DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Tanya Dion, RN Chairperson Renate Davidson Public Member David Edwards, RPN Member Lina Kiskunas, RN Member Ashleigh Molloy Public Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) EMILY LAWRENCE for ) College of Nurses of Ontario
- and - )
LINDA MAY D’ASCANIO ) NO REPRESENTATION for Reg. No. 8900656 ) Linda May D’Ascanio
) JOHANNA BRADEN ) Independent Legal Counsel
) Heard: June 13 – 14, 2017
DECISION AND REASONS
This matter came on for hearing before a panel of the Discipline Committee on June 13, 2017 and June 14, 2017 at the College of Nurses of Ontario (“the College”) at Toronto.
As Linda May D’Ascanio (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.
Counsel for the College provided the Panel with evidence that the Member had been sent the Notice of Hearing on February 22, 2017. College Counsel also informed the Panel that the Member had sent an email on June 10, 2017 indicating that she would not be attending. The Panel was satisfied that the Member had received adequate notice and therefore proceeded with the hearing in the Member’s absence.
Publication Ban
On request of the College, the Panel made an Order pursuant to s. 45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, that no person shall publish, broadcast or otherwise disclose health records and health information of clients or any information that could disclose the identity of the clients who are referred to during the hearing, or in any document or exhibit filed at the hearing
The Allegations
Counsel for the College advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs 4(a)i, 4(a)vii, 4(a)viii, 4(b)ii, and 4(b)ix of the Notice of Hearing dated February 21, 2017. Those allegations related to contravention of provisions of the Nursing Act, the Regulated Health Professions Act or the regulations under either of those Acts. The Panel granted this request. The remaining allegations set out in the Notice of Hearing 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 in nursing at the Pond Mills Medical Clinic (the “Facility”) in London, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, and in particular:
a. you recommended a prescription medication (Ventolin) to client [Client A], without consulting with a physician, on January 3, 2015;
and/or
b. you wrote [Doctor A’s] name and a CPSO number on prescriptions you issued, without [Doctor A’s] direction or authority to do so, between November 2014 and January 2015, in respect of, but not limited to, one or more of the following clients:
Client Date
i. [Client A] December 21, 2014
ii. [Client B] November 29, 2014
iii. [Client C] December 20, 2014
iv. [Client D] December 20, 2014
v. [Client E] November 28, 2014
vi. [Client F] December 21, 2014
- 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 employed in nursing by the Facility, you failed to keep records as required, in respect of, but not limited to, one or more of the following clients:
Client Date
i. [Client G] November 28, 2014
ii. [Client H] November 28, 2014
iii. [Client I] November 28, 2014
iv. [Client F] December 21, 2014
v. [Client J] January 8, 2015
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(16) of Ontario Regulation 799/93, in that, while employed in nursing at the Facility, you inappropriately used a term, title or designation in respect of your practice by holding yourself out as a Nurse Practitioner, to clients and/or in the resume you provided to the Facility, when you were not a member of the extended class, in violation of s. 11(1), 11(5) of the Nursing Act, 1991, and/or s. 4.2(7) of Ontario Regulation 275/94, between November 2014 and January 2015.
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(19) of Ontario Regulation 799/93, in that, while employed in nursing at the Facility, you contravened a provision of the Nursing Act, 1991, the Regulated Health Professions Act, 1991 or the regulations under either of those Acts, and in particular:
a. you performed the controlled act of communicating to a client, or a client’s representative, a diagnosis or diagnoses made by you identifying as the cause of the client’s symptoms, a disease or disorder, in violation of s. 27(1) of the Regulated Health Professions Act, 1991, and/or s. 4 and/or s. 5.1(1) of the Nursing Act, 1991, between November 2014 and January 2015, in respect of but not limited to one or more of the following clients:
Client Date
i. Withdrawn
ii. [Client H] November 28, 2014
iii. [Client A] December 1 2014; December 21,
2014; and January 3, 2015
iv. [Client K] December 21, 2014
v. [Client C] December 20, 2014
vi. [Client D] January 3, 2015
vii. Withdrawn
viii. Withdrawn
and/or
b. you performed the controlled act of prescribing, dispensing, selling or compounding a drug, in violation of s. 27(1) of the Regulated Health Professions Act, 1991, and/or s. 4 and/or s. 5.1(1) of the Nursing Act, 1991, between November 2014 and January 2015, in respect of, but not limited to, one or more of the following clients:
Client Date
i. [Client A] December 21, 2014
ii. Withdrawn
iii. [Client B] November 29, 2014
iv. [Client C] December 20, 2014
v. [Client D] December 20, 2014
vi. [Client I] November 28, 2014
vii. [Client E] November 28, 2014
viii. [Client F] December 21, 2014
ix. Withdrawn
x. [Client L] January 5, 2015
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
The Member registered with the College of Nurses of Ontario (the “College”) as a Registered Nurse (“RN”) on August 3, 1988. Although the Member completed a Masters in Nursing in a Nurse Practitioner –Adult Program in 2009, she did not apply to be a Nurse Practitioner (“NP”) in the College’s extended class.
The Member obtained a position at the Pond Mills Medical Clinic (the “Clinic”) in London, Ontario as a Nurse Practitioner. She was employed at the Clinic from November 28, 2014 to January 8, 2015 when her employment was terminated. The Member resigned from the College on November 9, 2016.
The Clinic is a walk-in medical clinic where the Member was employed as a Nurse Practitioner.
It is alleged that the Member contravened standards of practice of the profession or failed to meet the standards of the profession when:
She recommended a prescription medication (Ventolin) to [Client A] without consulting a physician;
She wrote [Doctor A’s] name and CPSO number on prescriptions she issued for six clients ([Client A], [Client B], [Client C], [Client D], and/or [Client F]) without [Doctor A’s] direction or authority;
She failed to keep records as required on one or more of clients ([Client G] on Nov. 28, 2014; [Client H] on Nov. 28, 2018; [Client I] on Nov. 28, 2018; [Client F] on Dec. 21, 2014; [Client J] on January 8, 2015).
She inappropriately held herself out as a Nurse Practitioner to clients, and/or in her resume to the Clinic, while not being a member of the extended class.
She performed the controlled act of communicating to a client, or a client’s representative, a diagnosis to one or more of clients ([Client H] on Nov. 28, 2014; [Client A] on Dec. 1, 2014; Dec. 21, 2014; and Jan. 3, 2015; [Client K] on Dec. 21, 2014; [Client C] on Dec. 20, 2014; [Client D] on Jan. 3, 2015).
She performed the controlled act of prescribing, dispensing, selling or compounding a drug to one or more of clients ([Client A] on Dec. 21, 2014; [Client B] on Nov. 29, 2014; [Client C] on Dec. 20, 2014; [Client D] on Dec. 20,2014; [Client I] on Nov. 28, 2014; [Client E] on Nov. 28, 2014; [Client F] on Dec. 21, 2014; [Client L] on Jan. 5, 2015.)
The Panel received testimony from 10 witnesses (7 by affidavit) including an expert witness regarding a Nurse Practitioner’s scope of practice. The Panel also received 52 documentary exhibits, including clients’ clinical charts, copies of prescriptions issued by the Member, the Member’s CV and her Record of Employment.
The issues the Panel was asked to consider are as follows:
(1) Did the Member commit professional misconduct by failing to meet the standards of practice?
(2) Did the Member commit professional misconduct by using [Doctor A’s] name and CPSO number on prescriptions she issued without [Doctor A’s] authority to do so.
(3) Did the Member commit professional misconduct by failing to keep records as required?
(4) Did the Member commit professional misconduct by communicating a diagnosis?
(5) Did the Member hold herself out to be a Nurse Practitioner although she was not registered with the College in the extended class?
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); 2; 3; 4 (a) (b) in the Notice of Hearing.
The Evidence
The Investigation – Witness #1 – [Witness A]
[Witness A] has been employed by the College for over four years as an Investigator. He testified that the College received an anonymous letter indicating that the Member was practicing as a Nurse Practitioner in the “Facility”. He contacted the Clinic Manager on April 13, 2015 and requested documentation in order to proceed with the investigation (Ex. 3).
The witness testified that as part of his investigation, he visited the work site, obtained the Member’s work schedule, then from the Member’s client files randomly pulled 10 to 12 names of the Member’s clients to examine the documentation the Member had made on those charts.
He also obtained a copy of the Member’s resume, her Master of Nursing Diploma (Ex. 4) and the Member’s Record of Employment, dated January 20, 2015 in which her occupation was shown as Nurse Practitioner (Ex. 5).
The witness testified that he then conducted a document review of the 10-12 client records he had randomly requested and examined the clinical chart of each client. He stated he then called the clients to determine what pharmacy they used so that he could obtain the prescription scripts the clients had received from the Member. The witness testified that he verified the Member’s handwriting by comparing it with her entries on the clients’ clinical charts.
He indicated that copies of all the documents he obtained during his investigation were forwarded to the Member for her response. He provided documentary evidence that the Member received a follow-up letter on February 19, 2016 requesting her response by March 14, 2016.
The witness also stated that the College had sent a letter to the Member, dated June 29, 2011 which included a notation that the Member was holding herself out as an NP and was directed to “immediately cease using the initials “NP” after your name, the designation RN (EC) and APNC” (Ex. 32).
Witness #2 – [Doctor A]
The witness stated that he served as Medical Director at the Clinic during the period under investigation. He indicated his specialty area is family medicine and that his role in this walk-in clinic was primarily to look after patients. He testified that he worked with a front-desk assistant and a physician’s assistant. He stated the only assistant whose work he supervised was a physician’s assistant.
The witness stated that he did not see patients with the Member and that he never delegated his responsibilities to the Member. He testified that he never gave authorization to the Member to chart in his clients’ charts, to issue prescriptions on his behalf, to use his name or his CPSO number. He testified that he was asked by the manager to supervise the Member but he declined.
The witness examined the prescription records for [Client A] (Ex.24), [Client G], (Ex.25), [Client H] (Ex.26), [Client C], (Ex.27), [Client D] (Ex. 28), [Client F] (Ex. 29), (Ex.30). In each case, he testified no consult had taken place with the Member, that he was unaware his name and number were being used, and that it was not his signature on the prescriptions.
The Panel found [Doctor A] to be a credible and forthright witness. He had good recall of the pertinent details of the case and freely acknowledged that there were some memory issues given the length of time since the incidents referred to.
The Panel accepted affidavit evidence of seven witnesses.
College Counsel advised that these witnesses were not readily available to testify and asked the Panel to consider the cost, time and inconvenience of the witnesses to be present in person. The affidavits would be hearsay evidence; the Member would not be present to cross-examine these witnesses or to raise any objection.
The Panel decided it would admit the affidavits into evidence and would determine the weight of the evidence when coming to a decision regarding the allegations against the Member.
Witness – [Doctor B] (Ex. 42)
[Doctor B] attested that he practiced as a covering walk-in Physician at Pond Mills Medical Clinic from November, 2013 to October, 2014. He stated that during the last month of his practice [the Facility], he recalled a nurse practitioner working at the clinic. He attested that he did not work directly with this nurse practitioner nor did he employ her or supervise her in any manner.
The witness attested that he did not delegate to any nurse practitioner or anyone else at [the Facility] to write any prescriptions on his behalf, to use his name on any prescription, or to use his CPSO number on any prescription.
The witness attested that he reviewed the prescription contained under Tab A (Ex. 31); that it appeared to be a computer-generated renewal prescription faxed by the pharmacy to [the Facility]. He did not give anyone at Pond Mills Clinic permission to use his name or CPSO number. He noted that the prescription was dated January 5, 2015, and he was no longer practicing at the clinic on that date.
Witness – [Witness B] (Ex. 35)
The witness attested that she visited the clinic on November 28, 2014 with her son [Client G], five years old, who was experiencing a skin rash on both of his legs and on his feet. She stated the Member introduced herself as a Nurse Practitioner and was the only health professional who treated [Client G] on that day.
The Member examined [Client G] and stated she believed he had impetigo but was unsure. She recommended [Client G] be brought back to the Clinic the next day to see the doctor.
The witness described that she returned with her son [Client G] on November 29, 2014; [Client G] was treated by a doctor, who diagnosed [Client G] with a viral rash and wrote him a prescription for a topical medication.
Witness – [Client H] (Ex. 36)
The witness attested that she attended the Pond Mills Medical Clinic on November 28, 2014 because she wanted to obtain a prescription for orthotics. She described that the Member treated her, told her she had flat feet and issued her a prescription to obtain orthotics. She stated that the Member was the only medical professional who treated her that day.
Witness – [Client A] (Ex. 37)
The witness attested she had attended Pond Mills Medical Clinic in December, 2014 and January, 2015 because she was experiencing ongoing cold symptoms such as fever, sore throat, coughing and sinus pain. At the December 1 and 24, 2014 appointments, the Member told her that she had sinusitis and an upper respiratory tract infection. The Member also gave her a prescription for antibiotics. The Member was the only medical professional who treated her on these two dates.
The witness explained that she again attended the Clinic on January 3, 2015 and was treated by the Member who diagnosed her with an upper respiratory tract infection and sinusitis. She indicated that the Member then discussed with her “the fact that I had a Ventolin puffer for my asthma, and she recommended to me that I try using my Ventolin puffer in relation to my current symptoms”. She stated that the Member was the only medical professional who treated her on January 3, 2015.
Witness – [Client K] (Ex. 38)
The witness attested that she attended the Pond Mills Medical Clinic on December 21, 2014 because she had been coughing and had a fever that had lasted for weeks prior. She stated that the Member treated her, told her that she had a respiratory infection and gave her a prescription. She explained that the Member was the only medical professional who treated her that day.
Witness – [Client C] (Ex. 39)
The witness attested that she visited the clinic on December 20, 2014 because she was experiencing sinus pain and congestion. She stated that the nurse who treated her was the Member. The Member told her that she had acute sinusitis and gave her a prescription for Zithromax, an antibiotic.
She stated that she was breastfeeding at the time and asked the Member whether it was safe for her to take antibiotics. The Member told her it was fine to take the Zithromax and that it would not have any effect on her breastfeeding.
She attested that the Member was the only medical professional who treated her that day.
Witness - [Witness C] (Ex. 40)
The witness attested that she visited Pond Mills Medical Clinic in December, 2014 and again on January 3, 2015 with her daughter who had a fever. She stated that the Member attended to her daughter on both occasions, and told her on both occasions that her daughter had bronchitis and gave her a prescription for Zithromax to fill for her daughter.
She indicated that the Member was the only medical professional who treated her daughter on both occasions.
Witness – [Client I] (Ex. 41)
The witness attested that she visited Pond Mills Medical Clinic on November 28, 2014 to obtain a refill on her prescriptions. The nurse who treated her was the Member. She stated that the Member wrote her a prescription for Naproxen, Fucidin and Zovirax.
She stated that the Member was the only medical professional who treated her that day.
Expert Witness – Dr. Michelle Acorn
Dr. Michelle Acorn was tendered by College Counsel as an expert regarding nursing standards.
Her formal education includes the following:
Doctor of Nursing Practice/Family Nurse Practitioner, D’Youville, Buffalo, New York (2012-2014)
Master of Nursing/Acute Care Nurse Practitioner, University of Toronto (2000-2002)
Primary Health Nurse Practitioner (summa cum laude) York University (1999)
The Panel determined after reviewing Dr. Acorn’s curriculum vitae and hearing her responses to questions posed by Counsel that she was qualified to give opinion evidence with respect to nursing standards.
Dr. Acorn testified that she had received a hypothetical scenario from Counsel with a request to provide an opinion. She also received copies of the College’s standards of practice including Professional Standards (Ex. 46); Medication Standard (Ex. 47); Documentation (Ex. 48); RHPA: Scope of Practice Controlled Acts Model (Ex. 49); Decisions About Procedure and Authority (Ex. 50); Authorizing Mechanisms (Ex. 51); Nurse Practitioner (Ex. 52).
College Counsel took Dr. Acorn to the hypothetical scenario which reflected the facts of the case as submitted by the College (Ex. 45). With respect to incident 1, Dr. Acorn stated that because the Member was registered in the general class, recommending a prescription medication without consulting with a physician was a contravention of the standard of practice.
The expert testified that based on incident 2, paragraphs 12, 13, 14 of the hypothetical situation in which the Member used the physician’s name and CPSO number on prescriptions for six clients without authorization of the physician, the Member failed to meet the prescribing, communication, accountability and ethics, authority standards of practice.
With respect to incident 3, i.e. documentation, the expert testified that the following information should be recorded by a registered nurse: issue, age, birthdate, allergies, medicine prescriptions, subjective findings. The expert also stated that it is mandatory for a nurse to include her name and designation in the documentation.
The expert reviewed the client charts noted in incident 3, and stated that in each situation the Member breached a standard of practice, for failing to provide the necessary information.
The Panel found Dr. Acorn’s opinion to be reasonable and well within her area of expertise, given her work and educational experience. The expert’s review of the hypothetical facts and the relevant standards was clear and measured.
Final Submissions
Counsel acknowledged that it bears the onus to prove, on a balance of probabilities that the conduct alleged in the Notice of Hearing occurred.
The Member is deemed to have denied the allegations; however, the College must prove the case. The Member has not contested the evidence in person or attempted to object through affidavit. As such, there is no competing evidence or narrative for the Panel to consider.
Counsel submitted that the Panel is well within its authority to accept affidavit evidence and give it the weight it deserves. All this evidence is uncontested. The evidence comes from witnesses with no interest in the outcome of this proceeding.
[Doctor A’s] evidence was that he did not authorize the Member to use his name and CPSO number. Although he was not able to provide specific information regarding conversations he might have had with the Member, he concluded that she was able to practice independently; there is no dispute on that point.
Counsel submitted that the Member held herself out as a Nurse Practitioner; that she performed as if she was a Nurse Practitioner; and used work orders she was not authorized to use, including CPSO work numbers.
In practising as a Nurse Practitioner, the Member took steps to complete controlled acts outside her scope of practice.
Counsel submitted that the evidence of the expert witness confirmed a failing of the Member to keep adequate records.
Counsel submitted that the evidence is clear and compelling and consistent with the documentary record.
Counsel submitted that members can practice as Nurse Practitioners only if they are registered with the College in the extended class. No member can be a Nurse Practitioner unless in the extended class.
Counsel submitted that if a member acts outside the scope of her practise she is in violation of governing legislation.
Decision
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); 1(b)(i), (ii), (iii), (iv), (v), (vi); 2 (i), (ii), (iii), (iv), (v); 3; 4 (a) (ii), (iii),(iv),(v),(vi);
4 (b) (i),(iii),(iv),(v),(vi),(vii),(viii),(x).
Reasons for Decision
The Panel was presented with a significant number of documentary exhibits and evidence from nine witnesses, either in person or by affidavit. The Panel was also presented with the uncontroverted expert opinion of Nurse Practitioner, Dr. Acorn.
Allegation 1(a)
The Panel reviewed and accepted the documentary evidence contained in the clinical chart of [Client A] (Ex. 6) in which the Member recommended Ventolin to [Client A], without recording that she had consulted a physician first. [Doctor A] testified that he did not authorize the Member to prescribe medications to [Client A] on January 3, 2015. The Panel found [Doctor A’s] testimony credible and accepted the expert witness testimony given by Dr. Acorn that this is a breach of the standard of practice of the profession.
The Panel finds that the Member has committed an act of professional misconduct as alleged.
Allegation 1(b)
The Panel reviewed and accepted the documentary evidence pertaining to Clients [Client A] (Ex. 24); [Client B] (Ex. 30); [Client C] (Ex. 27); [Client D] (Ex. 28); [Client E] (Ex. 25); [Client F] (Ex. 29). The Panel accepted the witness testimony of [Doctor A] who testified that these were not his signatures and that he did not authorize the use of his name or his CPSO number on these prescriptions. The Panel accepted the expert witness testimony given by Dr. Acorn that confirmed that this was a breach of the standard of practice of the profession.
The Panel finds that the Member has committed acts of professional misconduct as alleged.
Allegation 2
The Panel reviewed and accepted the documentary evidence pertaining to Clients [Client G] (Ex. 7); [Client H] (Ex. 8); [Client I] (Ex. 14); [Client F] (Ex. 13); [Client J] (Ex. 15); the Documentation Practice Standard (Ex. 48); and the Professional Standards Practice (Ex. 46). The Panel accepted the expert witness testimony of Dr. Acorn who confirmed the Member breached a standard of practice by failing to keep client records as required.
As such, the Panel finds that the Member has committed an act of professional misconduct as alleged.
Allegation 3
The Panel reviewed and accepted the documentary evidence contained in the Member’s CV (Ex. 4); College Register (Ex. 33); Affidavit testimony of [Witness B] (Ex. 35); Affidavit testimony of [Client H] (Ex. 36); and [Doctor A’s] testimony that he understood the Member was a Nurse Practitioner. The Panel found that the Member contravened Professional Standards (Ex.46), including Ethics, Therapeutic Nurse-Client Relationship; Decisions About Procedures and Authority (Ex. 50). The Panel also accepted the expert witness testimony of Dr. Acorn that although the Member completed a graduate programme in the nurse practitioner stream, she was not registered in the extended class and could not use the title of Nurse Practitioner.
As such, the Panel finds that the Member has committed an act of professional misconduct.
Allegation 4(a)
The Panel reviewed and accepted documentary evidence and affidavit testimony pertaining to the following Clients:
ii. [Client H] (Ex.8); (Ex. 36)
iii. [Client A] (Ex. 6); (Ex. 37)
iv. [Client K] (Ex.9); (Ex.38)
v. [Client C] (Ex. 10; (Ex. 39)
vi. [Client D] (Ex. 11); (Ex.40)
The expert confirmed that the Member had made a diagnosis with respect to the clients listed in each exhibit and confirmed that to do so was outside the Member’s scope of practice based on the Decisions About Procedures and Authority Standard (Ex. 50); Professional Standard (Ex. 46); and the RHPA Scope of Practice, Controlled Acts (Ex. 49).
As such, the Panel finds that the Member has committed an act(s) of professional misconduct.
Allegation 4(b)
The Panel reviewed and accepted documentary evidence and affidavit testimony pertaining to the following Clients:
i. [Client A] (Ex. 6); (Ex.24); (Ex.37)
iii. [Client B] (Ex. 18); (Ex. 30)
iv. [Client C] (Ex. 10); (Ex.27); (Ex.39)
v. [Client D] (Ex.28); (Ex.40)
vi [Client I] (Ex. 14); (Ex.41)
vii. [Client E] (Ex. 12); (Ex. 25)
viii. [Client F] (Ex. 13): (Ex. 29)
x [Client L] (Ex. 31); (Ex.32)
The Panel found breaches of practice standards: Professional Standards (Ex. 46); Medication (Ex. 47); RHPA, Scope of Practice, Controlled Acts (Ex.49); Decisions About Procedures and Authority (Ex. 50); Authorizing Mechanisms (Ex. 51); Nurse Practitioner (Ex. 52).
The expert witness testimony of Dr. Acorn confirmed that while the act of prescribing is within the scope of practice of a Nurse Practitioner, the Member was not a nurse practitioner at the relevant time and as such she completed a controlled act outside the scope of her practice.
The Panel therefore finds that the Member has committed an act of professional misconduct.
Penalty
Penalty Submissions
Counsel submitted two proposed orders for the Panel’s consideration, i.e, a primary submission for immediate revocation, or alternately an order that included a reprimand, suspension of the Member’s certificate of registration for 12 months, a meeting with an expert and employer notification.
Counsel submitted a mitigating factor in this case is the fact that the Member had no prior discipline proceedings. As the Member has not participated in this proceeding, however, Counsel was unable to provide any additional mitigating factors.
The aggravating factors in this case are the seriousness of the offences that occurred, in that the Member operated outside her scope of practice; she inappropriately used a physician’s name and CPSO number in writing a prescription. As a regulator, the College requires members to act within the scope of their registration.
The Member’s conduct was inappropriate in that she held herself out as a Nurse Practitioner even though she was not registered as such. This conduct was further exasperated by the fact that she had received a previous warning specifically advising her not to hold herself out as a Nurse Practitioner. This decision must give a message to the membership as a whole that this conduct is intolerable.
Counsel submitted that the Member took on the mantel of Nurse Practitioner. Counsel submitted cases to the Panel, although not directly applicable, that deal with governability issues and the seriousness of acting outside of the scope of a member’s scope of practice.
CNO vs Cecilioni (Discipline Committee, 2012)
The member, a RN, intended to give a patient a cosmetic procedure. The member previously engaged in injections of Botox without authority from a doctor. The member had been warned and breached an undertaking. The penalty ordered was a reprimand, a four-month suspension, meetings with a nursing expert and notification to future employers.
The similarities in this case are that the member was practicing outside the scope of practice and had also been warned previously.
CNO vs Lim (Discipline Committee, 2012)
This member, a RN, engaged in a series of administering medications without authorization. The member also failed to properly document the administration of drugs. The member had been previously disciplined by her employer and continued to repeat the conduct.
The member’s licence was revoked. This case is an example of the seriousness of practicing outside the scope of practice.
CNO vs Desrosiers (Discipline Committee, 2014)
This member was registered as a Nurse Practitioner. The member had failed to comply with her Quality Assurance obligations. As an NP, she was legally permitted to prescribe certain drugs but prohibited from prescribing a controlled substance within the meaning of the Controlled Drugs and Substances Act. The member prescribed four controlled substances outside the scope of her role as an NP.
The penalty ordered was a reprimand, a nine-month suspension, terms, conditions and limitations in respect of medications and scope of practice and employer notification.
Penalty Decision
The Panel directs the Executive Director to immediately revoke the Member’s certificate of registration.
Reasons for Penalty Decision
The acts of this Member were deliberate. She held herself out as a Nurse Practitioner even though she was instructed by the College to cease using this designation in 2011. She was not entitled to use the Nurse Practitioner designation as she was not registered in the extended class. She recommended a prescription medication without consulting with a physician; she used [Doctor A’s] name and CPSO number on prescriptions she issued without his direction or authorization; she performed the controlled acts of communicating a diagnosis, and prescribing knowing that it was outside her scope of practice; and she failed to document her activities properly.
The Member’s behaviour transgressed the regulatory model and exceeded her legislated scope of practice. By doing so, she abused the public’s trust.
The Member’s failure to participate in the Discipline hearing process did not allow the Panel to assess her rehabilitation potential. As such, in the interest of public protection, it is the decision of this Panel to direct the Executive Director to immediately revoke the Member’s certificate of registration.
I, Tanya Dion, 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