DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Grace Fox, NP Chairperson Renate Davidson Public Member Lina Kiskunas, RN Member Mary MacMillan-Gilkinson Public Member George Rudanycz, RN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO EMILY LAWRENCE for College of Nurses of Ontario
- and -
CARA RUSSON, Reg. No. 07329125 NO REPRESENTATION for Cara Russon
CHRIS WIRTH Independent Legal Counsel
Heard: November 1-2, 2018
AMENDED DECISION AND REASONS
This matter came on for hearing before a panel of the Discipline Committee (the “Panel”) on November 1-2, 2018 at the College of Nurses of Ontario (the “College”) at Toronto.
As Cara Russon (the “Member”) was not present, the hearing recessed for 15 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 August 21, 2018. The Panel was satisfied that the Member had received adequate notice and therefore proceeded with the hearing in the Member’s absence.
Publication Ban
At the 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, preventing the public disclosure of the names of the patients referred to orally or in any documents presented in the Discipline hearing of Cara Russon or any information that could disclose the identities of the patients, including a ban on the publication or broadcasting of this information. In addition, the Panel made an Order preventing the public disclosure of Exhibits 20 and 21, including a ban on the publication or broadcasting of them.
The Allegations
The allegations against the Member, as stated in the Notice of Hearing dated August 17, 2018 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, while employed as a registered nurse at Azure Medispa (the “Facility”) in Sault Ste. Marie, Ontario, you failed to maintain the standards of practice of the profession, in that:
a. on or about September 17, 2016, you performed a controlled act authorized to nursing on [Client A], namely administration of Xeomin by injection, without a physician’s order, without proper delegation from a physician or nurse practitioner, and/or without meeting the conditions of an applicable medical directive;
b. on or about September 17, 2016, you failed to complete a therapeutic assessment of [Client A] before injecting her with Xeomin;
c. on or about September 17, 2016, you failed to ensure that [Client A] was assessed by a physician or nurse practitioner;
d. on or about September 17, 2016, you failed to document your treatment of [Client A] in a complete and accurate manner;
e. on or about November 16, 2016, you performed a controlled act authorized to nursing on [Client B], namely administration of Xeomin by injection, without a physician’s order, without proper delegation from a physician or nurse practitioner, and/or without meeting the conditions of an applicable medical directive;
f. on or about November 16, 2016, you failed to complete a therapeutic assessment of [Client B] before injecting her with Xeomin;
g. on or about November 16, 2016, you failed to ensure that [Client B] was assessed by the physician or nurse practitioner; and/or
h. on or about November 16, 2016, you failed to document your treatment of [Client B] in a complete and accurate manner.
- 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, while employed as a registered nurse at the Facility, you contravened provisions of the Nursing Act, 1991, the Regulated Health Professions Act, 1991, or the regulations under either of those Acts, and in particular,
a. on or about September 17, 2016, you performed a controlled act authorized to nursing on [Client A], namely administration of Xeomin by injection, without appropriate authorization or an order to do so, which was a contravention of:
i. section 27 of the Regulated Health Professions Act, 1991; and/or
ii. section 5 of the Nursing Act, 1991; and/or
b. on or about November 16, 2016, you performed a controlled act authorized to nursing on [Client B], namely administration of Xeomin by injection, without appropriate authorization or an order to do so, which was a contravention of:
i. section 27 of the Regulated Health Professions Act, 1991; and/or
ii. section 5 of the Nursing Act, 1991; and/or
- 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 while employed as a registered nurse at the Facility, that you engaged in conduct or performed an act, relevant to the practice of nursing that, having regard to all of the circumstances would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional, in that:
a. on or about September 17, 2016, you performed a controlled act authorized to nursing on [Client A], namely administration of Xeomin by injection, without a physician’s order, without proper delegation from a physician or nurse practitioner, and/or without meeting the conditions of an applicable medical directive;
b. on or about September 17, 2016, you failed to complete a therapeutic assessment of [Client A] before injecting her with Xeomin;
c. on or about September 17, 2016, you failed to ensure that [Client A] was assessed by a physician or nurse practitioner;
d. on or about September 17, 2016, you failed to document your treatment of [Client A] in a complete and accurate manner;
e. on or about November 16, 2016, you performed a controlled act authorized to nursing on [Client B], namely administration of Xeomin by injection, without a physician’s order, without proper delegation from a physician or nurse practitioner, and/or without meeting the conditions of an applicable medical directive;
f. on or about November 16, 2016, you failed to complete a therapeutic assessment of [Client B] before injecting her with Xeomin;
g. on or about November 16, 2016, you failed to ensure that [Client B] was assessed by the physician or nurse practitioner;
h. on or about November 16, 2016, you failed to document your treatment of [Client B] in a complete and accurate manner; and/or
i. on or about September 17, 2016, you contravened section 27 of the Regulated Health Professions Act, 1991, and/or section 5 of the Nursing Act, 1991, when you performed a controlled act authorized to nursing on [Client A], namely administration of Xeomin by injection, without appropriate authorization or an order to do so;
j. on or about November 16, 2016, you contravened section 27 of the Regulated Health Professions Act, 1991, and/or section 5 of the Nursing Act, 1991, when you performed a controlled act authorized to nursing on [Client B], namely administration of Xeomin by injection, without appropriate authorization or an order to do so.
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 as a Registered Nurse on September 12, 2007. The Member voluntarily surrendered her Certificate of Registration on October 26, 2017, and as such, is not entitled to practice nursing at the present time.
Azure Medispa (the “Facility”) provides treatments by medical professionals. The services include laser skin treatments, vein therapy, and injectable treatments such as dermal fillers and neuromodulators (Xeomin and Botox).
It is alleged that the Member injected Xeomin on two occasions, involving two different clients, [Client A] on September 17, 2016 and [Client B] on November 16, 2016, without proper authorization, without completing a therapeutic assessment before the injection and without completing proper documentation.
The allegations present the following issues:
Did the Member commit professional misconduct by failing to meet the standards of practice of the profession and by contravening provisions of the Nursing Act, 1991 and the Regulated Health Professions Act, 1991?
Did the Member perform the controlled act of injection without authorization on [Client A] and [Client B]?
Did the Member fail to complete a therapeutic assessment of the clients before the injection?
Did the Member fail to properly document the procedure performed on the clients?
Did the Member commit professional misconduct by engaging in conduct that would reasonably be regarded by members of the profession to be disgraceful, dishonourable, or unprofessional?
Having considered the evidence and the onus and standard of proof, the Panel found that the Member committed acts of professional misconduct as alleged in paragraphs 1 (a), (b), (c), (d), (e), (f), (g), (h); 2 (a)(i),(ii), 2 (b)(i),(ii); and 3 (a), (b), (c), (d), (e), (f), (g), (h), (i), (j) of the Notice of Hearing. As to allegation 3, the Panel found that the Member engaged in conduct that would reasonably be considered by members of the profession to be disgraceful, dishonourable and unprofessional.
The Evidence
[Witness A]
[Witness A], [ ], testified that it opened in 2015 offering services such as facials, skin resurfacing, IPL, and injection of neuromodulators. He testified that he visited the Facility once per week for administrative purposes.
[Witness A] testified that the Member worked with a physician, nurse practitioner, and naturopathic doctor at the Facility. He testified that the Member’s responsibilities included most of the treatments, i.e. injections, laser, and skin care. He stated that the procedure was for the client to be initially assessed by the Member and, where an injection of a neuromodulator was being discussed, the client would then be scheduled to meet with the Nurse Practitioner or Physician to discuss the procedure. If the client was a good candidate for the procedure (Botox or Xeomin), the client would be scheduled for the injection. He testified that the injection could be done by the nurse but had to be prescribed by either the NP or the Physician and there was no need for another consult on each subsequent visit.
[Witness A] testified that [Witness C] at the Facility informed him that the Member was the treatment advisor for [Client A] on September 17, 2016 and that she had given the client a hydrafacial that included the injection of eight units of Xeomin without authorization. [Witness A] testified that he reviewed the charts for [Client A]. He did not recall if he discussed the matter with anyone else but that he subsequently met with the Member and clarified that a prescription was required for her to do the injection procedure.
[Witness A] testified that he was informed through a text message from the [ ] that another client ([Client B]) had been injected by the Member in November 2016, without prior authorization. [Witness A] stated that the Member was suspended until he completed his investigation (Exhibit 7). He stated that once he learned through his investigation that authorization for the procedure had not been given to the Member, she was terminated for just cause on November 30, 2016.
The Panel found the testimony of [Witness A] to be vague and with a limited recall of the actual events. It was evident that he was not involved in the running of the Facility as he was imprecise about the events that occurred. The witness relied heavily on the information he obtained from his staff.
[Witness B]
The witness has been registered with the College since [ ] and became a Nurse Practitioner in [ ].
[Witness B] testified that her role at the spa was to do a consultation prior to injectable procedures and determine if the client was a good candidate for the procedure. If so, she could either do the injection herself or write a prescription for it. [Witness B] testified that clients did not need a repeat consultation for the same procedure but would need a new directive if the procedure was being done in a different area or for new procedures. [Witness B] stated that she developed the policy entitled Medical Directive for the use of Neuromodulators (Exhibit 4). The witness also testified that the Member was very aware that a consultation had to be done before the Member would be able to perform the procedure.
[Witness B] testified that she examined the chart for [Client A] dated September 17, 2016 (Exhibit 5) and stated that it indicated the client had a hydrafacial. In addition, the Member performed an injection of 8 units of Xeomin without authorization. The witness testified that the Member should have referred [Client A] to her before proceeding with the injection.
With regard to [Client B], [Witness B] testified that she had not seen this client. [Witness B] reviewed the chart for [Client B] (Exhibit 8) and indicated that there appeared to have been four injections done on this client, i.e. June 2, 2016, June 29, 2016, October 3, 2016, and November 16, 2016. The witness also noted that there was insufficient documentation on the chart.
The Panel found this witness to be forthcoming and credible. She gave information on the protocols in place at the Facility, the type of charting normally required and was accurate and complete in her investigation.
[Witness C]
[Witness C] stated that she has been the [ ] at the Facility since the spa opened and that she works full-time 4 days per week.
The witness testified that she had made the initial appointment for [Client A] who wanted to have a facial [ ]. She testified that the treatment was performed by the Member. The witness testified that on a staff outing a week later, the Member admitted at that social event to doing the injection.
The witness testified that there was another incident where a client paid for an injectable not scheduled. The witness attested that she did not raise her concerns directly with the Member but advised [Witness A].
The witness reviewed the client chart for [Client B] (Exhibit 8) and indicated that there were 4 separate appointment dates for injectables for this client totalling 40 units.
The Panel found this witness to be forthright, calm, assured and knowledgeable in her role as the spa [ ]. This witness was found to be credible.
[Client A]
The witness testified that she was a client of the Facility and had her first treatment on September 17, 2016. She stated that the Member gave her a hydrafacial. She testified that when the Member overheard her talking to her [ ] about a Botox injection, the Member said “I can do that today, no problem”. The witness testified that the Member did not ask any questions about her current health before proceeding with the injection and gave her little information as to what she might expect following the procedure.
The Panel found this witness to be credible as she was forthright in her testimony. The witness testified in a manner that was consistent with the documentary evidence which clearly indicated she had an appointment at the Facility on September 17, 2016 and that the procedure was done by the Member. The witness appeared to have no reason to mislead or embellish her evidence in any way.
[Client B]
The witness testified that she is a former client of the Facility. She had decided to try their service and decided to have a hydrafacial which was performed by the Member. The witness testified that she was not treated by anyone else and that she had IPL procedures starting on June 2, 2016. She stated that on June 29, 2016 when she was in for IPL follow-up, she mentioned using Botox for her forehead and that the Member then proceeded to inject her with the first injection. The witness stated that there was no discussion about injectables except what it would feel like. She testified that the Member did not ask her about her health condition or give her any authorization forms to sign. The witness testified that she returned for follow-up and at this appointment, the eyebrow areas were injected. The witness testified that at her August 10, 2016 appointment, the Member was adamant that she not give an injection the same day as a hydrafacial.
The witness testified that she had purchased 60 units of the procedure but did not use them all. She did not recall filling out any forms in advance of the procedures or having any discussions regarding her health prior to the injections.
The witness testified that [Witness A] called her in the summer of 2017 and asked if the Member had treated her with a neuromodulator. The witness indicated that she did not know what the word was and said “No” but since then has found out that it was Xeomin.
The Panel found the witness to be honest and forthright. She corrected herself when she viewed charts and documents and realized she had given wrong information. She was found to be credible.
Expert Witness – Margaret Ann Wilson
Margaret Ann Wilson was tendered by College Counsel as an expert in the scope of practice of Registered Nurses and Nurse Practitioners, and an expert in the standards of practice of nurses in the areas of assessment and documentation. The Panel reviewed Ms. Wilson’s curriculum vitae (Exhibit 12) and heard her responses to questions posed by College Counsel to qualify her as an expert to give opinion evidence on the areas in question.
Her formal education includes the following:
B. Sc. in Nursing – Laurentian University – 1985
M. Sc. in Nursing – University of Toronto – 1993
Post-Master’s Acute Care Nurse Practitioner Certificate - 2001
Canadian Diabetes Educator Certificate – 2012
Controlled Drugs and Substances Education – 2017
Ms. Wilson became a Registered Nurse in 1985 and has been a member of the extended class since 2008. She has extensive advanced nursing practice experience and was a course instructor at the University of Toronto from 2014 to 2017 in the area of Advanced Practice Roles and Issues, Nurse Practitioner Program.
The Panel accepted Ms. Wilson as an expert witness in the areas of scope of practice for Registered Nurses and Nurse Practitioners, and on the standards of practice of nurses for assessment and documentation.
Ms. Wilson stated that she had received a hypothetical scenario from Counsel (Exhibit 15) with a request to provide an opinion. She was provided with copies of the College’s standards of practice including Professional Standards, (Rev. 2002) (Exhibit 16); Medication Standard, (Rev. 2017) (Exhibit 17); Documentation (Rev. 2008) (Exhibit18); and a practice guide for Authorizing Mechanisms (Rev. 2018) (Exhibit 19).
College Counsel took Ms. Wilson through the hypothetical scenario which reflected the facts of the case as submitted by the College (Exhibit 15). It was the opinion of Ms. Wilson that the hypothetical scenario demonstrated clear failures by the Member in meeting the standards of practice and in maintaining scope of practice. For the controlled act of injection, the standards and practice guideline clearly identify the need to have a proper authorization mechanism for this act, whether by direct order from a qualified professional (verbal or written), a delegation or through an appropriate medical directive. The hypothetical scenario did not identify the Member as following any proper authorization mechanism before performing the controlled act of injection. Ms. Wilson opined that this was a clear breach of the standards of practice and thereby goes outside the scope of practice for Registered Nurses. With respect to assessment, it was the opinion of Ms. Wilson that based upon the hypothetical scenario, the Member fell below the standards of practice for assessment, as no assessment information was documented. Ms. Wilson testified that the standards require a nurse to have the knowledge, skill and judgement to assess a patient, prior to any therapeutic intervention, which in this case would have included assessment notes on physical assessment, medical history, allergies, and any other relevant medical history. With respect to documentation, it was the opinion of Ms. Wilson that based upon the hypothetical scenario, the Member fell below the standards of practice for documentation, as only minimal documentation was present, including number of units administered for the medication and location. Ms. Wilson testified that the standards require a nurse to fully document all aspects of care and associated interventions, which in this case would have included patient consent, assessment findings, details of the medication administration (drug name, dose, site, time, route, etc.), outcome of the intervention, and evaluation of the intervention (i.e. how the patient tolerated).
The Panel found Ms. Wilson’s opinions to be reasonable and well within her area of expertise, given her work and educational experience. The witness responded openly and directly to all questions asked during her examination. Her opinions were grounded in the published standards and practice guideline of the College.
Final Submissions
College Counsel acknowledged that the College has the onus to prove the allegations set out in the Notice of Hearing on the balance of probabilities.
Five factual witnesses and one expert witness provided testimony. The College submitted that the evidence provided demonstrated numerous clear breaches of the standards of practice for assessment and documentation. In addition, there was evidence that showed that the Member performed a controlled act, namely administration of Xeomin by injection, without appropriate authorization or an order to do so, which contravenes section 5 of the Nursing Act, 1991 and section 27 of the Regulated Health Professions Act, 1991. The Member’s conduct demonstrates a recklessness with respect to patient safety, a carelessness in assessment and documentation practices, and a disregard for the scope of practice and responsibilities entrusted to nurses.
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 has committed acts of professional misconduct as alleged in paragraphs 1 (a), (b), (c), (d), (e), (f), (g), (h); 2 (a)(i),(ii), 2 (b)(i),(ii); and 3 (a), (b), (c), (d), (e), (f), (g), (h), (i), (j) in the Notice of Hearing. In particular, with respect to the allegations contained in paragraph 3, the Member engaged in conduct that would reasonably be regarded by members of the profession as disgraceful, dishonourable, and unprofessional by performing a controlled act without proper authorization from a physician or other prescriber, by failing to conduct an assessment of the clients and by failing to complete the required documentation.
Reasons for Decision
The Panel considered the documentary evidence, witness testimony and the expert testimony of Margaret Ann Wilson. The Panel found that this evidence supported findings of professional misconduct as alleged in the Notice of Hearing.
With respect to allegations 1 (a), (c), (e) and (g), the Member failed to maintain the standards of practice and work within her scope as a Registered Nurse. The expert witness testified that the practice standards and guidelines for the College all require a proper authorization mechanism to be in place for controlled acts (Exhibits 15, 16, 17, 19). The Nurse Practitioner testified that she wrote the policy on neuromodulators for the Facility (Exhibit 4), and that the Member was aware of the policy and requirements. [Client A] testified that she received an injection from the Member without having had a consultation with a Nurse Practitioner or Physician. [Client A’s] chart did not contain any documentation that would demonstrate a consultation was done by a Nurse Practitioner or Physician (Exhibit 5). [Client B] testified that she received an injection from the Member without having had a consultation with a Nurse Practitioner or Physician. [Client B’s] chart did not contain any documentation that would demonstrate a consultation was done by a Nurse Practitioner or Physician (Exhibit 8).
With respect to allegations 1 (b) and (f), the Member failed to maintain the standards of practice of the profession for assessment. The expert witness testimony on the hypothetical scenario was of the opinion that the conduct presented fell below the standards of practice for assessment (Exhibits 16, 17, 18, 19). The client record for [Client A] (Exhibit 5) and [Client B] (Exhibit 8) did not include elements of a fulsome assessment, as outlined by the expert witness. [Client A’s] testimony confirmed that no history was taken or an assessment done. [Client B’s] testimony confirmed that no history or assessment was done.
With respect to allegations 1 (d) and (h), the Member failed to maintain the standards of practice of the profession for documentation. The expert witness testimony on the hypothetical scenario was of the opinion that the conduct presented fell below the standards of practice for documentation (Exhibits 16, 17, 18, 19). The client record for [Client A] (Exhibit 5) and [Client B] (Exhibit 8) did not include the required elements for documentation, as outlined by the expert witness.
With respect to allegations 2 (a) and (b), the Member contravened Section 5 of the Nursing Act, 1991 and Section 27 of the Regulated Health Professions Act, 1991 by engaging in the controlled act of injections without proper authorization mechanisms. The Nurse Practitioner testified that she did not consult on [Client A] or [Client B] for the purposes of injection of Xeomin. [Witness C] testified that she processed invoices for injections for [Client B] (Exhibit 8) and noticed that there was no consultation done by a Physician or Nurse Practitioner, and no consultation indicated on the Member’s work schedule (Exhibit 10, 11). [Witness C] testified that the Member disclosed to her at a social event that she provided injections to [Client A], and [Witness C] disclosed this to [Witness A]. [Witness A] testified that he called both the Physician and Nurse Practitioner after receiving this notification and both confirmed to him that they had not consulted on [Client B]. The client records for [Client A] (Exhibit 5) and [Client B] (Exhibit 8) do not include consultation notes from either the Physician or Nurse Practitioner. [Client A] confirmed that she received an injection from the Member and did not have a consult with a Physician or Nurse Practitioner. [Client B] confirmed that she received an injection from the Member and did not have a consult with a Physician or Nurse Practitioner.
With respect to allegations 3 (a-j), the Panel finds that the Member’s conduct was unprofessional, dishonorable and disgraceful. The Panel finds that the Member’s conduct was unprofessional, as it lacked good judgment and demonstrated a disregard for basic components of care.
The Panel also finds that the Member’s conduct was dishonorable, and falls well below the conduct that is expected of a nursing professional. There were no flagrant elements of deceit or deception, but this behaviour goes to the very core of nursing, especially in independent practice, and demonstrated persistent and ongoing breaches. The Member ought to have known that engaging in the controlled act of injection without proper authorization is very serious misconduct.
Finally, the Panel finds that the Member’s conduct was disgraceful, as it shames the Member, and by extension, the entire nursing profession. The conduct of engaging in the controlled act of injection without proper authorization shows a moral failing, and falls well below the standards of the profession. It casts serious doubt on the Member’s moral fitness and inherent ability to discharge the higher obligations the public expects nursing professionals to meet.
Penalty
Penalty Submissions
College Counsel provided the Panel with a written Submission on Order and submitted that this meets the goals of penalty, including specific deterrence, general deterrence, rehabilitation and remediation.
She submitted that the aggravating factors include the number of findings and the fact that the alleged misconduct is serious in nature. The Member was not present to identify any potential mitigating factors that could apply. The College acknowledged that the Member’s lack of attendance at the hearing could not be used against her in the consideration of penalty.
Counsel submitted that the proposed penalty provides for specific and general deterrence through the suspension of the Member’s certificate of registration for a period of four months and an oral reprimand. This sends a message to the Member and the profession that acting outside one’s scope of practice and failing to maintain the standards of practice for assessment and documentation will not be tolerated.
Although the Member is not currently practicing, elements of remediation and rehabilitation are addressed through the condition to meet with a Regulatory Expert, and the requirement for employer notification for a period of 24 months. This allows for self-reflection on the conduct and permits the Member to practice for 24 months with increased monitoring of her practice.
The penalty as a whole promotes confidence in the regulation of nursing by providing assurances to the public that Registered Nurses must act only when authorized to do so, and to the extent they are authorized to do so.
Mentorship was not considered as part of the proposed penalty, as the Member is not currently practicing and has not cooperated with the discipline process, so it is unclear as to whether a mentor would be effective or appropriate.
College Counsel submitted cases to the panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee.
CNO v Zorn (Discipline Committee, 2017)
The member was found to have performed the controlled act of injecting Botox without proper authorization, sold Botox, and engaged in improper advertising on a website. The member cooperated with the discipline process through an Agreed Statement of Facts and a Joint Submission on Order. The member was given a three month suspension, an oral reprimand, and terms, conditions and limitations were imposed on her certificate of registration in the form of two meetings with a nursing expert and 18 months of working with a nurse mentor once she returned to the practice of nursing.
CNO v Cecilioni (Discipline Committee, 2013)
This member had a prior history with the College from 2008. The member was found to have intended to perform the controlled act of injecting Botox without a physician’s order or proper delegation. She also failed to meet the conditions of a medical directive, failed to ensure the client was assessed by a physician, failed to retain records, and failed to abide by an undertaking given to the College in 2008. The member cooperated with the discipline process through an Agreed Statement of Facts and a Joint Submission on Order. The member was given a four month suspension, an oral reprimand, and terms, conditions and limitations were on her certificate of registration in the form of two meetings with a nursing expert and a 12-month employer notification.
CNO v Ozueh (Discipline Committee, 2017)
The member was found to have performed the controlled act of injecting Botox without proper authorization on multiple clients, sold Botox, misused the title of Registered Nurse, and failed to engage in proper assessment and documentation practices. The member cooperated with the discipline process through an Agreed Statement of Facts and Joint Submission on Order. The member was given a three month suspension, an oral reprimand, and terms, conditions and limitations were imposed on her certificate of registration in the form of two meetings with a nursing expert and 18 months of working with a nurse mentor once she returned to the practice of nursing.
Penalty Decision
The Panel accepts the College Submission on Order and makes the following order:
The Member is required to appear before the Panel to be reprimanded within three months of the date that this Order becomes final.
The Executive Director is directed to suspend the Member’s certificate of registration for four months. This suspension shall take effect from the date the Member obtains an active certificate of registration and shall continue to run without interruption as long as the Member remains in the practising class.
The Executive Director is directed to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) The Member will attend two meetings with a Regulatory Expert (the “Expert”), at her own expense and within six months from the date the Member’s suspension ends. 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, 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 (where applicable):
Professional Standards,
Medication,
Documentation
RHPA: Scope of Practice, Controlled Act Model
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 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, 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 concluded that the proposed penalty is reasonable and in the public’s interest.
The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation, remediation and public protection. The Member has voluntarily surrendered her Certificate of Registration, and will need to meet re-entry requirements before obtaining a certificate of registration, at which time this penalty will take effect. The penalty sends a strong message to the Member, and the membership as a whole, that engaging in controlled acts without proper authorization and failing to maintain the standards of practice for assessment and documentation will not be tolerated. Confidence in the nursing profession and protection of public safety will be strengthened by this message.
The penalty is also in line with what has been ordered in previous similar cases.
I, Grace Fox, NP, 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