College of Nurses of Ontario v. The Member, 2000 ONCNO 50769

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: September 15, 2000

DECISIONS AND REASONS

This matter came for hearing before a Panel of the Discipline Committee on September 15th, 2000 at the College of Nurses of Ontario at Toronto.

The Allegations

The allegations against The Member as stated in the Notice of Hearing (Exhibit #1) dated August 17, 2000, are as follows:

IT IS ALLEGED:

1. You have committed an act or acts 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, while employed as a Registered Nurse at the Hospital for Sick Children, Toronto, Ontario, you contravened the standard of practice of the profession or failed to meet the standard of practice of the profession with respect to the following incidents:
   1. communication with [name] regarding a bomb threat on or about [date], 1999; and/or
   2. administration of morphine to a client, Client A, instead of codeine and/or failure to document administration of morphine, on or about [date], 1998; and/or
   3. failure to administer calcium carbonate and/or prednisone to a client, Client B, and/or failure to advise other staff that the medication had not been administered, on or about [date], 1998; and/or
   4. communications with the parent of a client, Client C, with respect to diagnosis or possible diagnosis of the client on or about [date], 1998; and/or
   5. leaving an intubated client, Client D, unattended in the resuscitation room on or about [date], 1998.
2. You have committed an act or acts 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, while employed as a Registered Nurse at the Hospital for Sick Children, Toronto, Ontario, you engaged in conduct or performed acts, relevant to the practice of nursing, that, having regard to all of the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional with respect to the following incidents:
   1. communication with [name] regarding a bomb threat on or about [date], 1999; and/or
   2. administration of morphine to a client, Client A, instead of codeine and/or failure to document administration of morphine, on or about [date], 1998; and/or
   3. failure to administer calcium carbonate and/or prednisone to a client, Client B, and/or failure to advise other staff that the medication had not been administered, on or about [date], 1998; and/or
   4. communications with the parent of a client, Client C, with respect to diagnosis or possible diagnosis of the client on or about [date], 1998; and/or
   5. leaving an intubated client, Client D, unattended in the resuscitation room on or about [date], 1998.

Counsel for the College advised the Panel that the College was not calling any evidence with respect to allegations 1a) and 2, in its entirety, as set out in the Notice of Hearing.

Agreed Statement of Facts

Counsel for the College advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts (Exhibit #2) which provided as follows:

The Member

1. The Member received her Bachelor of Nursing Science from Queens University in 1992, at which time she became a member of the College.
2. The Member has participated in continuing education at Queen;s, McMaster and Ryerson Universities, receiving several certificates in Emergency, Pediatric and Nephrology Nursing.
3. The Member worked at the Hospital for Sick Children (the Hospital) in the Emergency, Multi-organ Transplantation, Nephrology, G.I., Rheumatology and Urology Departments from April 1994 until May 1999 when she was terminated from her position. In addition to her clinical duties, between February and October 1998, the Member worked as a research assistant at the Hospital.
4. Since July 1999, The Member has been working as an agency nurse in the Emergency Department of the North York General Hospital.
5. At the time of the incidents described below, The Member was working an average of 45 hours per week as a casual staff nurse in the Emergency department and on Unit 6A.
6. The member has been in treatment with a psychiatrist since October, 1997. The psychiatrist's diagnosis of the Member is major depressive disorder, recurrent (in remission as of October, 1999) and dysthymic disorder, early onset. The treatment plan involves psychotherapy and pharmacotherapy. The psychiatrist reported in October, 1999 that the Member was complying with his treatment recommendations. He also reported, on the basis of his observations in his sessions with her, that he did not question the Member's sense of responsibility and commitment or her ability adequately to function in the job entailing the responsibilities of a registered nurse.

The Facility

7. The Hospital is an acute care facility with approximately 500 beds providing care for children.
8. Unit 6A treats clients with Nephrology, GI/Nutrition, Rheumatology and Transplant diagnoses.

Allegation 1(b) - Failure to maintain the standards of practice with respect to the administration of Morphine

9. Client A was a six year old boy admitted to Unit 6A on [date] 1998 with an erythematous left leg secondary to Nephrotic Syndrome. The physician had ordered Codeine 15 mg by mouth every four hours for pain when necessary.
10. Three days later the Member was assigned to care for Client A. It was a busy floor and the Member had a greater than average client assignment.
11. At approximately 1420 hours the Member incorrectly administered Morphine syrup to Client A
12. The Member charted on the Narcotic and Controlled Drug Administration Record and Audit that she had removed 3 mg of Morphine syrup for Client A. On the Medication Administration Record, The Member charted that she had administered Codeine syrup 15 mg.
13. The Member completed an incident report regarding the medication error, stating that the unit was short staffed and that in her rush to administer the medication, she forgot to recheck the medication.
14. The Member admits that her conduct amounts to professional misconduct as set out in allegation 1(b) of the Notice of Hearing in that she failed to meet the standards of practice of the profession with respect to her administration of Morphine syrup rather than Codeine syrup to Client A.

Allegation 1(c) - Failure to maintain the standard of practice with respect to the administration of Calcium Carbonate and Prednisone

15. Client B was a 13 year old boy on Unit 6A with end stage renal disease. The client was scheduled to receive Calcium Carbonate 1500mg and Prednisone 20 mg by mouth three times a day with meals at 0800, 1200 and 1800 hours.
16. On [date] 1998, the Member was assigned to care for Client B on the day shift. At approximately 1200 hours, the Member felt ill and left the Unit.
17. Prior to leaving the Unit the Member did not administer the 1200 hour doses of Calcium Carbonate and Prednisone. The Member failed to effectively communicate to the nurse taking over the care of the client that she had not administered the 1200 hour medications.
18. The Member admits that her conduct amounts to professional misconduct as set out in allegation 1(c) of the Notice of Hearing in that she failed to meet the standards of practice of the profession by failing to effectively communicate to the oncoming nurse that she had not administered the 1200 hour doses of Calcium Carbonate and Prednisone for Client B.

Allegation 1(d) - Failure to maintain the standard of practice with respect to communications with the parent of a client

19. Client C was a seven month old baby admitted on [date], 1998 to Unit 6A, with severe diarrhea and weight loss of unknown etiology.
20. Eight days later, the Member was assigned to care for Client C. At that time, Client C's condition remained undiagnosed.
21. Client C's mother expressed anxiety about the still unknown etiology of her son's condition. The Member spoke with Client C's mother for approximately one hour, discussing possible diagnoses, including telling Client C's mother about other clients with conditions of a similar nature who had required emergency surgery.
22. Following the discussion with the Member, Client C's mother complained to the charge nurse that she experienced increased anxiety and felt overwhelmed by the Member's comments.
23. The Member admits that her conduct amounts to professional misconduct as set out in allegation 1(d) of the Notice of Hearing in that she failed to meet the standards of practice of the profession with respect to her communication with Client C's mother regarding her son's condition.

Allegation 1(e) - Failure to maintain the standard of practice with respect to the care of an intubated client

24. Client D was a five year old boy admitted to the Emergency Department on [date], 1998 with the following diagnoses: seizure disorder - status epilepticus, cervical adenitis and neglect. Client D was neurologically depressed with an insecure airway. He had recently been intubated and was waiting to be transferred to the Pediatric Intensive Care Unit.
25. The Member was assigned to care for Client D while he was in the Emergency Department.
26. At approximately 1930 hours on the day he was admitted, The Member left Client D unattended in the resuscitation room in the Emergency Department for approximately five minutes. Another staff nurse noticed that The Member was not attending to Client D and told her to go back to the resuscitation room and stay with him.
27. The Member admits that her conduct amounts to professional misconduct as set out in allegation 1(e) of the Notice of Hearing in that she failed to meet the standards of practice of the profession with respect to the care she provided to Client D, in particular that she left a five year old neurologically depressed, intubated client unattended.

Allegations 1(a), 2(a), 2(b), 2(c), 2(d) and 2(e) - Disgraceful, dishonourable and unprofessional conduct

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

Member's Plea

By way of the Agreed Statement of Facts, the Member admitted the allegations of professional misconduct as set out in paragraphs numbered 1b), 1c), 1d) and 1e) in the Notice of Hearing. The Panel made its usual "plea inquiry" and was satisfied that the Member's admission was voluntary, informed and unequivocal.

Decision

The Panel considered the Agreed Statement of Facts and finds that the facts support a finding of professional misconduct and, in particular, finds that the Member committed an act of professional misconduct as alleged in paragraphs numbered 1b), 1c), 1d) and 1e) in the Notice of Hearing in that:

1. You have committed an act or acts 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, while employed as a Registered Nurse at the Hospital for Sick Children, Toronto, Ontario, you contravened the standard of practice of the profession or failed to meet the standard of practice of the profession with respect to the following incidents:
   1. administration of morphine to Client A, instead of codeine and/or failure to document administration of morphine, on or about [date], 1998; and/or
   2. failure to administer calcium carbonate and/or prednisone to Client B, and/or failure to advise other staff that the medication had not been administered, on or about [date], 1998; and/or
   3. communications with the parent of Client C, with respect to diagnosis or possible diagnosis of the client on or about [date], 1998; and/or
   4. leaving an intubated client, Client D, unattended in the resuscitation room on or about [date], 1998.

Penalty

Counsel for the College advised that a Joint Submission as to Penalty had been agreed upon. The Joint Submission as to Penalty (Exhibit #3) provides as follows:

1. 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 within three months of the date of this order;
   2. Requiring the Member to meet with a Practice Consultant from the College to review the standards on medication administration and communication as well as the Explanation of Professional Misconduct;
   3. Requiring the Member to continue to see her psychiatrist, or other psychiatrist, for treatment as required.

Counsel for the Member advised the panel that the Member would be prepared to accept an oral reprimand as provided in the Joint Submission on Penalty immediately following the conclusion of the hearing.

Penalty Decision

The Panel deliberated. The Panel sought advice from Independent Legal Counsel (ILC) regarding some administrative implications arising out of paragraphs 1a) and 1c) as set out in the Joint Submission on Penalty. ILC advised the Panel to seek further submissions from both Counsel.

Both Counsel made further submissions.

The Panel accepts the Joint Submission as to Penalty and accordingly orders:

1. 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 within three months of the date of this order;
   2. Requiring the Member to meet with a Practice Consultant from the College to review the standards on medication administration and communication as well as the Explanation of Professional Misconduct;
   3. Requiring the Member to continue to see her psychiatrist, or other psychiatrist, for treatment as required.

The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has cooperated with the College and, by agreeing to the facts and a proposed penalty, has avoided unnecessary expense to the College and the public

I, [ ], sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members o[f] the Discipline panel as listed.