College of Nurses of Ontario v. Joanna Flynn, 2017 ONCNO 142608

PANEL: MARGARET TUOMI Public Member, Chair

DAVID EDWARDS, RPN Member

TERRY HOLLAND, RPN Member MARY MACMILLAN-GILKINSON Public Member

BETWEEN:

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

and - )

JOANNA FLYNN ) KATE HUGHES for

Reg. No. 0182683 ) Joanna Flynn

) LUISA RITACCA

) Independent Legal Counsel

) Heard: November 27, 2017

DECISION AND REASONS

[February 2, 2018 Addendum: Following the release of our Decision and Reasons, it was brought to the panel’s attention that the panel’s Decision and Reasons signed on January 12, 2018 contained a few errors. On reviewing the Decision and Reasons, the panel decided to make the following three corrections: (a) On page 2, last paragraph, last sentence, of the Decision and Reasons, the phrase “…did not chart progress notes at or about 2055 and 2108 hours and…” was deleted and replaced with “…charted progress notes at or about 2055 and 2108 hours that failed to record…” (b) on page 7, last paragraph, second sentence of the Decision and Reasons, the phrase “…did not chart progress notes at or about 2055 and 2108 hours and…”was deleted and replaced with the phrase “…charted progress noted at or about 2055 and 2108 hours that failed to record…” (c) on page 8, third paragraph, second sentence of the Decision and Reasons, the phrase “however she failed to chart any progress notes between 20:55 and 21:08 hours” was deleted.]

This matter came on for hearing before a panel of the Discipline Committee on November 27, 2017 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 2 and 3 of the Notice of Hearing dated November 27, 2017. The panel granted this request. The remaining allegations against Joanna Flynn (the “Member”) 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 employed as a Registered Nurse at Georgian Bay General Hospital in Midland, Ontario, 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 on March 2, 2014:

(a) discontinuing life support for the client, [the Client], without having both of the required medical authorization and the informed consent of the substitute decision maker; and/or

(b) charting progress notes at or about 2055 and/or 2108 hours that falsely documented instruction or consent of the substitute decision maker to discontinue life support and/or that failed to record that medical authorization to discontinue life support had been refused by the responsible physician.

[Withdrawn]
[Withdrawn]
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 as a Registered Nurse at Georgian Bay General Hospital in Midland, Ontario, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional with respect to the following incidents on March 2, 2014:

(a) discontinuing life support for the client, [the Client], without having both of the required medical authorization and the informed consent of the substitute decision maker; and/or

Member’s Plea

With respect to allegation 1(a) in the Notice of Hearing, the Member admitted that she discontinued life support for the client, [the Client], without having the required medical authorization. With respect to allegation 1(b) in the Notice of Hearing, the Member admitted that she charted progress notes at or about 2055 and 2108 hours that failed to record that medical authorization to discontinue life support had been refused by the responsible physician. With respect to allegations 4(a) and (b), the Member admits that it was unprofessional and dishonourable when she discontinued life support for client, [the Client], without having the required medical authorization and when she failed to record that medical authorization to discontinue life support had been refused by the responsible physician.

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 and the Member advised the panel that agreement had been reached on the facts. The parties introduced an Agreed Statement of Facts, which provides as follows.

THE MEMBER

Joanna Flynn (the “Member”) obtained a diploma in nursing from Georgian College in 2001.
The Member registered with the College of Nurses of Ontario (the “College”) as a Registered Nurse (“RN”) on May 1, 2001.
The Member was employed at Georgian Bay General Hospital (the “Hospital”) from November 15, 2004 to March 7, 2014, when her employment was terminated as a result of the incident below.

THE HOSPITAL

The Hospital is located in Midland, Ontario. It is a 116 bed community hospital.
The Member worked in various roles at the Hospital. From October 2007 to January 2012, she worked in the Emergency Department. From January 2012 until her employment was terminated, the Member worked on the Intensive Care Unit (the “ICU”) as a full-time staff nurse on day and night shifts.
The ICU has between six and eight beds.

FACILITY POLICY

The Hospital had a “Discontinuation of Life Support System” policy that was part of the Intensive Care Manual.
The policy stated:

The decision to discontinue a patient’s Life Support System (i.e. Ventilator) is a medical one. The decision is to be made after consultation with the patient’s family, advocate or substitute decision maker. The consultation with the family must be documented on the Progress Record by the physician. The physician must be present when the mechanical ventilation is discontinued.

THE CLIENT

[The Client] (the “Client”) was 39 years old at the time of the incident.
On Friday, February 28, 2014, the Client underwent a prolonged arthroscopy (day knee surgery) at Southlake Regional Health Centre. The Client was otherwise healthy.
On Saturday, March 1, 2014, the Client was at home. She felt short of breath but did not seek medical attention. She watched a hockey game with her husband, [the Client’s Spouse], and went to sleep.
Early the next morning, on March 2, 2014, the Client woke with shortness of breath and crushing chest pain.
At 04:14, [the Client’s Spouse] called an ambulance, which arrived at 04:25.
While being carried downstairs at 04:34, the Client had a seizure and was vital signs absent (VSA).
EMS recorded at 04:37:57 that CPR was initiated while the Client was on the stretcher. The Client’s carotid pulse returned and she took some respirations. At 04:39, though, she was VSA again.
When the Client arrived at the Hospital at 04:44, ER staff tried to revive her. CPR was performed on the Client seven times in the ER. At 04:50, the Client was intubated and at 05:20, she was placed on a mechanical ventilator. [The Client’s Spouse]., as the substitute decision maker was informed of her status by the ER physician, [Physician A].
At 07:10, resuscitation efforts ended. The ER physician, [Physician A], noted that “resuscitation started at 04:44 and ended at 07:10.” He then wrote:

this patient was admitted in the hospital with possible acute pulmonary emboli and I neglected to say in my dictation this morning that she came in with a Glasgow coma scale of 3. She was totally unresponsive. No effort to breath, no moving any of her limbs. Pupils were equal and dilated, not responding to light. She also had no corneal reflex.

At 09:00, the Client was transferred to the ICU on life support. Trillium Gift of Life Support Network was contacted. No efforts were made to transport her to higher level hospital.

INCIDENT RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

[Physician B] was the physician on shift in the ICU when the Client arrived. He charted:

the situation suggests to me she is bleeding from the mediastinum. She may have some DIC post-cardiac arrest. I comfortably cannot anticoagulate her. It seems unlikely she is going to survive this crisis. I had a fairly long conversation with her husband and explained the gravity of the situation.

[Nurse A] was the day shift nurse on March 2, 2014. At 15:01, she charted: “[Physician B] states he spoke to the husband and family about the gravity of patient condition and poor prognosis.”
[Physician C] took over care of the Client from [Physician B] around 13:00. He received report, including that the Client’s prognosis was poor and that she was probably dying. [Physician C] met with the family to discuss the Client’s prognosis. [Nurse A] was present during the meeting.
At 18:30, [Nurse A] charted:

[Physician C] spoke with husband [the Client’s Spouse] and the pt’s mother-in-law about poor prognosis and absence of brain activity. Husband and mother-in-law verbalizing understanding of severity of the condition. Support given to family.

If [Nurse A] were to testify, she would say that immediately following the meeting with [Physician C] and the family, [the Client’s Spouse’s] mother asked if [Physician C] was saying the Client was brain dead, and [Nurse A] confirmed that was the case.
The Member started the night shift on March 2, 2014 at 19:00. She received report from [Nurse A], including that the Client’s family were aware of the gravity of the situation (including their understanding that [Physician C] said the Client was brain dead) and understood they would have to make a decision about continuing care.
[Nurse A] also expressed concern to the Member that [the Client’s Spouse] had not communicated his wishes in the event the Client’s heart stopped. The Member said she would take care of obtaining a do not resuscitate (DNR) order.
The Member did a head to toe assessment of the Client, including a neurological examination, which indicated that her pupils were fixed and dilated, and a deep sternal rub, where there was no response. She listened to the Client’s chest, checked her heart rate (which was elevated) and her blood pressure (which was very low). The Client’s hands were cyanotic and there was no urinary output. The Member checked the Client’s reflexes (there were none) and noted that her limbs were flaccid. The Member wrote her assessment and placed it in her pocket to chart on the computer at a later time.
After assessing the Client, the Member went to the lounge to speak with [the Client’s Spouse] and his family. If the Member were to testify, she would say [the Client’s Spouse] expressed his wish to discontinue life support because his wife was not there anymore. The Member then took the family in to the Client’s room to say goodbye.
The Member went to speak with [Physician C] at the nursing station. She informed [Physician C] that [the Client’s Spouse] wanted to withdraw care. [Nurse A] was present when the Member approached the nursing station to speak with [Physician C]. In response to the Member, [Physician C] shrugged his shoulders and stated that the decision to terminate life support should be left to the following day. He also made some irrelevant comments to the Member that seemed out of place in the circumstances.
At 19:30, the Member charted:

pt advised this nurse that he wanted to withdraw medical support.

“she wouldn’t want this”

[Physician C] advised of same.

The Member went back to the Client’s room.
If the Member were to testify, she would say that [the Client’s Spouse] told her he wanted care to be withdrawn that night and that he did not want to wait until the morning. After speaking with [the Client’s Spouse], the Member went back to the nursing station to speak with [Physician C] again and to advocate for what she believed were the family’s wishes. If the Member were to testify, she would say that [Physician C] acted strangely towards her, despite her communicating the family’s wishes to him to discontinue life support that night. She would further testify that she could not recall that he gave any response to her request that he terminate the Client’s life support.
The Member’s nursing manager, [the Nurse Manager], was present at the nursing station during the second interaction between the Member and [Physician C]. If [the Nurse Manager] were to testify, she would say that [Physician C] did act bizarrely towards the Member and he also told her the decision to stop life support should wait until Monday (the following day). [The Nurse Manager] also told the Member that the decision of the substitute decision maker had to be respected.
Following her second attempt to speak with [Physician C], the Member returned to the lounge to speak with [the Client’s Spouse] and confirmed that it was still the family's wish to discontinue life support that night. When [the Client’s Spouse] confirmed that he thought his wife would want him to discontinue life support, the Member ensured that the Client’s family had the opportunity to say goodbye to the Client. With [the Client’s Spouse] in the room, the Member turned off the Client’s life support machines. She stayed with [the Client’s Spouse] until the Client died.
At 20:15, the Member charted that the Client was VSA and she pronounced the Client’s death. The Member did not chart that medical authorization to terminate life support had been refused by [Physician C].
The family thanked the Member for her support and she comforted them. [Physician C] called the coroner because the death occurred within 48 hours of surgery. The Member advised the day supervisor of her concerns about [Physician C] The supervisor followed up and the Member readily agreed that there was no physician’s order to terminate life support.
If the Member were to testify, she would say that, at the time, she understood that the substitute decision maker made decisions about end of life care. She would say she understood that the College's Practice Guideline, Guiding Decisions About End-of-Life Care, 2009, in place at the time, provided that her role was to ensure the substitute decision maker’s wishes regarding end of life care were respected. However, she recognizes now that life support should not have been terminated without a medical order.
The Member’s employment was terminated by the Hospital on March 7, 2014. Her union grieved the termination and the matter went to arbitration.
The Hospital notified the police who investigated. The police contacted [the Client’s Spouse] and he initially had no concerns regarding the Member's care. Over a year later, on April 9, 2015, the Member was charged with manslaughter and criminal negligence causing death in relation to terminating the Client’s life support on March 2, 2014. Her arbitration was put into abeyance pending the criminal process. She was acquitted of both charges on June 8, 2017.

COLLEGE DOCUMENTS

The Practice Guideline for Guiding Decisions About End-of-Life Care, 2009, in effect at the relevant times, provided that the role of the nurse was to ensure that the wishes of clients and substitute decision makers were respected. It further stated that these wishes should be communicated to the inter-professional team so they could be included in the plan of care. If the nurse disagreed with the physician’s plan of treatment, the Practice Guideline for Disagreeing With the Plan of Care provided that the nurse should consult with her manager and higher authority at the facility and, if the dispute was not resolved, the nurse should document her concerns.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1(a) of the Notice of Hearing, in that she discontinued the Client’s life support without having the required medical authorization, as described in paragraphs 19 to 38 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1(b) of the Notice of Hearing, in that she failed to document that medical authorization to discontinue life support had been refused by the responsible physician ([Physician C]), as described in paragraphs 19 to 38 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 4 (a) and (b) of the Notice of Hearing, and in particular that her conduct would reasonably be regarded by members as dishonourable and unprofessional, with respect to terminating the Client’s life support without medical authorization, and without documenting that medical authorization had been refused, as described in paragraphs 19 to 38 above.
With leave of the Discipline Committee, the College withdraws the following allegations from the Notice of Hearing:

#2; and
#3

Decision

The panel finds that the Member committed acts of professional misconduct as set out in paragraphs 1(a) and (b) in the Notice of Hearing and as admitted by the Member in the Agreed Statement of Facts. In particular, the panel finds that the Member discontinued life support for the client, [the Client], without having the required medical authorization and that she charted progress notes at or about 2055 and 2108 that failed to record that medical authorization to discontinue life support had been refused by the responsible physician. As to allegation 4, the panel finds that the Member engaged in conduct that would reasonably be regarded by members to be dishonourable and unprofessional.

Reasons for Decision

The panel considered the Agreed Statement of Facts and the Member’s plea and finds that this evidence supports findings of professional misconduct as alleged in the Notice of Hearing.

Allegation #1 (a) in the Notice of Hearing is supported by paragraphs 19 - 38 in the Agreed Statement of Facts. The Client was admitted into the Hospital with vital signs absent. Despite several attempts to resuscitate the Client, she could not be revived and was placed on life support. Her family was aware that she was brain dead. If the Member were to testify she would state that the Client’s husband wanted to discontinue life support because his wife was not there anymore and “she wouldn’t want this”. The Member spoke to [Physician C], the ICU physician, two times inquiring as to whether life support could be withdrawn that evening as per the family’s wishes. Both times, no permission was granted. Even though the Member did not have the required medical authorization to do so, she turned off the Client’s life support machines. This is a breach of the standard of practice and the principles enshrined in the College’s Practice Guidelines Guiding Decision About End-of-Life Care and Disagreeing with the Plan of Care. While the Member’s actions may have been well-intentioned, she nonetheless failed to follow the required protocol and acted without a medical order. The Member’s actions resulted in serious consequences for the family, the Hospital and the Member herself.

Allegation #1(b) in the Notice of Hearing is supported by paragraphs 19-38 in the Agreed Statement of Facts. The Member charted that the Client was pronounced dead at 20:15. Further, the Member, neglected to chart that the medical authorization to terminate life support had been expressly refused by [Physician C]. The Member should have made note of [Physician C’s] refusal. Her failure to do so resulted in incomplete and inaccurate charts. This too was a breach of the standards of practice.

With respect to Allegation # 4(a) and (b), the panel finds that the Member’s conduct was unprofessional as it demonstrated a serious disregard for her professional obligations. The Member failed to live up to the standards expected of her when she ignored the physician’s decision regarding removing life support and proceeded to act independently without a medical order. The panel also finds that the Member’s conduct was dishonourable when she neglected to chart the conversations she had with the attending physician where he expressly refused to permit the termination of life support that evening. The Member ought to have known that the two discussions that she had with the physician were relevant and that they should have been documented. While the panel did not conclude that the Member acted deceitfully, the panel did find that the conduct brought shame to both the Member and the profession at large, and as such would reasonably be regarded by others in the profession as dishonourable. The Member should not have taken matters into her own hands as she did in this case. If she did not agree with the doctor’s orders, she should have taken the issue up to others at the Hospital.

Penalty

Counsel for the College and the Member advised the panel that a Joint Submission on

Order had been agreed upon. The Joint Submission requests that this panel make an order as follows.

Requiring the Member to appear before the Panel to be reprimanded within three months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for five months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in the practising class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend two meetings with a Nursing Expert (the “Expert”), at her own expense and within six months from the date of this Order. To comply, the Member is required to ensure that:

i. The Expert has expertise in nursing regulation and has been approved by the Director of Professional Conduct (the “Director”) in advance of the meetings;

ii. At least seven days before the first meeting, the Member provides the Expert with a copy of:

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
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, online learning modules, decision tools and online participation forms (where applicable):

Professional Standards and,
Disagreeing With the Plan of Care.

iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, and online participation forms;

v. The subject of the sessions with the Expert will include:

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

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

the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into her behaviour;

vii. If the Member does not comply with any one or more 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;

b) For a period of 24 months from the date the Member returns to the practice of nursing, the Member will notify her employers of the decision. To comply, the Member is required to:

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

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

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;

iii. Ensure that within 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:

that they received a copy of the required documents, and
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession; and
All documents delivered by the Member to the College, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.

Penalty Submissions

Submissions were made by College Counsel and the Member’s Counsel.

The parties agreed that the mitigating factors in this case included the following:

The Member has been registered since 2001 and has no prior disciplinary history with the College.
The Member was forthright with the Hospital from the beginning.
The Member has admitted the allegations and has accepted responsibility for them.
By cooperating with the College, the Member has avoided a costly contested hearing where witnesses would have had to come to the College to testify.
The circumstances of this case are unusual.
In hindsight, the Member acknowledges that she would have acted differently.

The aggravating factor in this case was the seriousness of the Member’s actions when she withdrew life support from her Client without a medical order and when she failed to chart her discussions with the physician. An additional aggravating factor is that the Member was criminally charged, and ultimately acquitted, of manslaughter and criminal negligence causing death.

The proposed penalty provides for both specific and general deterrence. The five month suspension and the imposition of terms, conditions and limitations will act to remind both the Member and the members at large that this conduct will not be tolerated. It sends a strong message that serious conduct results in serious consequences. In addition, the reprimand and the educational aspects of the proposed penalty provide for remediation and rehabilitation.

Overall, the public is protected because the Member will have the opportunity to reflect on her conduct, gain a deeper understanding into her actions and improve on her practice so that this will not happen again. The 24-month employer notification ensures that the Member’s employer is aware of her discipline history and will alert the Director immediately if she breaches the standards of the profession. The public will be reassured that the College is able to govern its members.

Counsel submitted two cases to the panel which were loosely analogous to this case in order to demonstrate that the proposed penalty fell within the appropriate range. The two cases both involved situations where nurses were required to take action but failed to do so. Counsel acknowledged that, in the case, the opposite occurred and, as a result, the value of these comparisons are limited.

The College submitted the case of CNO v. Papiya Mia Sircar (Discipline Committee, 2011). The member, in that case, failed to monitor her client and intervene properly when the client’s vital signs remained abnormal. Her lack of action caused the client’s condition to deteriorate. This ultimately resulted in the client’s death. The member also failed to keep records as required. The Joint Submission on Order was accepted. The Member was given a 5-month suspension, one meeting with a Nursing Expert and a 12-month employer notification requirement.

The College also submitted the case of CNO v. Rose Gyasi (Discipline Committee, 2014). In this case, the member failed to adequately assess, monitor and provide appropriate nursing care to a pregnant inmate. The member failed to transfer the client to a medical facility where her needs could be addressed. As a result, the baby was born in the inmate’s cell. The member was given a 5-month suspension, two meetings with a Nursing Expert and a 12-month employer notification requirement.

Counsel for the parties and independent legal counsel reminded the panel that Joint Submissions on Order are not to be interfered with lightly. Both counsels agreed that this Joint Submission on Order met all the requirements for general and specific deterrents as well as rehabilitation, remediation and public protection. Independent legal counsel stated that the panel could take comfort in the fact that the Joint Submission on Order was the product of negotiations between two very experienced counsel. She stated that the proposed penalty is well within the reasonable range of other cases.

Penalty Decision

The panel accepts the Joint Submission as to Order and accordingly orders:

Requiring the Member to appear before the Panel to be reprimanded within three months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for five months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in the practising class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

i. The Expert has expertise in nursing regulation and has been approved by the Director of Professional Conduct (the “Director”) in advance of the meetings;

ii. At least seven days before the first meeting, the Member provides the Expert with a copy of:

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;

Professional Standards and,
Disagreeing With the Plan of Care.

iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, and online participation forms;

v. The subject of the sessions with the Expert will include:

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

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

the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into her behaviour;

b) For a period of 24 months from the date the Member returns to the practice of nursing, the Member will notify her employers of the decision. To comply, the Member is required to:

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

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

Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;

iii. Ensure that within 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:

that they received a copy of the required documents, and
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession; and
All documents delivered by the Member to the College, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.

Reasons for Penalty Decision

The panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly.

The panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility. This penalty sends a strong message to the membership that members should not act independently when medical authorization is required. The penalty also serves as a reminder that it is incumbent on a nurse to follow proper procedures and protocols and to seek clarification with a person in higher authority when there is a dispute regarding a plan of treatment.

The penalty reflects the seriousness of the matter and in in line with what has been ordered in previous cases.

I, MARGARET TUOMI, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel.

Chairperson Date