College of Nurses of Ontario v. Mohamed, 2012 ONCNO 98106

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Nancy Sears, RN, Chairperson Samantha Diceman, RPN, Member Abdul Patel, Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO NICK COLEMAN for College of Nurses of Ontario

• and -

ANAB MOHAMED (Registration No. 0291872) SUSAN BALLANTYNE for Anab Mohamed

Heard: February 16, 2012

DECISION AND REASONS

This matter came on for hearing before a panel of the Discipline Committee on February 16, 2012 at the College of Nurses of Ontario ("the College") at Toronto.

The Allegations

Counsel for the College advised the panel that the College was requesting leave to withdraw the allegations set out in paragraphs 1(a) (after the word "gloves"), 1 (c) (ii) (after the word "properly"), 1 (c) (iv), 1 (c) (vii), 1 (c) (x), 1 (c) (xii), 6 (a) (after the word "gloves"), 6 (c) (ii) (after the word "properly"), 6 (c) (iv), 6 (c) (vii), 6 (c) (x), 6 (c) (xii), and 7 of the Notice of Hearing dated February 3 2012. The panel granted this request.

The remaining allegations against Anab Mohamed (the "Member") as set out in the Notice of Hearing 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, while engaged in the practice of nursing as a Registered Nurse, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to the following incidents:

(a) at [Facility A], on or about June 8, 2007, you misappropriated a box of sterile gloves;

(b) at [Facility B], in or about July - August 2007, you submitted a resume with an application for employment providing false information regarding your employment at [Agency A] and/or made other false statements regarding your prior employment and/or the status of persons you indentified for reference checks;

(c) at [Facility C]:

(i) in or about August 2007, you submitted a resume with an application for employment providing false information regarding your employment at [Agency A];

(ii) on or about May 19, 2008, you failed to administer a chemotherapy drug properly;

(iii) on or about May 20, 2008, you signed the medication administration record for a client indicating that you administered Dilaudid at 1000 hours before you actually administered the narcotic to the [client];

(iv) [Withdrawn];

(v) on or about July 8, 2008, you failed to note that [Client A] was admitted to the hospital for pain management rather than imminent death, and you failed to complete a confusion scale or notify the physician regarding the client's confused state;

(vi) on or about July 8, 2008, you failed to assess [Client B] after it was reported to you that the client had vomited;

(vii) [Withdrawn];

(viii) on or about July 10, 2008, you failed to introduce yourself to [Client C] and/or you left the client unattended during bathing and dressing despite the nursing directive that required constant observation;

(ix) on or about July 10, 2008, you failed to introduce yourself to [Client D], failed to assess the client's abilities, left him alone in the bathroom to do his own bathing when the nursing directive required supervision, and failed to guide this client, who was new to the unit, to the dining room or to set him up for his breakfast;

(x) [Withdrawn];

(xi) on or about July 28, 29 and 30, 2008, you arrived late for work and took extended unauthorized breaks during your shift; and/or

(xii) [Withdrawn]

(xiii) on or about August 1, 2008, you failed to complete an admission assessment of [Client E];

(d) at [Facility D]:

(i) on or about September 23, 2010, you administered a dose of insulin to [Client F] in excess of the amount ordered for her;

(ii) on or about October 14, 2010, you failed to remove the packing from an abscess as directed to prepare [Client G] for x-rays;

(iii) on or about October 30, 2010, you failed to transcribe clearly and accurately into the [client] chart a physician's order for Humulin R insulin for [Client H]; and/or

(iv) on or about November 8, 2010, you prepared a 6 cc dose of Ketamine to administer to [Client I] when the order was for a .6 cc dose.

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(8) of Ontario Regulation 799/93, in that, while engaged in the practice of nursing as a Registered Nurse, you misappropriated property from a client or work place, and in particular, at [Facility A] , on or about June 8, 2007, you misappropriated a box of sterile gloves.

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(13) of Ontario Regulation 799/93, in that, while engaged in the practice of nursing as a Registered Nurse at [Facility D], you failed to keep records as required with respect to failing to transcribe clearly and accurately into the [client] chart a physician's order for Humulin R insulin for [Client H] on or about October 30, 2010.

4. 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(14) of Ontario Regulation 799/93, in that, while engaged in the practice of nursing as a Registered Nurse, you falsified a record relating to your practice with respect to the following incidents:

(a) at [Facility B], in or about July - August 2007, you submitted a resume with an application for employment providing false information regarding your employment at [Agency A] and/or made other false statements regarding your prior employment and/or the status of persons you indentified for reference checks;

(b) at [Facility C]:

(i) in or about August 2007, you submitted a resume with an application for employment providing false information regarding your employment at [Agency A]; and

(ii) on or about May 20, 2008, you signed the medication administration record for a client indicating that you administered Dilaudid at 1000 hours before you actually administered the narcotic to the [client].

5. 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(15) of Ontario Regulation 799/93, in that, while engaged in the practice of nursing as a Registered Nurse, you signed or issued, in your professional capacity, a document that you knew, or ought to have known contained a false or misleading statement with respect to the following incidents:

(a) at [Facility B], in or about July - August 2007, you submitted a resume with an application for employment providing false information regarding your employment at [Agency A] and/or made other false statements regarding your prior employment and/or the status of persons you indentified for reference checks;

(b) at [Facility C]:

(i) in or about August 2007, you submitted a resume with an application for employment providing false information regarding your employment at [Agency A]; and

(ii) on or about May 20, 2008, you signed the medication administration record for a client indicating that you administered Dilaudid at 1000 hours before you actually administered the narcotic to the [client].

6. 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 engaged in the practice of nursing as a Registered Nurse, 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 of the profession as disgraceful, dishonourable or unprofessional with respect to the following incidents:

(a) at [Facility A] , on or about June 8, 2007, you misappropriated a box of sterile gloves;

(b) at [Facility B], in or about July - August 2007, you submitted a resume with an application for employment providing false information regarding your employment at [Agency A] and/or made other false statements regarding your prior employment and/or the status of persons you indentified for reference checks;

(c) at [Facility C]:

(i) in or about August 2007, you submitted a resume with an application for employment providing false information regarding your employment at [Agency A];

(ii) on or about May 19, 2008, you failed to administer a chemotherapy drug properly;

(iii) on or about May 20, 2008, you signed the medication administration record for a client indicating that you administered Dilaudid at 1000 hours before you actually administered the narcotic to the [client];

(iv) [Withdrawn];

(v) on or about July 8, 2008, you failed to note that [Client A] was admitted to the hospital for pain management rather than imminent death, and you failed to complete a confusion scale or notify the physician regarding the client's confused state;

(vi) on or about July 8, 2008, you failed to assess [Client B] after it was reported to you that the client had vomited;

(vii) [Withdrawn];

(viii) on or about July 10, 2008, you failed to introduce yourself to [Client C] and/or you left the client unattended during bathing and dressing despite the nursing directive that required constant observation;

(ix) on or about July 10, 2008, you failed to introduce yourself to [Client D], failed to assess the client's abilities, left him alone in the bathroom to do his own bathing when the nursing directive required supervision, and failed to guide this client, who was new to the unit, to the dining room or to set him up for his breakfast;

(x) [Withdrawn];

(xi) on or about July 28, 29 and 30, 2008, you arrived late for work and took extended unauthorized breaks during your shift; and/or

(xii) [Withdrawn];

(xiii) on or about August 1, 2008, you failed to complete an admission assessment of [Client E];

(d) at [Facility D]:

(i) on or about September 23, 2010, you administered a dose of insulin to [Client F] in excess of the amount ordered for her;

(ii) on or about October 14, 2010, you failed to remove the packing from an abscess as directed to prepare [Client G] for x-rays;

(iii) on or about October 30, 2010, you failed to transcribe clearly and accurately into the patient chart a physician's order for Humulin R insulin for [Client H]; and/or

(iv) on or about November 8, 2010, you prepared a 6 cc dose of Ketamine to administer to [Client I] when the order was for a .6 cc dose.

7. [Withdrawn]

Member's Plea

Anab Mohamed admitted the allegations set out in paragraphs numbered 1 (a) (ending at the word "gloves"); (b); (c) (i), (ii) (ending at the word "properly"), (iii), (v), (vi), (viii), (ix), (xi), (xiii); (d), (i), (ii), (iii), (iv); 2; 3; 4 (a); 4 (b) (i), and (ii); 5 (a); 5 (b) (i) and (ii); 6 (a) (up to the word "gloves"); 6 (b); 6 (c) (i), (ii) (up to the word "properly"), (iii), (v), (vi), (viii), (ix), (xi), (xiii); and 6 (d) (i), (ii), (iii), (iv) in the Notice of Hearing. The panel received a written plea inquiry which was signed by the Member. The panel also conducted an oral 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 which provided as follows.

THE MEMBER

1. Anab Mohamed (the "Member") studied nursing [abroad] and graduated with a three-year degree in 1981.
2. Following graduation, she worked as a nurse for seven years on a medical/surgical ward in a hospital [before moving] to Canada in 1990.
3. The Member registered with the College of Nurses of Ontario (the "College") as a Registered Nurse ("RN") with a temporary certificate of registration ("certificate") on June 17, 2002 and subsequently received her general class registration on February 6, 2003.
4. The Member's certificate was suspended on an interim basis on October 3, 2011 pending the outcome of this matter. The interim suspension was lifted and interim terms, conditions and limitations were imposed on the Member's certificate on January 11, 2012.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

(A) [Facility A]

5. [Facility A] is a 944-bed facility located in [ ] Ontario.
6. On April 2, 2007, the Member commenced a part-time position on [the unit]. The unit is staffed by RNs, Registered Practical Nurses and one orderly. The staff work[ed] eight-hour shifts and the nurse to client ratio [was] 1:5.
7. On June 24, 2007, the Member misappropriated a full box of latex gloves from [the unit]. The orderly witnessed the Member placing the box of gloves into her purse, but did not say anything to the Member.
8. The orderly reported the incident to the team leader [ ] and the manager of the unit [ ].
9. The manager spoke to the Member, who admitted taking the gloves. The Member offered to return the gloves, and further offered her $100.
10. If the manager were to testify, she would say that the $100 was offered as a bribe to not report the incident.
11. If the Member were to testify, she would say that she returned the gloves when asked by the team leader, and that she offered $100 to the manager so that a new box of gloves could be purchased.
12. On July 3, 2007, the Member resigned during her probationary period as a result of the incident described above.

(B) [Facility B]

13. [Facility B] is a 230-bed facility located in [ ] Ontario.
14. In or about July 2007, the Member submitted a resume to [Facility B] that indicated that she was employed at [Agency A] from "2002 to current."
15. On July 9, 2007, the Member was interviewed by [a] Nurse Manager [ ] at [Facility B]. During this interview, the Member confirmed that she was currently working at [Agency A] and provided two employment references. She specifically advised that one of the references [ ] was her supervisor and the other was a co-worker.
16. Based in part on the information provided by these two references, on July 16, 2007, [the Nurse Manager] offered a part-time RN position to the Member. [The Nurse Manager] later became suspicious about the Member's references and followed up with the Human Resources Department.
17. [Facility B] then received a letter from [Agency A] confirming that the Member was employed at [Agency A] from February 14, 2005 to November 2006. The Member had resigned from [Agency A] on November 6, 2006.
18. On August 3, 2007, [the Nurse Manager] met with the Member in relation to the inaccuracies on her resume. The Member indicated that the letter from [Agency A] was incorrect and that she could provide an updated letter.
19. During this meeting, the Member was also asked to provide an employment reference from her manager at [Agency A] as the two other references whose names she provided were no longer working there.
20. On August 7, 2007, in a follow-up conversation, the Member indicated to [the Nurse Manager] that she had not told the truth about the duration of her employment at [Agency A] and that the information from [Agency A] regarding the length of her employment was correct. Additionally, the Member gave [the Nurse Manager] the name of her former manager at [Agency A] and gave her permission to contact her.
21. When [the Nurse Manager] contacted the Member's former manager, she was told that [the individual], who had been identified [by the Member] previously as a supervisory reference, was a visiting nurse at [Agency A] and not the Member's supervisor.
22. If the Member were to testify, she would say that she indicated that [the individual] was her supervisor because [the individual] had visited [clients] with her and she believed that [Facility B] wanted her to identify someone who could comment on her day-to-day nursing practice. In addition, she would say that she assumed the nature of the relationship would have become clear to [Facility B] when they spoke with [the individual].
23. On August 28, 2007, during her probationary period, the Member was terminated as a result of the above incident.

(C) [Facility C]

24. [Facility C] is now known [under a different name]. It is located in [ ] Ontario.
25. The Member worked as an RN on the Palliative Care Unit and Rehabilitation Level 3. She was hired at [Facility C] on a part-time basis on July 16, 2007 and was terminated on August 8, 2008 as a result of the incidents described below.

a) Providing False Information to [Facility C]

26. In July 2007, the Member submitted a resume with her application for employment at [Facility C] in August 2007.
27. The Member's resume falsely indicated that she had worked at [Agency A] from 2002 until 2007, while she had in fact resigned on November 8, 2006.

b) Failure to Administer a Chemotherapy Drug Properly

28. [Client J] was a 75-year-old client and had been admitted to the Palliative Care Unit.
29. On or about May 19, 2008, while providing care to [Client J], the Member provided chemotherapy medication to her in a sealed pharmacy packet. The Member left the client to administer the chemotherapy medication to herself without any further assistance.
30. The Member should have used gloves to remove the medication from the unit-dose envelope and she should have given the medication to [Client J] in a paper cup.
31. If the Member were to testify, she would say that it was her first time administering the medication and she did not understand how to administer it properly. She would also say that she now appreciates the importance of understanding how to administer medication before attempting to do so.

c) Failure to Administer Medication

32. [Client K] was a 77-year-old client who had been admitted to the Palliative Care Unit and was suffering from end stage Chronic Obstructive Pulmonary Disease.
33. On or about June 20, 2008 at around 10:00am, the Member signed that she had administered Dilaudid in the Medication Administration Record for [Client K]. However, the Member had not yet actually administered the Dilaudid to the client.
34. If the Member were to testify, she would state that she must have been distracted and as a result, forgot to administer the Dilaudid to the client. In addition, she would say that she understands that it is important never to chart that a medication has been administered before it is in fact administered.

d) Failure to Note Client's Health Status and Failure to Complete Confusion Scale

35. [Client A] was a 74-year-old client and had been admitted to the Palliative Care Unit on July 6, 2008. He was admitted for symptom management and assistance with [his] activities of daily living.
36. On July 8, 2008, during a shadow shift with an Advanced Practice Nurse [(APN)], the Member failed to observe and chart that [Client A] was admitted for symptom management.
37. When [the APN] asked the Member why [Client A] was admitted, the Member replied, "He is sick and dying like every other patient," or words to that effect.
38. The Nursing Delirium Scale (the "Scale") measures levels of disorientation, inappropriate behaviour and communication, illusions/hallucinations and psychomotor retardation. The Scale is a chart with space documenting day, evening and night assessments for each calendar day.
39. On July 8, 2008, the Member did not document any assessments on the Scale for [Client A]. In contrast, staff had documented one to three assessments each day between July 3 and July 18, 2008. Specifically, an assessment was documented once on July 3, and 13, twice on July 5, 6, 10, 11, 12, 17, 18 and three times on July 4, 7, 9, 14, 15, 16, 2008. July 8, 2008 was the only day in this two-week period when there were no documented assessments on the Scale.
40. On the same day, the Member noted in the Interdisciplinary Patient Progress Notes that [Client A] was slightly confused. There is no indication in [Client A]'s records to indicate that the Member notified the physician of this confusion.

e) Failure to Assess Client after Client Vomited

41. [Client B] was a 72-year-old client and had been admitted to the Palliative Care Unit.
42. On July 8, 2008, [Client B] had an episode of vomiting while the Member was on a break. When the Member returned from her break, another nurse informed her that [Client B] had vomited. The Member did not complete a follow-up assessment.

f) Failure to Introduce Herself and Attend [to Client C]

43. [Client C] was a 91-year-old client at the time of the incident. She had been admitted to Rehabilitation Level 3.
44. On or about July 10, 2008, the Member failed to introduce herself to [Client C] when she greeted her. Instead, the Member said "Hello, how are you?" or words to that effect. The Member now understands that it is important to identify herself to each client.
45. The Nursing Patient Care Flow Sheet indicated that [Client C] required constant supervision for some aspects of bathing and dressing.
46. On July 10, 2008, the Member left [Client C] alone when she was set-up at the sink to wash. The Member was in the hallway outside the room.
47. If the Member were to testify, she would say that [Client C] was left alone only briefly and that she was in the hallway immediately outside the room.
48. The Member did not follow [Client C]'s care plan.

g) Failure to Introduce Herself and Attend [to Client D]

49. [Client D] was an 87-year-old client at the time of the incident. He had been admitted to Rehabilitation Level 3.
50. On or about July 10, 2008, the Member failed to introduce herself to [Client D] when she greeted him. Instead, the Member said "Hello, how are you?" or words to that effect. The Member now understands that it is important to identify herself to each client.
51. [Client D]'s Nursing Care Guide indicated that he was at risk of falling and wandering. It was noted that [Client D] was independent with his walker in his room and that he was independent to wash and dress. The Nursing Care Guide also referred to the Nursing Diagnosis, which indicated that [Client D] needed supervision to stand while bathing and dressing.
52. Also on July 10, 2008, the Member left [Client D] in the bathroom to do his own bathing. The Member did not check on him to assess what care he was able to do for himself. The Member completed his peri-care.
53. In addition, the Member did not assess [Client D] or ask him what he was able to do in relation to dressing himself. The Member dressed [Client D], allowing him to only put on his T-shirt.
54. The Member sent [Client D] to the dining room, but did not accompany him to ensure that he got his breakfast. [Client D] wheeled himself into the dining room and continued toward the back door. Another registered staff stopped him and ensured that he was set up for his breakfast.

h) Failure to Work as Scheduled

55. On or about July 28, 30, and 31 2008, the Member was scheduled for mentored shifts [ ]. On at least one day, the Member arrived late and took one hour for lunch when she was only supposed to take 30 minutes. According to [the mentor], the Member had been counselled previously about arriving on time and returning promptly from lunch and other breaks.
56. If the Member were to testify, she would say that she took the extra time because she had not taken her breaks. She acknowledges that she should have made this clearer to her co-workers.

i) Failure to Complete an Admission Assessment as Required

57. [Client E] was a 68-year-old client who had been admitted to Rehabilitation Level 3 on or about July 31, 2008.
58. The Member did not complete an admission assessment of [Client E] as required, and failed to make notations about [Client E]'s activities of daily living.
59. On July 7, 2008, three weeks prior to the above incident, the Member had been specifically coached by the practice support nurse on the documentation requirements for [client] admission. This information had been reviewed with the Member on at least two different occasions.

(D) [Facility D]

60. [Facility D] is a small rural hospital located in [ ] Ontario.
61. The Member started working as a part-time RN on the [ ] inpatient medical/surgical unit on October 21, 2008. The majority of clients on the unit were elderly and suffered from conditions such as pneumonia, post-myocardial infarction, coronary disease, dementia and dehydration. The nurse-client ratio was 1:4 or 1:5.
62. In June 2010, the Member resigned from her part-time position and was hired into a casual position. She resigned because she wanted to travel [outside the country] and did not have enough vacation time accrued and did not have enough seniority to apply for a leave of absence.
63. On November 16, 2010, as a result of the incidents described below, the Member was placed on a leave of absence until she had successfully completed a medication course. The Member completed the course but has not yet returned to [Facility D]. She has made a request to do so through her union.

a) Failure to Administer High Risk Medication Properly

64. [Facility D]'s policy for High Risk Medications requires, in part, [that] RNs and doctors are to double check the medication at the time of mixing or hanging. Additionally, a poster on each medication cart at [Facility D] included a warning that high alert medication must be handled differently than other drugs. High alert medication was defined on the poster as "drugs that bear a heightened risk of causing significant patient harm when they are used in error."
65. [Client F] was a 53-year-old client who had been admitted to [Facility D] on September 16, 2010 for Diabetic Ketoacidosis.
66. [Client F] had a physician's order for Levemir Insulin, specifically 14 units in the morning and eight units in the evening. [Facility D] considered Levemir Insulin to be a High Risk Medication.
67. On or about September 23, 2010, the Member administered 14 units of Levemir Insulin subcutaneously to [Client F] in the evening, contrary to the physician's order. She should have given eight units at that time. When the Member noticed the error, she notified [Client F] and the attending physician.
68. If the Member were to testify, she would say that she noticed the error immediately and notified [Client F] and the attending physician.
69. [Client I] was a 36-year-old client and was admitted to [Facility D] on November 5, 2010 with abdominal wall abscesses. Among other medication, [Client I] had a physician's order for Ketamine 0.6mLs prior to her dressing change. Ketamine is a parenteral anesthetic. [Facility D] considered Ketamine to be a High Risk Medication.
70. On November 8, 2010, the Member drew up 6mLs of Ketamine to administer, instead of the prescribed 0.6mLs. [RN A] observed that the Member had drawn too much of the medication into the syringe. She intervened to ensure that the Member did not administer the anesthetic.
71. If the Member were to testify, she would say that she caught the mistake herself at the same time as [RN A]. The overdose of anesthetic was not administered.

b) Failure to Transcribe Physician's Order Properly

72. [Client H] was a 71-year-old client and was admitted to [Facility D] on October 26, 2010 for a stroke.
73. On October 30, 2010, the Member failed to transcribe fully and clearly a doctor's order for Humulin R. for [Client H]. [Facility D] considers Humulin R to be a High Risk medication.
74. The Member was required to transcribe an Order for Humulin R. According to the incident report dated October 30, 2010, the Member failed to transcribe the order as ordered by the doctor. In particular, the Member did not include details about the route or time of administration and the Member used a dangerous abbreviation.

c) Failure to follow Physician's Order

75. [Client G] was 47 years old at the time of the incident and had been admitted on October 12, 2010 with cellulitis to rule out sepsis. The Member was assigned to care for [Client G] on October 14, 2010 and [Client G] was scheduled to have an x-ray of the abscess on that day.
76. The October 13, 2010 physician's order requested that the packing be removed from the affected area before the x-ray was completed. The Nursing Interventions in the Individual Care Plan - Basic also listed the same order.
77. On the morning of October 14, 2010, night staff told the Member of the need to remove the packing from the abscess before [Client G] was sent to x-ray.
78. The Member did not remove the packing before [Client G] was sent to x-ray, so [RN B] had to remove the packing from the abscess.
79. If the Member were to testify, she would say that she had asked [RN B] to remove the packing before [Client G] was sent to the x-ray department and that she assumed [RN B] would complete this task. The Member acknowledges that she should have ensured that the task had been completed before the client was sent to the X-Ray Department.
80. If [RN B] were to testify, she would deny that the Member had asked her to remove the packing.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

81. The Member admits that she committed the acts of professional misconduct as alleged in the Notice of Hearing in:

• Paragraph: 1(a) (only with respect to misappropriating a box of gloves), 1(b), 1(c)(i), 1(c)(ii) (only with respect to administering the chemotherapy drug properly), 1(c)(iii), 1(c)(v), 1(c)(vi), 1(c)(viii), 1(c)(ix), 1(c)(xi), 1(c)(xiii), and 1(d)(i), 1(d)(ii), 1(d)(iii), 1(d)(iv),
• Paragraph: 2,
• Paragraph: 3,
• Paragraph: 4(a), 4(b)(i), 4(b)(ii),
• Paragraph: 5(a), 5(b)(i), 5(b)(ii),
• Paragraph: 6(a) (only with respect to misappropriating a box of gloves), 6(b), 6(c)(i), 6(c)(ii) (only with respect to administering the chemotherapy drug properly), 6(c)(iii), 6(c)(v), 6(c)(vi), 6(c)(viii), 6(c)(ix), 6(c)(xi), 6(c)(xiii), 6(d)(i), 6(d)(ii), 6(d)(iii) and 6(d)(iv),

and in particular her conduct was disgraceful, dishonourable and unprofessional, as described in paragraphs 5-80 above.

Following questions from the panel, the parties clarified the Agreed Statement of Facts as follows:

• Paragraphs 33 and 34: the Dilaudid was administered by the Member approximate[ly] 3.5 hours late; and
• Paragraphs 44 and 50: the standard breached was the Therapeutic Nurse-Client Relationship Standard, revised 2006.

Decision

The panel considered the Agreed Statement of Facts, and clarifications as agreed by both parties, and finds that the facts support a finding of professional misconduct and, in particular, finds that the Member committed acts of professional misconduct as alleged in the Notice of Hearing (minus those allegations that were withdrawn) and as agreed to by the Member.

Reasons for Decision

The facts clearly supported the allegations in the Notice of Hearing. The public's trust in nurses and in the profession is a paramount value that underlies the privilege of professional self-regulation. Nurses must always practi[s]e their profession in accordance with the standards of practice. The admitted actions of the Member were a breach of several of the published Standards of Practice. The Member knew or ought to have known that her behaviour was unacceptable and fell below the standards of practice of the profession.

As to allegation #6, disgraceful conduct has the effect of shaming the Member and, by extension, the profession. It casts serious doubt on the Member's inherent ability to discharge the high obligations the public expects nurses to met. Dishonourable conduct car[ri]es an element of dishonesty and deceit. Unprofessional behaviour includes behaviour that persistently breaches the standards of practice. The panel finds that in totality, the conduct of the Member includes all the elements of disgraceful, dishonourable and unprofessional. However, the panel also finds that not every incident includes all such elements. As such, the panel finds the Member's misappropriation of property to be dishonourable and unprofessional. Her conduct with respect to misrepresentation of information provided by means of her resume and interviews with employers and prospective employers would reasonably be regarded by members as disgraceful, dishonourable and unprofessional. The panel finds that the conduct of the Member with all other incidents under examination would reasonably be regarded as unprofessional.

Penalty

Counsel for the College advised the panel that a Joint Submission as to Order had been agreed upon. The Joint Submission as to Order requests that this panel ma[k]e an order as follows:

1. Requiring the Member to appear before the Panel to be reprimanded within three (3) months of the date of this Order.
2. Directing the Executive Director to suspend the Member's certificate of registration for two (2) months. This suspension shall take effect from the date of this Order and shall continue to run without interruption.
3. Directing the Executive Director to impose the following terms, conditions and limitations on the Member's certificate of registration:

a) The Member shall successfully complete, at her own expense, a medication administration course and an assessment course (the "Courses") within 12 months of the date of this Order. The Courses must contain a clinical or laboratory component and must be approved by the Director of Professional Conduct (the "Director") in advance.

b) The Member shall only practise nursing subject to the following terms, conditions and limitations until she has successfully completed the Courses mentioned above:

i. Within fourteen (14) days of commencing employment in a nursing position, the Member must provide the Director with written notification of the name, address and telephone number of her nursing employer; and

ii. In advance of commencing employment in a nursing position, the Member must inform her nursing employer that:

1. Allegations of professional misconduct and incompetence have been referred to the Discipline Committee in respect of her and must provide her employer(s) with the documents identified in paragraph 3 (e) (ii); and

2. Her certificate of registration is subject to specific terms, conditions and limitations until she has completed the Courses mentioned in paragraph 3 (a);

iii. The Member shall not practise independently and may practise only in an employment setting where:

1. Another registered staff is on duty in the same practi[c]e location and for the duration of the Member's shift; and

2. The Director has received a signed acknowledgment from the Member's nursing employer that the employer has been informed of the information identified in paragraph (ii) and agrees to immediately notify the Director upon receipt of reasonable information that the Member's practice, particularly any concerns with medications, is not in accordance with the standards of practice of the profession.

c) The Member will, at her own expense, attend a remedial program (the "Remedial Program") with a Nursing Expert (the "Expert"). The number of meetings for the Remedial Program shall be determined by the Expert, based upon the Expert's assessment of whether the Member has gained sufficient insight into the conduct set out in the Agreed Statement of Facts such that similar conduct is unlikely to recur. The first meeting shall be completed within two (2) months of the date of this Order. If the Expert determines that more than one (1) meeting is required for the successful completion of the Remedial Program, the Expert will advise the Member and write to the Director regarding the total number of meetings that are required and the length of time required to complete the additional meetings, but in any event, all meetings shall be completed within six (6) months from the date of this Order. To comply, the Member is required to ensure that:

i. The Expert has expertise in communication and ethical issues for nurses, has been approved by the Director in advance of the meeting(s), and has confirmed he/she will provide a report following the meeting(s);

ii. At least [seven] (7) days before the first meeting, the Member provides the Expert with a copy of:

1. the Panel's Order,
2. the Notice of Hearing,
3. the Agreed Statement of Facts,
4. this Joint Submission on Order, and
5. if available, a copy of the Panel's Decision and Reasons;

iii. Before the first meeting, the Member reviews the following College publications and completes the associated Reflective Questionnaires and online learning modules:

1. Professional Standards (Revised 2002),
2. Documentation Standard (Revised 2008),
3. Medication Standard (Revised 2008);

iv. Before the first meeting, the Member reviews the Practice Guideline: Conflict Prevention and Management (Revised 2009). The Member also reviews the Communication in Nursing Practice web module available on the College of Registered Nurses of British Columbia's website and completes the associated Communication in Nursing Practice Workbook (the "Workbook");

v. At least [seven] (7) days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, online participation forms and the Workbook;

vi. The subject of the meeting(s) with the Expert will include:

1. the acts or omissions for which the Member was found to have committed professional misconduct,
2. the potential consequences of the misconduct to the Member's clients, colleagues, profession and self,
3. strategies for preventing the misconduct from recurring,
4. the publications, questionnaires, modules and Workbook set out above, and
5. the development of a learning plan in collaboration with the Expert;

vii. Within 30 days after the Member has completed the last meeting, the Expert forwards his/her report to the Director, in which the Expert will confirm:

1. the date(s) the Member attended the meeting(s),
2. that the Expert received the required documents from the Member,
3. that the Expert reviewed the required documents and subjects with the Member, and
4. the Expert's assessment of the Member's insight into her behaviour;

viii. If the Member does not comply with any of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation[ ] on her certificate of registration;

d) For a period of 12 months following the date upon which the Member has successfully completed the Courses, the Member shall not practise independently in the community;

e) For a period of 12 months following the date upon which the Member has successfully completed the Courses, the Member will notify her employers of this decision. To comply, the Member is required to ensure that:

i. The Director is notified of the name, address, and telephone number of all employer(s) within fourteen (14) days of commencing or resuming employment in any nursing position;

ii. Provide her employer(s) with a copy of:

1. the Panel's Order,
2. the Notice of Hearing,
3. the Agreed Statement of Facts,
4. this Joint Submission on Order, and
5. a copy of the Panel's Decision and Reasons, once available;

iii. Within fourteen (14) days of the commencement or resumption of the Member's employment in any nursing position, the employer(s) forward(s) a report to the Director, in which it will confirm:

1. that it received a copy of the required documents,
2. that it agrees to conduct spot audits at the intervals of six (6) months and twelve (12) months. The spot audits shall include:

a. a review of the Member's charts to ensure that they meet with both College and employer standards, b. supervision of a medication pass to ensure that it meets with both College and employer standards, c. calling at least three of the Member's clients on each occasion to verify that the Member is utilizing appropriate communication techniques which are consistent with the therapeutic nurse-client relationship;

3. that it agrees to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession; and

iv. All documents delivered by the Member to the College, the Expert or the employer(s) will be made by verifiable method of delivery, the proof of which the Member will retain.

Counsel for the College submitted that the Joint Submission on Order addresses the seriousness of the Member's conduct, the relevant aggravating and mitigating factors, rehabilitation and remediation, and is in the best interest of the public, the profession and the Member. College Counsel described the Member's behaviours as generally falling into two categories.

• The first is a pattern of dishonest behaviour as shown by the misappropriation of property and the issuing of false statement[s] on her resume and to her employers. As a nurse, it is expected that the Member would always act with scrupulous honesty. To engage in dishonest behaviour is a serious act of professional misconduct.
• The second was a pattern of sub-standard conduct with respect to client care across multiple facilities. However, the Member has admitted her conduct and accepted responsibility.

College Counsel argued that the proposed order is intended to discourage the Member and others in the profession from engaging in such behaviour. Its provisions address the goals of specific and general deterrence, but place an emphasis on rehabilitation. The joint submission takes into consideration the interests of the public, the profession and the Member. Protection of the public is of paramount interest to the College. The proposed order sends a clear message that such conduct is not acceptable. Remedial training and counselling is intended to support rehabilitation of the Member's practice. Restrictions on her practice and monitoring of her conduct will further protect the public interest. The proposed penalty would send a message that the profession of nursing is capable of regulating the conduct of its members and dealing with matters of misconduct. It would provide the Member with an understanding of her conduct and allow her the opportunity to avoid recurrence of such conduct and support her return to the profession.

Counsel for the Member endorsed the College's submissions.

Penalty Decision

The panel accepts the Joint Submission on Order with one addition. Accordingly the panel orders as follows.

1. The Member shall appear before the Panel to be reprimanded within three (3) months of the date of this Order.
2. The Executive Director is directed to suspend the Member's certificate of registration for two (2) months. This suspension shall take effect from the date of this Order and shall continue to run without interruption.
3. The Executive Director is directed to impose the following terms, conditions and limitations on the Member's certificate of registration:

a) The Member shall successfully complete, at her own expense, a medication administration course and an assessment course (the "Courses") within 12 months of the date of this Order. The Courses must contain a clinical or laboratory component and must be approved by the Director of Professional Conduct (the "Director") in advance.

b) The Member shall only practise nursing subject to the following terms, conditions and limitations until she has successfully completed the Courses mentioned above:

i. Within fourteen (14) days of commencing employment in a nursing position, the Member must provide the Director with written notification of the name, address and telephone number of her nursing employer; and

ii. In advance of commencing employment in a nursing position, the Member must inform her nursing employer that:

1. Allegations of professional misconduct and incompetence have been referred to the Discipline Committee in respect of her and must provide her employer(s) with the documents identified in paragraph 3 (e) (ii); and

2. Her certificate of registration is subject to specific terms, conditions and limitations until she has completed the Courses mentioned in paragraph 3 (a);

iii. The Member shall not practise independently and may practise only in an employment setting where:

1. Another registered staff is on duty in the same practi[c]e location and for the duration of the Member's shift; and

2. The Director has received a signed acknowledgment from the Member's nursing employer that the employer has been informed of the information identified in paragraph (ii) and agrees to immediately notify the Director upon receipt of reasonable information that the Member's practice, particularly any concerns with medications, is not in accordance with the standards of practice of the profession.

c) The Member will, at her own expense, attend a remedial program (the "Remedial Program") with a Nursing Expert (the "Expert"). The number of meetings for the Remedial Program shall be determined by the Expert, based upon the Expert's assessment of whether the Member has gained sufficient insight into the conduct set out in the Agreed Statement of Facts such that similar conduct is unlikely to recur. The first meeting shall be completed within two (2) months of the date of this Order. If the Expert determines that more than one (1) meeting is required for the successful completion of the Remedial Program, the Expert will advise the Member and write to the Director regarding the total number of meetings that are required and the length of time required to complete the additional meetings, but in any event, all meetings shall be completed within six (6) months from the date of this Order. To comply, the Member is required to ensure that:

i. The Expert has expertise in communication and ethical issues for nurses, has been approved by the Director in advance of the meeting(s), and has confirmed he/she will provide a report following the meeting(s);

ii. At least [seven] (7) days before the first meeting, the Member provides the Expert with a copy of:

1. the Panel's Order,
2. the Notice of Hearing,
3. the Agreed Statement of Facts,
4. this Joint Submission on Order, and
5. if available, a copy of the Panel's Decision and Reasons;

iii. Before the first meeting, the Member reviews the following College publications and completes the associated Reflective Questionnaires and online learning modules:

1. Professional Standards (Revised 2002),
2. Documentation Standard (Revised 2008),
3. Medication Standard (Revised 2008),
4. Therapeutic Nurse-Client Relationship (Revised 2006);

iv. Before the first meeting, the Member reviews the Practice Guideline: Conflict Prevention and Management (Revised 2009). The Member also reviews the Communication in Nursing Practice web module available on the College of Registered Nurses of British Columbia's website and completes the associated Communication in Nursing Practice Workbook (the "Workbook");

v. At least [seven] (7) days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, online participation forms and the Workbook;

vi. The subject of the meeting(s) with the Expert will include:

1. the acts or omissions for which the Member was found to have committed professional misconduct,
2. the potential consequences of the misconduct to the Member's clients, colleagues, profession and self,
3. strategies for preventing the misconduct from recurring,
4. the publications, questionnaires, modules and Workbook set out above, and
5. the development of a learning plan in collaboration with the Expert;

vii. Within 30 days after the Member has completed the last meeting, the Expert forwards his/her report to the Director, in which the Expert will confirm:

1. the date(s) the Member attended the meeting(s),
2. that the Expert received the required documents from the Member,
3. that the Expert reviewed the required documents and subjects with the Member, and
4. the Expert's assessment of the Member's insight into her behaviour;

viii. If the Member does not comply with any of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation{ ] on her certificate of registration;

d) For a period of 12 months following the date upon which the Member has successfully completed the Courses, the Member shall not practise independently in the community;

e) For a period of 12 months following the date upon which the Member has successfully completed the Courses, the Member will notify her employers of this decision. To comply, the Member is required to ensure that:

i. The Director is notified of the name, address, and telephone number of all employer(s) within fourteen (14) days of commencing or resuming employment in any nursing position;

ii. Provide her employer(s) with a copy of:

1. the Panel's Order,
2. the Notice of Hearing,
3. the Agreed Statement of Facts,
4. this Joint Submission on Order, and
5. a copy of the Panel's Decision and Reasons, once available;

iii. Within fourteen (14) days of the commencement or resumption of the Member's employment in any nursing position, the employer(s) forward(s) a report to the Director, in which it will confirm:

1. that it received a copy of the required documents,
2. that it agrees to conduct spot audits at the intervals of six (6) months and twelve (12) months. The spot audits shall include:

a. a review of the Member's charts to ensure that they meet with both College and employer standards, b. supervision of a medication pass to ensure that it meets with both College and employer standards, c. calling at least three of the Member's clients on each occasion to verify that the Member is utilizing appropriate communication techniques which are consistent with the therapeutic nurse-client relationship;

3. that it agrees to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession; and

iv. All documents delivered by the Member to the College, the Expert or the employer(s) will be made by verifiable method of delivery, the proof of which the Member will retain.

Reasons for Penalty Decision

The panel concluded that the 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 accepted responsibility for her actions. The penalty allows for specific deterrence in that it provides for an oral reprimand, suspension, and remediation. It also provides for general deterrence in that it sends a clear message to the membership. It provides sufficient protection for the public and provides for both remediation and monitoring.

To the terms agreed-upon by the parties, the panel added the requirement for the Member to review the Therapeutic Nurse Client Relationship Standard (revised 2006), and to complete the associated questionnaires and online learning modules. The panel ordered this to address remediation relating to this Standard, which was breached on at least two occasions.

I, Nancy Sears, RN, 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: Samantha Diceman, RPN Abdul Patel, Public Member