College of Nurses of Ontario v. [The Member], 2006 ONCNO 81725

PANEL: Joanne Furletti, RN Chairperson Deirdre Armstrong, RN Member Rosalie Woods, RPN Member Faira Bari Public Member Karen Harder Public Member

BETWEEN:

MEGAN SHORTREED for COLLEGE OF NURSES OF ONTARIO

and - DAVID MATHESON for [The Member]

[MEMBER] Registration No. [ ]

PAUL LEVAY and CHRISTOPHER WIRTH Independent Legal Counsel

Heard: September 11, 12, 13 and 14, 2006

DECISION AND REASONS

This matter came on for hearing before a panel of the Discipline Committee on September 11, 12, 13 and 14, 2006 at the College of Nurses of Ontario (the “College”) at Toronto.

The Allegations

The allegations against [the Member] as stated in the Notice of Hearing dated June 27, 2006, 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(8) of Ontario Regulation 799/93, in that while employed as a [ ] Nurse by [the Hospital], you misappropriated property from your workplace, and in particular:

a. on or about November 28, 2003, you misappropriated Demerol from your workplace; and/or

b. on or about December 26, 2003, you misappropriated morphine on one or more occasion from your workplace.

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 while employed [at the Hospital], 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, and in particular:

a. on or about November 28, 2003, you misappropriated Demerol from your employer and/or falsified documentation and/or inaccurately documented a narcotic count; and/or

b. on or about December 26, 2003, you misappropriated morphine on one or more occasions from your workplace; and/or

c. on or about December 26, 2003, you removed one or more ampoules of Morphine from the narcotic cupboard and failed to properly document its removal and use; and/or

d. on or about December 26, 2003, you altered and/or falsified the Morphine count on a narcotic record; and/or

e. on or about December 26, 2003, you documented administering 5 mg Morphine IV push to a client when you had not administered the Morphine to the client; and/or

f. on or about December 26, 2003, you put a syringe labeled as containing Morphine in a patient chart slot when the syringe did not contain morphine.

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 while employed [at the Hospital], you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, and in particular:

a. on or about November 28, 2003, you failed to meet the standards of practice with respect to your handling, documentation and administration of Demerol;

b. on or about December 26, 2003, you failed to meet the standards of practice with respect to your handling, documentation and administration of Morphine.

Member’s Plea

The Member denied the allegations set out in the Notice of Hearing.

Overview

The Member is a Registered Nurse who graduated from [ ] College in April 2002. The Member has been employed as a [ ] Nurse by [the Hospital] ever since graduating in the spring of 2002, until [the Member] resigned in February 2004. He started working on an [ ] unit [ ] for approximately one year and a half before transferring to [the Unit], in September 2003. The College received a letter from the Member’s employer in January 2004 reporting suspected allegations of professional misconduct while employed in [the Unit], specifically on the dates of November 28, 2003 & December 26, 2003. The issues are as follows:

Did the Member misappropriate narcotics from the workplace?
Did the Member misappropriate narcotics, falsify documentation and/or fail to administer Morphine to a client?
Did the Member fail to meet the standards of practice with respect to handling, documenting and administrating narcotics?

Witness # 1 – [RN A]

Counsel for the College presented [RN A], as its first witness. [RN A] indicated that she was a Registered Nurse who graduated in 1998. She has been employed at [the Hospital] since 1999 and has worked in [the Unit] since 2001.

[RN A] testified she worked in [the Unit] in the fall of 2003. She stated that she knew the Member and had worked with [the Member]. She was aware of issues around narcotics going missing in the department, but was not aware of how or why they went missing. She stated that on the night shift of December 26, 2003, she witnessed the Member take an ampoule of ‘medicine’ from the narcotic cupboard and witnessed [the Member] throw out an empty package. She reported this immediately to the nurse in charge, [RN B]. She also reported this to her manager, [Manager A]. She made anecdotal notes after completing her shift that night at the direction of her manager; [RN A] had to rely on her anecdotal notes in giving her testimony related to the events on December 26, 2003 (Exhibit #1, Tab 2).

The panel agreed that [RN A’s] testimony was not convincing to find the Member guilty of the allegations before the panel in that her evidence did not clearly convince the panel that the Member had in fact misappropriated narcotics.

Witness # 2 - [RN B]

Counsel for the College presented [RN B] as its next witness. [RN B] indicated that she was a Registered Nurse who graduated in 1972. She has been employed at [the Hospital] in [the Unit] since 1973.

[RN B] testified that she worked with the Member on December 26, 2003. She received a report at 2015 hours from [RN A] regarding an alleged misappropriation of a narcotic by the Member. She testified that [RN A] told her that she saw the Member “at the narcotic cupboard”. She further testified that [RN A] had shown her the narcotic count sheet on that shift and the Morphine 15 mg had been altered visibly altered from 11 to 10.

The panel found that the testimony with regards to the misappropriation was hearsay because [RN B] was not present and could not give a detailed report. The panel acknowledges that [RN B’s] testimony corroborates the fact that the narcotic record was incorrect and had been altered. She could not give evidence as to how, who, why, and when the narcotic record was altered. The panel could give little weight to her testimony.

Witness # 3 - [The Shift Manager]

Counsel for the College presented [the Shift Manager] as its next witness. [The Shift Manager] indicated that she has been a Registered Nurse with the College since 1984. Prior to being registered with the College she also practiced as a nurse in [another country]. She has been employed at [the Hospital] in [the Unit] since May 1985, and became a shift supervisor in May 2003.

[The Shift Manager] testified that she was the shift manager on the evening of December 26, 2003, in which the Member was allegedly engaged in two incidents involving misappropriation of Morphine, failure to document and administer a narcotic as ordered. Furthermore, it was reported to [the Shift Manager] by [the Charge Nurse] in ER that shift, that [RN A] had seen the Member take something out of the narcotic cupboard. [The Shift Manager] became aware of the allegations when she was paged by [the Charge Nurse] just prior to 2200 hours.

[The Shift Manager] paged her manager, [ ] to make her aware of the allegations against the Member and she was instructed to meet with everyone involved from [the Unit] immediately that evening. [The Shift Manager, Charge Nurse and RN A] first met in the scheduling room and reviewed the incidents in question, which were misappropriation of narcotics, altered documentation, and failure to administer Morphine. [The Shift Manager] then spoke to [Manager A], and [ ], the hospital manager and was advised to contact the [ ] Police precinct. She contacted the Police and spoke with the Sergeant on call. The Police decided not to get involved and advised the hospital to deal with it internally. A second meeting was subsequently held with [the Shift Manager], [the Charge Nurse], [RN B], two hospital security guards and the Member, in [Manager A’s] office. [The Shift Manager] testified that the Member was questioned in regard to the incidents and the hospital decided to send [the Member] home.

[The Shift Manager] testified that the syringe in question on this particular shift, which the Member had allegedly left in the patient’s chart, had been confiscated by [the Charge Nurse] and [RN B] after the Member was escorted out of the building. The alleged syringe was locked up in a sealed envelope in [Manager A’s] office.

This witness was credible, but her testimony did not carry a lot of weight as she was not directly involved in the incidents. Furthermore in regard to the incident with the syringe on this particular shift, the panel concluded that one cannot make the conclusion that the syringe secured that evening was the actual syringe that the Member had left in the patient’s chart. The syringe had been unsupervised for the duration of the meeting with the Member, [The Shift Manager], [the Charge Nurse],[ RN B] and the two hospital security guards.

Witness # 4 – [Manager A]

Counsel for the College presented [Manager A] as its next witness. [Manager A] indicated that she had been a Registered Nurse since 1987. She worked at [the Hospital] from 1991 to 1993 as staff nurse on a surgical unit, from1993 to 2001 as a staff nurse in [the Unit] and from 2002 to 2005 as [a Unit] manager. She is currently working as a Director at another facility.

[Manager A] was made aware by [RN A] of the alleged incident on November 28, 2003, regarding the Member. She didn’t follow-up at that time. She was aware of discrepancies in narcotic counts in [the Unit] since the fall of 2003, and had implemented 4 hour counts (Exhibit #4) to tighten up control. Prior to this new practice in narcotic counts, narcotics were counted only every 12 hours. In cross-examination [Manager A] admitted that even though she had implemented this change in practice, she was aware that staff was not diligent in adhering to this expectation.

[Manager A] testified that narcotics were kept in two places, in the [ ] room and in the nurses’ station, in a double-locked cupboard. Each location had its own keys. The expectation was that the nurse in charge would carry the keys, and she admitted that this practice was not being followed. Furthermore, she admitted, narcotic counts and wastages must be done and signed by two nurses. She admitted this was not being done.

[Manager A]was notified at home by [the Shift Manager] of the incidents of December 26, 2003 with regards to the Member. She made the decision to have [the Shift Manager] interview the Member immediately and to suspend [the Member] for the remainder of [the] shift and pending investigation.

Upon return to work on December 29, 2003, [Manager A] located the syringe that had been locked up in her office on December 26th when it was alleged that the Member misappropriated Morphine. She sent the syringe to pharmacy to be analyzed and it was subsequently, found to contain only normal saline.

During the week of December 29, 2003, after consultation with Human Resources (HR), a meeting was set up between the Member, HR, [Manager A] and the union representative. The Member was given a three day suspension. Subsequent to this meeting, the Member requested a leave of absence, which was granted. [Manager A] reported the Member to the College in January 2004. The Member submitted a letter of resignation to the hospital on February 2, 2004.

The panel found this witness to be credible but we did not put much weight on the evidence she provided because it did not support or disprove the allegations. She appeared to have no personal interest in the outcome especially given the fact that she is no longer employed at the organization in question.

Witness # 5 – [The Charge Nurse]

Counsel for the College presented [the Charge Nurse] as its next witness. [The Charge Nurse] has been a Registered Nurse since 1976. She has worked most of her career at [the Hospital] and has been the [the Unit] since 1985. She currently works in the pre-assessment but worked in the [the Unit] in 2003 when the Member was working.

[The Charge Nurse] was the nurse in charge on the evening of December 26, 2003. She testified that she knew the Member but only worked with [the Member] a few times. [The Charge Nurse] testified that she was aware of reported narcotic discrepancies occurring in the unit and that these discrepancies had been occurring since September 2003. She testified that she did not observe anything unusual about the Member when she worked with [the Member].

[The Charge Nurse] testified that she worked an evening shift with the Member on December 26, 2003. She stated that she ended up extending her shift for four hours that particular evening. She stated that the Member had worked in the [ ] area, which is right in front of the nursing station on that particular shift. [ ].

[The Charge Nurse] testified that she had done the narcotic count for injectables with [RN B] at 1930 hours and recalls that she was the counter and [RN B] was the recorder (Exhibit # 1; tab 5). [The Charge Nurse] testified that she counted 11 ampoules of Morphine 15mg/1ml, specifically 10 ampoules in one package and 1 ampoule in another package. [The Charge Nurse] could not recall doing the oral and topical narcotic count at the same time but in reviewing the narcotic count for oral and topical medications (Exhibit # 1; tab 7) it is evident that she had counted but neither the date, time nor the signature of the nurse she had counted with was documented. She stated that the person must have forgotten. [The Charge Nurse] further testified that when she had done the narcotic count at 1930 hours, there were no empty narcotic packages in the cupboard. She further testified that approximately 10 minutes after the count at 1930 hours the recording on the narcotic sheet had been changed from 11 to 10. She testified that she did not know who altered the narcotic count.

[The Charge Nurse] testified that usually the charge nurse was the one who had the narcotic keys but she did not have the keys when she went for dinner break at approximately 1950 hours that evening. She stated that either [RN A] or [RN B] had them. In reviewing the oral narcotic administration sheet she testified that two Tylenol # 3 had been taken out by the Member but could not tell who had the keys and who had given the Member the keys.

[The Charge Nurse] testified that when she returned from her dinner break, she did review the patient records in the holding area to see if anyone had been given Morphine injection. No Morphine had been ordered or given to these patients. She tried to contact [Manager A] but was not able to reach her immediately so she contacted [the Shift Manager] and made her aware of the incident. [The Shift Manager] took a few hours to get back to her so she did her regular charge duties in the mean time. [The Charge Nurse] testified that she stayed overtime that evening in order to attend a meeting with the Member and management which took place after midnight. [The Charge Nurse] testified that she had to wait for the Member before accompanying [the Member] to the meeting because [the Member] was administering intravenous Morphine to a young patient being worked up for possible appendicitis. She observed the Member giving the medication directly using intravenous push. She stated that her practice was usually to hang the medication in a mini bag. Then she testified that she saw the Member put the syringe with the remaining Morphine in the patient’s chart (Exhibit # 5).

[The Charge Nurse] then accompanied the Member to [Manager A’s] office where the administrative meeting took place. The meeting lasted approximately 45 minutes. Attendees included herself, the Member, two security guards and [Manager A]. During the meeting, both security guards and [Manager A] talked with the Member. The Member stated that [the Member] found an empty package in the narcotic cupboard and threw it out. Security escorted the Member out after [the Member] retrieved [the Member’s] bag at the nursing station.

[The Charge Nurse] testified that after the meeting she and [RN B] decided to retrieve the syringe the Member used to administer the Morphine, which [the Member] had left in the patient’s chart and lock it up in [Manager A’s] office. She testified that she had a poor recall of the actual sequence of events after retrieving the syringe but remembers that the syringe had an orange medication label and that there was 5 cc of clear fluid remaining in the syringe. She testified that the label on the syringe included the patient’s name, the medication name, the Member’s signature, the date and time.

[The Charge Nurse] testified that she had no further incidents to report for the evening of December 26, 2003. She was interviewed after that evening by the hospital’s administration and the union. She testified that there were no further narcotic discrepancies after this incident on this particular shift.

The panel found this witness to be credible in that she had no vested interest in the outcome of the hearing. She appeared honest and forthright in her testimony; however, she was not directly involved in the alleged incidents. Furthermore, [the Charge Nurse’s] testimony could not support the allegations made by Counsel for the College that the Member misappropriated Morphine and failed to handle, document and administer Morphine to a patient on December 26, 2003, because the evidence she provided was all hearsay except for the telephone conversation and meeting after the allegations.

Witness # 6 – [RN C]

Counsel for the College presented [RN C] as their next witness. She has been a practicing Registered Nurse since 1990. [RN C] started her career working in surgery for 3 years, thereafter moving into [ ] nursing which she has been in for the last 13 years. She currently works in [the Unit] at [the Hospital] and has been for the past 7 years. She testified that she knew the Member and worked with him a few times a week. She also testified that she was aware of issues around narcotic control in the unit in the fall of 2003. She testified that the unit had implemented a practice of doing narcotic counts every four hours at the end of October 2003 because of the poor narcotic control issues on the unit.

[RN C] testified that the only thing she noticed about the Member’s appearance and demeanour is that [the Member] always carried a back pack to work, wore a fanny pack during the course of [the Member’s] shift and that [the Member] took frequent breaks alone. She testified that [the Member] never sat with them in the lounge for his breaks and was always drinking coffee.

[RN C] testified that on November 28, 2003 both the Member and she were working a day shift. She was scheduled a 12 hour shift and the Member was scheduled an 8 hour shift which he ended up extending for a twelve hour shift. [RN C] testified that she and the Member did the narcotic count at 1500 hours. She did the counting and the Member did the recording.

[RN C] then went on to testify that at approximately 1915 hours an ampoule of Demerol 100mg had gone missing after another shift count at 1902 hours with the Member and [RN D]. [RN C] testified that she went to the nurses’ station and saw the Member and [RN D] counting narcotics for the end of the shift. She testified that the Member had been standing on a stool doing the count and [RN D] was the recorder on the count sheet. Furthermore, she testified that the count had been interrupted by a personal telephone call that [RN D] had received. The Member waited for [RN D] to return to the count but while [the Member] was waiting she testified that she noticed [the Member] to be shuffling with the pink boxes in the narcotic cupboard. [RN D] returned and completed the narcotic count with the Member.

[RN C] gave evidence that after the Member and [RN D] counted she instinctively went back and double checked the count herself specifically the packages in which the Demerol ampoules were housed. She testified that she looked at each Demerol package only to find that the pink package which previously had 8 ampoules when she did shift count at 1530 hours now only had 7 ampoules (Exhibit # 1; tab 17). She asked the Member if [the Member] noticed there was an ampoule missing when [the Member] did the count. The Member testified that [the Member] had noticed that there were two packages of Demerol with the elastic band around them to keep them together and that [the Member] had not removed the elastic, so [the Member] had not noticed if there was an ampoule missing.

Following this incident, [RN C] asked all the nursing staff and the physicians if they had used Demerol 100mg between 1530 and 1930 hours. All staff and physicians denied using or ordering Demerol. [RN C] testified that the Member had asked her if [the Member] should stay because of the discrepancy in the narcotic count and she [replied the Member] didn’t have to stay because [the Member’s] shift was over and that the staff would figure it out. [RN C] notified her manager [Manager A] of the incident.

[RN C] testified in cross-examination that even though she had a clear view of the Member at the narcotic box, at no time did she see [the Member] open the boxes of ampoules. [RN C] testified that even though she had not actually witnessed [the Member] taking the ampoule out of a box that the Member hypothetically could have easily opened the package without anyone noticing.

The panel considered [RN C’s] testimony and found that they could not give it much weight given the fact that she did not have opportunity to observe the Member yet she could only make inferences as to what actually happened on November 28, 2003. Furthermore, [RN C’s] demeanour was bold and defensive during her testimony while being cross examined.

Witness # 7 – [RN D]

Counsel for the College presented [RN D] as the next witness. She has been a Registered Nurse since 1995 and has worked in [the Unit] at [the Hospital] since May 2000. Currently she is on maternity leave. She testified that she knew the Member but not very well.

On November 28, 2003 she worked a twelve hour day shift with the Member. She testified that she did the narcotic count at 1900 hours at the end of the shift with the Member. [RN D] testified that the Member was doing the counting and that she was the recorder. She further testified that the count had been interrupted by her receiving a personal phone call which only lasted a couple of minutes and the Member waited for her to complete the count.

In cross-examination [RN D] testified that she couldn’t recall what she did after the narcotic count. She did testify that she remembered [RN C] telling her that the narcotic count was wrong. She testified that [RN C] and herself recounted the Demerol ampoules but couldn’t recall anything unusual including the specifics with regard to how many ampoules were in each package or what colour the Demerol packages were, only that the count was wrong.

The panel did not give much weight to the witness’s evidence because her recall around redoing the count with [RN C] was vague and couldn’t recall how many ampoules were in each package of Demerol and if the packages were different colours.

Witness # 8 – [The Member]

Counsel for the Defence presented the Member as his first and only witness.

The Member testified that [the Member] had never been the subject of a complaint before the College until the allegations facing [the Member] today. Furthermore, [the Member] had no previous discipline issues with an employer.

The Member worked on [the previous unit] prior to being transferred to [the Unit]. The Member testified that [the previous unit] stocked more narcotics compared to [the Unit]. While employed on [the previous unit] the Member testified that there had been no narcotic discrepancies during the year and a half that [the Member] worked there.

The Member testified that on November 28, 2003, [the Member] was scheduled to work an eight-hour day shift but was asked to extend [the] shift by four hours which was not an unusual occurrence. [The Member] testified that [the Member] had done the narcotic count with [RN D] at the end of the twelve hour day shift and was aware of the narcotic discrepancy for this particular count. [The Member] testified that [the Member] had asked [RN C] if [the Member] should stay as a result of the discrepancy and she said no and that [the Member] could go home.

The Member testified that on December 26, 2003, that there were two incidents for which [the Member] was falsely accused. The first incident concerned misappropriation of Morphine, which he testified he was falsely accused. The Member testified that [the Member] found an empty Morphine package in the narcotic cupboard. [The Member] removed the empty package and threw it out while getting two Tylenol #3 tablets from the narcotic cupboard for a patient. [The Member] testified that in retrospect [the Member] should have made the charge nurse aware of the empty package because it was unusual.

In regard to the allegations involving the failure to administer and document Morphine to a patient, the Member testified [the Member] followed the standards and unit practice. The Member testified that [the Member] had administered Morphine to the patient [ ] as ordered and documented such. The practice in the holding area regarding the administration of injectable narcotics was to give the patient the injectable narcotic as ordered and if there was narcotic remaining in the syringe that the syringe was kept in the patient’s chart, which the Member did.

The Member testified that after administering Morphine to [the patient], [the Member] was escorted to [the Charge Nurse’s] office for a meeting with [the Charge Nurse, the Shift Manager] and two security guards. [The Member] testified that during the meeting [the Member] was asked if [the Member] had misappropriated narcotics and [the Member] denied all allegations. [The Member] was escorted off the property and did not complete [the Member’s] shift.

The panel found the witness to be confident and sincere in [the Member’s] testimony. [The Member’s] testimony was clear, cogent and concise.

Decision

The College bears the onus of proving the allegations in accordance with the standard of proof which the panel is familiar with, set out in Re: Bernstein and College of Physicians and Surgeons of Ontario (1977) 15 O.R. (2d) 477. The standard of proof applied by the panel, in accordance with the Bernstein decision, was a balance of probabilities with the qualification that the proof must be clear and convincing and based upon cogent evidence accepted by the panel. The panel also recognized that the more serious the allegation to be proved, the more cogent the evidence must be.

The panel deliberated and having considered the evidence and the onus and standard of proof, was unanimous in their opinion that the Member was not guilty of the allegations set out against [the Member] in the Notice of Hearing and finds that the Member:

did not commit 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(8) of Ontario Regulation 799/93, in that while employed as a [ ] Nurse by [the Hospital], in that [the Member] did not misappropriate narcotics from [the] workplace, as specified in allegations 1(a) and (b), 2 (a) and (b);
did not commit 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 [Nurse at the Hospital, the Member] did not engage in conduct or perform 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, as specified in allegations 2 (a), (b), (c), (d), (e), (f);
did not commit 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 while employed as a [Nurse at the Hospital, the Member], did not contravene a standard of practice of the profession or fail to meet the standards of practice of the profession, and specified in allegations 3 (a) and (b).

Reasons for Decision

After careful deliberation and review of the testimony of all witnesses and the Member’s testimony the panel found that the College had not met the standard of proof in accordance with the Bernstein decision to support a finding in that respect.

In reviewing the testimony given by all the witnesses in both examination-in-chief and cross-examination followed by final submissions, the panel could not find the Member guilty of allegations as stated in the Notice of Hearing. The evidence given by the prosecution’s witnesses was circumstantial evidence which the panel could only draw on inferences and not facts in deciding its finding. Keeping in mind that the College bears the onus of proving the allegations in accordance with the standard of proof, namely on a balance of probabilities. The panel concluded that the College did not meet the standard of proof, that the evidence was not clear, cogent and convincing. The testimony given by the witnesses drew on inferences and not facts as to what happened and could not be relied upon. The evidence provided did not substantiate the allegations against the Member in that [the Member] had;

(a) misappropriated narcotics from the workplace;

(b) misappropriated narcotics, falsified documentation and/or failed to administer Morphine to a client;

In review of the incidents on November 28, 2003 and particularly the incident on December 26, 2003 in which, the Member allegedly failed to administer Morphine to a patient, the evidence is not convincing. The panel concluded that one cannot make the conclusion that the syringe confiscated on December 26, 2003, is in fact the actual syringe that was left in the patient’s chart because it had been unsupervised for an undetermined amount of time.

Even though the panel could not make a finding based on the evidence in this particular case, the panel feels that this particular case sensitizes all members of the College about the professional and legal responsibilities inherent in the privilege of being able to administer controlled substances. Specifically, it reinforces the responsibility and accountability that members must adhere to in dealing with controlled substances.

I, Joanne Furletti, 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

Panel Members:

Deirdre Armstrong, RN Rosalie Woods, RPN Faira Bari, Public Member Karen Harder, Public Member