PUBLISHED JUNE 2002

Note: This is the full text of the decision of the Discipline panel in this matter. Any information identifying clients, witnesses or facilities has been removed [ ]. The member’s name is omitted if the allegations have been dismissed or if the results are not placed on the public portion of the Register.

Panel:

Marsha Taylor, RPN Chairperson Jo-Ann Marr, RN Member Kay Wetherall Public Representative Bill Weichel Public Representative

BETWEEN

COLLEGE OF NURSES OF ONTARIO Michelle Fuerst for College of Nurses of Ontario

and -

FRANCINE METCALF #GI-0858-5

DECISION AND REASONS

Elizabeth McIntyre for Francine Metcalf

Heard: September 13, 2001

This matter came on for hearing before a panel of the Discipline Committee on Thursday, September 13, 2001at the College of Nurses of Ontario at Toronto.

The Allegations

The allegations against Francine Metcalf as stated in the Amended Notice of Hearing (Exhibit #1) dated August 24, 2001 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 May 9, 1999 while working as a Registered Practical Nurse at the [Psychiatric Hospital], you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession in that you

c. Failed to intervene when one or both of clients “A” and “B” moved furniture so as to block the door of the special observation room; and/or

d. Failed to consult with a Registered Nurse before you suggested that clients “A” and “B” be locked in the special observation room; and/or

e. Failed to consult with a Registered Nurse when one or both of clients “A” and “B” moved furniture so as to block the door of the special observation room; and/or

f. Failed to report to supervisory nursing personnel, and/or the duty doctor, and/or the officer- in-charge that clients “A” and “B” had been locked in the special observation room by staff and that one or both clients had moved furniture so as to block the door; and/or

g. Failed to document the events involving clients “A” and “B” in the clients’ health records.

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 May 9, 1999 while working as a Registered Practical Nurse at the [Psychiatric Hospital], you abused a client or clients physically, in that you

a. Suggested that clients “A” and “B” be locked in the special observation room; and/or

b. Failed to intervene when clients “A” and “B” were locked in the special observation room; and/or

c. Failed to intervene when one or both of clients “A” and “B” moved furniture so as to block the door of the special observation room; and/or

d. Failed to consult with a Registered Nurse before you suggested that clients “A” and “B” be locked in the special observation room; and/or

e. Failed to consult with a Registered Nurse when one or both of clients “A” and “B” moved furniture so as to block the door of the special observation room; 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(7) of Ontario Regulation 799/93, in that on or about May 9, 1999 while working as a Registered Practical Nurse at the [Psychiatric Hospital], you abused a client or clients emotionally, in that you

a. Suggested that clients “A” and “B” be locked in the special observation room; and/or

b. Failed to intervene when clients “A” and “B” were locked in the special observation room; and/or

c. Failed to intervene when one or both of clients “A” and “B” moved furniture so as to block the door of the special observation room; and/or

d. Failed to consult with a Registered Nurse before suggesting that clients “A” and “B” be locked in the special observation room; and/or

e. Failed to consult with a Registered Nurse when one or both of clients “A” and “B” moved furniture so as to block the door of the special observation room; 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 May 9, 1999 while working as a Registered Practical Nurse at the [Psychiatric Hospital], 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

c. Failed to intervene when one or both of clients “A” and “B” moved furniture so as to block the door of the special observation room; and/or

d. Failed to consult with a Registered Nurse before suggesting that clients “A” and “B” be locked in the special observation room; and/or

e. Failed to consult with a Registered Nurse when one or both of clients “A” and “B” moved furniture so as to block the door of the special observation room; and/or

g. Failed to document the events involving clients “A” and “B” in the clients’ health records.

Counsel for the College tendered no evidence with respect to allegations 1(a) through (f), 2(a) through (f), 3(a) through (f), and 4(b), (d), (e), (f) and (g) in the Amended Notice of Hearing.

Member’s Plea

Francine Metcalf admitted to the allegations set out in paragraphs 1 (g), 4 (a) and 4 (c) in the Amended Notice of Hearing. The panel conducted a plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.

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:

Francine Metcalf #GI08585 (“the Member”) graduated from [ ] in 1977. She has been registered as a Registered Practical Nurse with the College of Nurses of Ontario (“the College”) since 1979.
In 1981, the Member began working as an RPN at the [Psychiatric Hospital]. She began working on [the Unit in question] in July 1998, when the Unit opened. [The Unit] is an admission unit for clients suffering from a range of psychiatric illnesses, including personality disorders and depression. On average, the Unit has 19 clients, with a maximum capacity of 25 clients. The Unit utilizes a primary nursing care model.
Client A [ ] was admitted to [the Unit] on May 6, 1999 after she expressed suicidal thoughts and suffered several puncture wounds on her legs after having stabbed herself with scissors. She had a history of psychiatric problems including Depression, Borderline Personality Disorder, and physical and sexual abuse. She remained on the Unit until her discharge on May 19, 1999.
Client B [ ] was admitted to the Unit on May 3, 1999 because of aggressive behaviour and threats to kill other persons. Immediately before her admission she had been involved in a car accident and had injured her back. On admission to the Unit, she expressed thoughts of delusional persecution and grandiosity. She was diagnosed as suffering from Bipolar Disorder in the manic phase with psychotic features. She was difficult to handle on the Unit initially. She was discharged on August 20, 1999.
Both [client A] and [client B] were housed in the Unit’s Special Observation Room for several days up to and including the night shift on May 8-9, 1999. Clients who are unfamiliar to the Unit staff, or who have expressed suicidal ideation or behaviour, or who are unpredictable and potentially aggressive, or who are fearful and require reassurance and proximity to nursing staff, are housed in the Special Observation Room. The Special Observation Room has a frosted window in the entrance door and two large curtained windows directly across the hall from the Nursing Station to permit observation of clients.
On May 8-9, 1999, the Member worked the night shift on the Unit, from 7:00 p.m. on May 8 until 7:00 a.m. on May 9. The three other nurses who also worked that shift were Diane Allingham RN, Vera Malek RN, and David Meinert RPN. Vera Malek was the primary nurse assigned to the care of [client B]. Diane Allingham was the primary nurse assigned to the care of [client A].
During the night shift, [client B] was restless, unable to sleep, demanding and argumentative. She reported being unable to sleep because of her back injury and requested pain medication. She was given Tylenol 650 mg orally at 1:00 a.m., without apparent effect. She refused to follow direction or stay in her room. She refused bedtime sleeping medication.
If Vera Malek were to testify, she would say that, between 9:00 p.m. and midnight, she observed that [client A] appeared to be sleeping and undisturbed by the unsettled behaviour of [client B]. If Diane Allingham were to give evidence, she would say that [client A] had retired by 11:30 p.m. - 12:00 a.m., that between that time and 3:00 a.m. [client A] was in bed and appeared to be resting quietly, and that [client A] did not voice any concerns about being in the Special Observation Room with [client B], despite [client B’s] unsettled behaviour.
At approximately 3 a.m., [client B] attempted to take a bath and refused to get out of the tub. Allingham, Malek and Meinert intervened in an attempt to return [client B] to her room, along with extra staff called for this purpose. At that time [client B] reluctantly accepted Haldol 5 mg orally for agitation, again without apparent effect.
If Vera Malek, Diane Allingham, or David Meinert were to give evidence, they would say that after [client B] returned to the Special Observation Room following the tubroom incident, they observed [client A] in bed, apparently asleep.
The Member went on break until about 4 a.m. and was not on the Unit when the incident in the tubroom occurred.
At around 4:15 – 4:30 a.m. the two RNs, Ms Malek and Ms Allingham, started their breaks. The Member and Mr. Meinert remained on duty on the Unit.
Some time around 5:00 a.m., [client B] again became unsettled and demanding. She was in and out of her room, and refused to return to her room. Extra staff were called to the Unit to assist with placing her in seclusion, however, they were sent back because [client B] agreed to return to her room. She was therefore not placed in one of the specially-designed, securable seclusion rooms the hospital maintains on each unit.
Shortly afterward, [client B] again became unsettled. As a result, the Member suggested that Mr. Meinert “stick the door” of the Special Observation Room, meaning ‘lock the door’. If the Member were to give evidence she would say that she suggested the door be locked in order to interrupt [client B’s] pattern of leaving and re-entering the Special Observation Room. Mr. Meinert locked the door to the Special Observation Room from the exterior, thereby locking [clients A and B] inside together.
The door of the Special Observation Room was locked for approximately 15 minutes. If Mr. Meinert were to give evidence, he would say that when he returned to unlock the door, he was able to see into the Special Observation Room and observed that both clients were in bed and apparently asleep. He would also say that he saw a wardrobe had been pushed up against the door, obstructing it from the inside. The wardrobes (also referred to as “lockers” or “rolling cabinets”) used on the Unit measure approximately 3.5 feet wide by 6 feet high and sit on wheels that allow them to be moved about.
Mr. Meinert took no steps to remove the furniture that was obstructing the door. The Member did not intervene when she learned from Mr. Meinert that that the door of the Special Observation Room had been obstructed with furniture from the inside.
Neither the Member, nor Mr. Meinert made any entry in the health record of either [client A or B] to document the events, including the locking and unlocking of the door, the obstructing of the Special Observation Room, or the clients’ status.
When Diane Allingham, RN, and Vera Malek, RN, returned from their breaks at around 6 a.m., and learned from the Member and Mr. Meinert that the door to the Special Observation Room had been locked, then unlocked, and was obstructed from the inside, neither intervened.
Although she had been on a break from approximately 4:15 to 6:00 a.m., Vera Malek, RN, the primary nurse assigned to the care of [client B] made the following entry in the Multidisciplinary Progress Notes of [client B] for May 9/99, 6:30 a.m., after returning to the Unit from her break:

Nsg Note: No settling effect observed, wouldn’t settle, remained awake, restless +++, numerous trips to bathroom, in and out of her room several times, demanding and argumentative. Eventually barricaded self in her room, placed closet against the door and currently remains in her room. Will report ineffectiveness of prn medication.

Around 7:00 a.m. on May 9, nurses on the day shift came on duty. The door to the Special Observation Room was still obstructed at that time. The day shift received Report, then at around 7:20 a.m., entered the Special Observation Room, with some difficulty, and removed the two rolling wardrobes and the client’s bed they found obstructing the door.
The day shift nursing staff made the following entries in the Multidisciplinary Progress Notes for [client A]:

May 9, 1999

When coming on shift day staff noticed that room was barricaded with the lockers. We entered with some difficulty. [Client A] said she was fearful but didn’t want to say anything to her peer who did the barricading. We removed her peer’s locker and re-emphasized appropriate behaviour. Her peer was silent with no response. [Client A] felt much more at ease with her door open. Will continue to support.

0830

[Client A] is in good spirits. We decided to move her bed in with another peer. This was done to ease [client A’s] anxiety about the potential for being barricaded in her room again. She was very appreciative of the room change.

and the following entry in the nursing notes for [client B]:

May 9, 1999

0720

After hearing report staff had to force [sic]gain entrance to observation room where [client B] had barricaded herself and [client A] in the room. She had used the rolling cabinets in the room to accomplish this. She had also pushed her roommate’s bed up against them. When we went in she was sitting up in her bed. Her eyes were closed and she remained mute. Refusing to offer an explanation for her behaviour. Health teaching done re: appropriate behaviour on the ward. Her roommate voiced being frightened by this act.

Neither [client A] or [client B] suffered any physical injury as a result of the events described above.
If [client A] were to testify, she would say as follows: [client B] had just been in an interaction with the nursing staff after which she returned to the Special Observation Room. [Client B] was very angry about being locked in the Special Observation Room and was pacing around the Special Observation Room. [Client B] told her that she was a paranoid schizophrenic, that she was off her medications, and that she “blew her husband’s head off”, pleaded insanity in order to avoid prison and was subsequently placed in [a psychiatric hospital] for two years. [Client B] also said: “If they are going to lock me in, I am going to lock them out!” and moved two rolling wardrobes and her bed in front of the door. [Client B] yelled at [client A], insisting that she remain awake and not move. During the incident, [client A] was very fearful, unsure of what [client B] was going to do and believed that her life was in danger. She could not see the nurses and no one could see her. Since the incident, [client A] has been very upset about the incident and has had nightmares. She now fears hospitals and would not willingly go back to the [Psychiatric Hospital], or the psychiatric ward of any hospital again.
The Member admits that she has committed professional misconduct in that she:

a. contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, in that she failed to document the events involving clients A [ ] and B [ ] in the client’s health records, as set out in allegation 1(g) of the Notice of Hearing, and

b. 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 she

i. suggested that Clients A [ ] and B [ ] be locked in the Special Observation Room, as set out in allegation 4(a) of the Notice of Hearing, and

failed to intervene when she learned that one or both of Clients A [ ] and B [ ] had moved furniture so as to block the door of the Special Observation Room from opening, as set out in allegation 4(c) of the Notice of Hearing.

Decision

The panel considered the Agreed Statement of Facts and found that the facts support a finding of professional misconduct and, in particular, found that the Member committed an act of professional misconduct as alleged in paragraphs 1 (g), 4 (a) and 4 (c) of the Amended Notice of Hearing.

Penalty

Counsel for the College tendered no evidence as to penalty at this time. Counsel for the defense tendered 12 letters of reference (Exhibit #3) for the panel’s consideration. The Member gave evidence about the impact of the events on her personal situation and her worklife. The Member described the personal hardship she had endured as a result of these investigations, that her family and personal life had been severely impacted and that she was “ashamed” of her behaviour. Counsel for the College established that the Member had not undertaken any remedial formal education outside of her work place during this time period However, it was established that she had undertaken inservice education.

Counsel for the College made the following submission on penalty:

The College of Nurses of Ontario (“the College”) submits that, in view of the professional misconduct admitted to by the Member in the Agreed Statement of Fact, and the circumstances set out in the Agreed Statement of Fact, the panel of the Discipline Committee should make an order doing the following, such order to become effective when the order becomes final:

Require the Member to appear before the panel to be reprimanded
Direct the Executive Director to suspend the Member’s certificate of registration for one month.
Direct the Executive Director to impose the following terms, conditions and limitations on the Member’s Certificate of Registration:

a. During the 12 month period from the date that the order becomes final, the Member shall complete a course satisfactory to the Director of Investigations and Hearings of the College (“the Director”) in psychiatric nursing assessment, or an equivalent course as approved by the Director in advance;

b. During the 12 month period referred to in (a) above, the Member shall view the abuse prevention video One is One Too Many and meet with a Nursing Practice Advisor to discuss the video; and,

c. During the 12-month period referred to in (a) above, the Member shall, at 6 month intervals, provide the Director with a total of two written performance reports prepared by the employer.

Defense Counsel argued against the panel’s acceptance of the College’s proposal on penalty.

Defence counsel presented argument against one component of the College proposed penalty, the one- month suspension of the Member’s Certificate of Registration. She also argued the suspension would serve little towards rehabilitation of the Member and reminded the panel of the Member’s work place suspension following its initial investigation. Counsel further stated the Member’s agreement to the remainder of the penalty.

Penalty Decision

The panel, after considering the submissions of counsel on penalty, unanimously determined that the appropriate penalty consist of:

Require the Member to appear before the panel to be reprimanded
Direct the Executive Director to impose the following terms, conditions and limitations on the Member’s Certificate of Registration:

b. During the 12 month period referred to in (a) above, the Member shall view the abuse prevention video One is One Too Many including completion of the workbook, and meet with a Nursing Practice Advisor to discuss the video; and

c. During the 12-month period referred to in (a) above, it will be the responsibility of the Member, at 6 month intervals, to provide the Director with a total of two written performance reports prepared by the employer.

The panel concluded that this penalty is reasonable and in the public interest. It addresses a general deterrence for the profession and remediation for the Member. The Member has co-operated with the College, agreed to the facts, has accepted responsibility for her actions and is remorseful and regretful. The Member has greater than 20 years of experience without incident. The panel determined that a suspension was not warranted and that the Member’s actions could be best addressed through remediation.

I, Marsha Taylor, 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 as listed below:

____________________, Chairperson Date Jo-Ann Marr, RN

Kay Wetherall, Public Representative Bill Weichel, Public Representative

College of Nurses of Ontario v. Metcalf, 2001 ONCNO 62542

Case Summary

Panel:

DECISION AND REASONS

The Allegations

Member’s Plea

Agreed Statement of Facts

Decision

Penalty

Penalty Decision