DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Michael Hogard, RPN Chairperson
Donna Rothwell, RN Member
Margaret Tuomi Public Member
Chuck Williams Public Member
Ingrid Wiltshire-Stoby, RN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) JEAN-CLAUDE KILLEY for
) College of Nurses of Ontario
- and - )
) NO REPRESENTATION for Catherine Anne Gilford
CATHERINE ANNE GILFORD )
Reg. No. 9026204 )
) LUISA RITACCA
) Independent Legal Counsel
) Heard: August 29-30, 2016
DECISION AND REASONS
This matter came on for hearing before a panel of the Discipline Committee (the “Panel”) on August 29 and 30, 2016 at the College of Nurses of Ontario (“the College”) at Toronto.
As Catherine Anne Gilford (the “Member”) was not present, the hearing recessed for 10 minutes to allow time for the Member to appear. Upon reconvening the Panel noted that the Member was not in attendance and not represented.
Counsel for the College provided the Panel with evidence, the affidavit of Vanessa Green dated
April 4, 2016, that the Member had been sent the Notice of Hearing on April 4, 2016. The Panel was satisfied that the Member had received adequate notice of the time, date, place and nature of the hearing, and therefore proceeded with the hearing in the Member’s absence.
The Allegations
The Allegations
The allegations against the Member as stated in the Notice of Hearing dated April 1, 2016, are as follows.
IT IS ALLEGED THAT:
- 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 practising as a Registered Nurse at Southlake Regional Health Centre (the “Facility”), 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 July 25, 2013, you attempted to force client [Client A] to take his medication by attempting to toss a pill into his mouth, and/or by attempting to force a pill into his mouth against his will;
(b) on or about June 6, 2014, you administered labetalol to client [Client B] when Levophed had been ordered;
(c) on or about June 6, 2014, you failed to document any vital signs for client [Client B] after 0912 in circumstances where you were required to do so;
- 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(9) of Ontario Regulation 799/93, in that, while practising as a Registered Nurse at Southlake Regional Health Centre (the “Facility”), you did something to a client for a therapeutic, preventative, palliative, diagnostic, cosmetic or other health related purpose in a situation in which a consent was required by law, without such consent, and in particular:
(a) on or about July 25, 2013, you attempted to force client [Client A] to take his medication by attempting to toss a pill into his mouth, and/or by attempting to force a pill into his mouth against his will;
- 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 practising as a Registered Nurse at the Facility, you failed to keep records as required, and in particular:
(a) on or about June 6, 2014, you failed to document any vital signs for client [Client B] after 0912 in circumstances where you were required to continue to do so;
- 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, while practising as a Registered Nurse at the Facility, you abused a client verbally, physically or emotionally, and in particular:
(a) on or about July 25, 2013, you attempted to force client [Client A] to take his medication by attempting to toss a pill into his mouth, and/or by attempting to force a pill into his mouth against his will;
- 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 practising as a Registered Nurse at the Facility, 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, and in particular:
(a) on or about July 25, 2013, you attempted to force client [Client A] to take his medication by attempting to toss a pill into his mouth, and/or by attempting to force the pill into his mouth against his will;
(b) on or about June 6, 2014, you administered labetalol to client [Client B] when Levophed had been ordered;
(c) on or about June 6, 2014, you failed to document any vital signs for client [Client B] after 0912 in circumstances where you were required to continue to do so;
Member’s Plea
Member’s Plea
Given that the Member was not present nor represented, she was deemed to have denied the allegations in the Notice of Hearing. The Hearing proceeded on the basis that the College bore the onus of proving the allegations in the Notice of Hearing against the Member.
Overview
Overview
The Member was a registered nurse from June 6, 1990 to February 18, 2015 when she was suspended for non-payment of fees. On March 20, 2015 her certificate of registration was administratively revoked by the Executive Director for non-payment of fees.
At the time of the allegations, the Member worked as a Registered Nurse at the Southlake Regional Health Centre (the “Hospital”) in the emergency department. She was employed by the Hospital from August 7, 2009 to June 25, 2014, when her employment was terminated because of three incidents of care between July 25, 2013 and June 6, 2014. The three incidents of care involve allegations that she attempted to force one client to take a pill medication, administered the wrong medication to another client, and failed to document vital signs for that client when required to do so.
The issues are: (a) Did the Member contravene a standard of practice of the profession or fail to meet the standards of practice of the profession, when she attempted to force a client to take medication, administered the wrong medication to a client and failed to document vital signs, when required to do so? (b) Did the Member do something to a client without consent of the client? (c) Did the Member fail to keep records? (d) Did the Member abuse a client? (e) Did the Member engage in conduct that would be considered by the members of the profession to be disgraceful, dishonorable and unprofessional?
The Panel found that all three incidents of care were proven to have occurred. As a result, the Member contravened a standard of practice of the profession in respect of all three incidents of care, abused a client, tried to force a client to take medication without consent, gave another client the wrong medication, and failed to keep records as required. The Panel found all of the above would reasonably be considered by members to be disgraceful, dishonourable and unprofessional.
The Evidence
The Evidence
The Panel was provided with a book of documents (Exhibit 1) and video footage (Exhibit 2).
The Panel also heard from two witnesses. [Witness A] was a fact witness from the Hospital who identified the documents entered as exhibits, the video evidence, and the expectation of the Hospital. The second witness, Karen Riddell, was qualified by the panel as an expert witness to give opinion evidence on the standards of practice of nursing in acute care settings.
[Witness A], was registered as an RN in 1994 with the College and had been working in various positions at the Hospital since 2001. She is currently employed in an educator position elsewhere. At the time of the incidents she was the clinical manager of the Hospital. She testified as to how the emergency department operated, how patients were assigned, the layout of the department, what was expected of the staff, charts for patients, the pump data and acudose report for the Member for the labetalol medication at issue, the requirements for monitoring the administration of labetalol and the Hospital’s policies and procedures on documentation, assessment and treatment following triage. All documents identified by her formed part of Exhibit 1.
The Panel found the witness to be credible, she presented the materials factually, and testified that she was not present during the incidents of care at issue, but that she did speak to the Member concerning the allegations. [Witness A] relied on her personal notes when she could not remember, otherwise her memory was good, she spoke clearly and had a good knowledge of the proper procedures and expectations of the staff. She presented as an honest witness, with nothing to gain from her testimony.
The first incident of care involved [Client A]. [Witness A] identified the video footage of the Member trying to force [Client A] to take a pill by throwing it at his mouth and then using more force to get him to take it. She also identified [Client A’s] chart (Tab 5, Exhibit #1). The Member in her letter to [Investigator], an investigator for the College, admitted to attempting to throw the medication into [Client A’s] mouth. After that admission, the Member’s story differed from the actual video footage, in that the Member said in her letter that [Client A] made a fist and threatened her. The video shows that did not happen.
As a result of the investigation by the Hospital of the [Client A] incident, the Hospital issued the Member a letter dated October 8, 2013 (Tab 7, Exhibit #1) with a learning plan and requirements to improve her practice. This learning plan was not completed in the timeline initially given by the Hospital, but was completed by March 3, 2014.
The other two incidents of care involved [Client B]. [Witness A] testified these incidents both took place on June 6, 2014 in the emergency department of the facility, when [Client B] was admitted for low blood pressure. The witness identified [Client B’s] medical record (Tab 9, Exhibit 1). The records showed that [Client B’s] blood pressure was monitored until 9:12 a.m. and then it was not charted after that time. The records showed a bolus was administered as directed by the doctor’s orders, and then the Member administered Labetalol, which had not been ordered and which lowers blood pressure, instead of Levophed, which was the drug that had been ordered and which raises blood pressure. [Client B] received this wrong medication for about 25-30 minutes. At 10:10 [Client B] went into cardiac arrest. Resuscitation efforts continued until about 11:30 am but were not successful. The Member admitted making a drug error in her letter to the College. [Witness A] testified that the Member admitted her error to her as well.
[Witness A] testified E.R. nurses should know the drugs they are administering and what they are used for and they need to ask if they don’t have the knowledge. She also testified that she would have expected to see [Client B’s] vital signs documented until such time as the patient was stable, and then continued monitoring on a regular basis. She also identified the drug report (Tabs 10 and 11, Exhibit #1) showing the wrong medication was given by the Member to [Client B]. [Witness A] also testified that the Member told her she did not realize she had given the wrong medication until it run for about 25 minutes and Code Blue was called.
Witness # 2, Karen Riddell was qualified by the panel to be an expert witness in the area of the standards of practice of nursing in acute care settings. College Counsel provided the panel with Ms. Riddell’s C.V., showing extensive experience and education in acute care. Ms. Riddell was given a hypothetical situation, similar to the incidents alleged against the Member. She identified the College’s published standards on Professional Standards, Practice, Documentation and the Therapeutic Nurse – Client Relationship. She was asked for her opinion.
Concerning the incident involving [Client A], Ms. Riddell testified this was a vulnerable client who should be treated with respect. There was a failure to get the client’s consent, which is required by law, and when the client refused the medication the Member should have left. In the video it showed physical abuse of the client and given the imbalance of power in the nurse-client relationship, it would also be a form of emotional abuse.
Concerning the two incidents involving [Client B], Ms. Riddell testified this was a breach of the standards of practice as the Member should have known the effects of the medication she was giving, and should have monitored the client closely. There are resources to access information and if a nurse doesn’t understand or agree then she needs to say so and ask direction. Her first failure was not knowing which drug lowers blood pressure and which drug increases blood pressure. Then she also failed to document the information in the patient chart on vitals, which was required to be done every 5 minutes until the patient stable. Her opinion was that the Member definitely breached the standards of practice of the profession by her actions in the care of [Client B].
Final Submissions
Final Submissions
College Counsel submitted that the College bears the burden of proof on the balance of probabilities, that is, the College must prove it is more likely than not that the incidents occurred. He also stated that while the Member not being present is not a factor for the Panel to rely on in the decision, it meant that there was no competing evidence to what was presented to the Panel.
College Counsel submitted that incident 1 involving [Client A] was proved by Exhibit 2, the video footage, and the testimony of [Witness A] that the Member confessed, and the Member’s admission in her letter to the College. Ms. Riddell testified that the standards were breached by this conduct, that the Member failed to obtain consent when required to do so, and that the conduct was physical and emotional abuse. College Counsel submitted that the Member’s actions where disgraceful, dishonourable and unprofessional.
Concerning the incidents involving [Client B], the evidence was clear that the Member administered the wrong drug, did not monitor the client, and did not chart properly. College Counsel submitted the Member did not follow Hospital policy on the care of the client and did not monitor her vitals as required. The evidence of the expert was that this was a violation of the standards of practice in that the Member gave the wrong medication and failed to monitor and document.
Decision
Decision
The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities and based upon clear, cogent and convincing evidence.
Having considered the evidence and the onus and standard of proof, the panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1 a, b, and c, 2 a, 3 a, 4 a, and 5, a, b, and c of the Notice of Hearing. In particular, the Member engaged in conduct that would reasonably be regarded by members of the profession as disgraceful, dishonourable and unprofessional; physically and emotionally abused a client; forced a client to take a pill without consent; administered the wrong drug to a client; failed to document vital signs of a client when required to do so; and therefore failed to meet the standards of the profession.
Reasons for Decision
Reasons for Decision
The Panel deliberated and watched the video evidence several more times to be sure of what the evidence showed on the video. The Panel relied on this evidence to find that the Member abused a client both emotionally and physically by forcing him to take a pill against his will and without consent.
The video footage showed the Member forcing the client [Client A] to take a pill, without consent. The evidence from the College’s expert was that this a breach of the standards of practice, and that consent was required. The Panel found this to be abuse as well as a failure to meet the standards of practice of the profession.
The Panel also relied on the two witnesses’ testimony concerning the administration of Labetalol to [Client B] and the failure to monitor vitals and document with respect to [Client B]. The documentary evidence was clear as to what occurred. The expert opinion evidence as to how this constituted a violation of the standards of practice was reasonable and clear.
The Panel found the Member’s actions would be considered by the members of the profession to be disgraceful, dishonourable and unprofessional, because of the abuse of a vulnerable client when forcing him to take a pill without consent, when such consent is required by law. The failure to monitor another vulnerable client, when it is a requirement of the hospital policy and was also an order for care, the medication error, the transporting of the client with no monitoring and the lack of documentation of the client all contributed to the panel’s decision.
I, Michael Hogard, 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