea

The Member admitted to allegation #1 as set out in the amended Notice of Hearing.

Plea Inquiry

The Chair of the panel conducted a plea inquiry in which the Member voluntarily admitted to the allegation.

Agreed Statement of Facts

Counsel for the College advised the panel that the parties had agreed to a statement of facts which supported a finding of professional misconduct and, in particular, failure to maintain the standards of the profession. The Agreed Statement of Facts provides as follows:

The Member

1. The Member completed her nursing training in 1987 at Humber College. She became a member of the College in 1987.
2. The Member has been employed with Sunnybrook Women's College & Health Sciences Centre (Sunnybrook HSC) since 1987, working as a full-time nurse in Chronic Care until 1988, and maintaining a casual position from 1988 until present on the unit K3 East.
3. The Member has worked in a full-time position on a surgical unit at Humber Memorial Hospital from 1988. Since April 1999, she has been in the position of nurse manager.

The Facility and the Unit

4. Sunnybrook HSC is an acute and chronic care facility with 1168 beds.
5. 3K East (the Unit) is an approximately 44-bed locked unit in the Kilgour Wing of Sunnybrook HSC, which is dedicated primarily to the care of veterans whom have significant cognitive impairment and require extensive physical care and assistance with activities of daily living.
6. At the time of the incident described below, the staffing on the night shift consisted of one RN and one RPN who had responsibility for all care required by the residents. Following the incident described below, the staffing on the night shift was increased to three nursing staff.

The Client

7. The Client, aged [ ] years, was admitted to the Unit in August 1998. He resided in a four-bed room.
8. The Client suffered from cognitive loss and dementia. He exhibited a number of behavioural problems including lashing out at staff, engaging in unsafe behaviour such as climbing over bed rails and refusing nursing care.
9. The Client had very thin fragile skin and bruised easily.

Allegation 1 - Failure to maintain the standards of practice

10. The Member and a co-worker RPN were assigned to care for all of the residents on the night shift on the Unit from 2330 hours to 0730 hours the next morning.
11. During their 0500 hour rounds, the Member and RPN entered the Client's room to find the Client trying to climb out of bed. One of his feet was between the space in the bed rails.
12. When they approached his bedside and assisted him back into bed, they noted that the Client had taken off his attends diaper and was covered in feces. The Client began to yell and kick out at the nurses.
13. The Member and RPN decided to leave the Client for a short while to see if he would calm down. In the interim, they assisted several other residents and completed their care.
14. Upon returning to the Client, the Member and RPN found the Client with his leg placed over the side rail of his bed. He remained agitated.
15. The Member and RPN decided to clean the Client and place him in his chair beside the bed. The Member held the Client on his right arm and leg and turned him towards her in order to allow the RPN to clean one side of his back and buttocks. The Client resisted aggressively, kicking and pulling his arm away. The Member did not release her grip.
16. When the Member and RPN placed the Client in his chair, they noted a superficial skin tear on his arm. They applied normal saline and a transparent occlusive dressing to the area. The Client did not indicate that he was in any discomfort and eventually became less agitated and then calm.
17. At the Member's direction, the RPN documented the following in the Interdisciplinary Progress Notes of the Client's health record.

"Pt. Incont. Of urine faeces. 2 nurses trying to changes attend. Pt. Pulling and kicking causes skin tear to left hand when trying to hold his hands. Cleanse, opsite applied".

18. The Member reported to the oncoming shift that the Client had skin tears due to his aggressive and agitated behaviour and that Opsite had been applied to the area.
19. Following concern expressed by the day nurse about the skin tears and bruises the Client had, the Client Care Manager of the Unit conducted a full investigation in which the Member admitted that she held the Client too tightly and expressed remorse that the Client sustained skin tears and bruising.
20. The Member admits that her conduct amounts to professional misconduct as set out in allegation 1 of the Notice of Hearing in that she failed to meet the standards of practice of the profession with respect to her care of the Client by holding him too tightly while attempting to provide care to him, resulting in skin tears and bruises.

Allegations 2 and 3

21. The College tenders no evidence with respect to these allegations.

Investigation and follow-up by Client Care Manager

22. The Client Care Manager conducted her investigation and provided the Member with a letter of performance expectations. The expectations, as listed below, have been successfully completed by the Member:
    • To meet with the Professional Practice Leader for Nursing at Sunnybrook HSC to review the incident and discuss alternative approaches to deal with the situation;
    • To apply the principles of client-focussed care when assigned to residents with cognitive impairment;
    • To adjust her approach to cognitively impaired residents based upon the resident's behaviours, emotional state and mood; and
    • To ensure that the approaches taken with residents involve minimal risk to the residents.

The Member met with the Professional Practice Leader as well as reviewed articles and videos in order to meet the above-listed expectations.

Finding of Professional Misconduct

The panel unanimously finds the Member committed an act of professional misconduct as set out in allegation #1 in the Amended Notice of Hearing. In particular, the panel finds that the Member failed to meet the standards of practice of the profession with respect to her care of the Client by holding him too tightly while attempting to provide care to him, resulting in skin tears and bruises, and that her conduct in this regard amounts to professional misconduct.

Joint Submission on Penalty

A Joint Submission on Penalty was tendered by both counsel for the College and counsel for the Member. It provides as follows:

WHEREAS the Member has provided the Director of Investigations and Hearings with the attached Undertaking, 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 attend before the Discipline Committee for an oral reprimand.

Undertaking

TO: Director, Investigations & Hearings College of Nurses of Ontario

I , [the Member], hereby undertake the following:

To meet with a Professional Practice Consultant from the College of Nurses of Ontario to discuss the incident, from which specified allegations of professional misconduct were referred to the Discipline Committee and to review the standards applicable to that incident.

Counsel for the College made submissions regarding publication of the Member's name. She reviewed with the panel sections of the Regulated Health Professions Act which state the following:

Section 56(1)

The College shall publish a panel's decision and its reasons, or a summary of its reasons, in its annual report and may publish the decision and reasons for summary in any other publication of the College.

Section 56 (2)

In publishing a decision and reasons or summary under subsection 1, the College shall publish the name of the Member who was the subject of the proceeding if,

1. The results of the proceeding may be obtained by a person from the register; or
2. The member requests the publication of his or her name.

Section 23(3)

A person may obtain, during normal business hours, the following information contained in the register:

3. The results of every disciplinary and incapacity proceeding completed within six years before the time the register was prepared or last updated,
   1. in which a member's certificate of registration was revoked or suspended or had terms, conditions or limitations imposed on it, or
   2. in which a member was required to pay fine or attend to be reprimanded or in which an order was suspended if the results of the proceeding were directed to be included in the register by a panel of the Discipline or fitness to Practise Committee.

The College counsel advised that in this case if the Joint Submission on Penalty is accepted, publication of the Member's name is in the discretion of the panel.

The College counsel and the Member's counsel submit that the Act does not require publication of the Members' name and it is not appropriate in this case. Both counsel asked the panel to make an order on terms as set out in the Joint Submission on Penalty.

Decision

The panel accepted the Joint Submission on Penalty. The Joint Submission on Penalty requires that the Member receive an oral reprimand. The panel accepted the Member's undertaking to meet with a Professional Practice Consultant from the College of Nurses of Ontario. The panel found that the publication of the Member's name was not appropriate. Accordingly, the panel directs that the results of this proceeding not appear in the public portion of the register.

Reasons for Decision

The Member had been a Registered Nurse with a long and unblemished professional record. This was an isolated incident occurring without any intent to harm the client in her care. The incident was reported to the next shift of staff. She fully cooperated with her employer and with the investigation by the College of Nurses of Ontario. The Member demonstrated remorse and has successfully completed remedial performance expectations as set out by her employer prior to this hearing. The publication of the actual decision without the Member's name serves the public interest by educating the profession as to the standard of conduct which is expected of the members of the College.

This order takes effect August 22, 2000.

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