Discipline Committee of the College of Nurses of Ontario
Panel: Terry Holland, RPN Chairperson Dawn Cutler, RN Member Deborah Graystone, NP Member Mary MacMillan-Gilkinson Public Member Devinder Walia Public Member
Between: College of Nurses of Ontario
- and - Ne Haas, Registration No. 0300897
Counsel: Nick Coleman for College of Nurses of Ontario Jane Letton for Ne Haas Christopher Wirth, Independent Legal Counsel
Heard: June 3, 2019
Decision and Reasons
This matter came on for hearing before a panel of the Discipline Committee (the “Panel”) on June 3, 2019, at the College of Nurses of Ontario (the “College”) at Toronto.
The Allegations
The allegations against Ne Haas (the “Member”) as stated in the Notice of Hearing dated February 20, 2019, 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 London Health Sciences Centre in London, Ontario, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to your care for [the patient], on or about January 18, 2016, and in particular, you:
a. failed to complete and/or document a full assessment of [the patient] at transfer of care;
b. failed to complete and/or document [the patient]’s vital signs “q1 hour”, or as otherwise required;
c. failed to complete and/or document fluid balance or bladder assessment “q1 hour”, or as otherwise required, with respect to IV flow rate;
d. failed to address, assess and/or call for medication to support [the patient]’s complaint of nausea;
e. failed to complete and/or document assessments regarding the epidural site, lower motor block or pump at start of shift, or as otherwise required;
f. failed to complete and/or document accurately the assessment related to Oxytocin infusion flow rate;
g. failed to reposition the FHS Monitor when the signal indicated inadequate tracing or contraction patterns (coincidence alarms);
h. failed to adjust the FHS monitor and/or assess [the patient] and baby when the FHS fetal and/or maternal heart rate signals were lost (coincidence alarms);
i. failed to apply the Oxygen Saturation Monitor promptly in response to inadequate tracings of fetal and maternal heart rates (coincidence alarms);
j. failed to notify the Obstetrical Consultant/Resident, complete an assessment, and/or palpate and complete a manual heart beat assessment promptly when the FHS signals were lost (coincidence alarms); and/or
k. failed to monitor, analyze, document, and/or notify the medical team regarding the status of [the patient] and baby, resulting in a delay in urgent Obstetrical Intervention.
- 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 as a Registered Nurse at London Health Sciences Centre in London, Ontario, you failed to keep records as required with respect to your care for [the patient], on or about January 18, 2016, and in particular, you:
a. failed to document a full assessment of [the patient] at transfer of care;
b. failed to document [the patient]’s vital signs “q1 hour”, or as otherwise required;
c. failed to document fluid balance or bladder assessment “q1 hour”, or as otherwise required, with respect to IV flow rate;
d. failed to document any response to [the patient]’s complaint of nausea;
e. failed to document assessments regarding the epidural site, lower motor block or pump at start of shift, or as otherwise required;
f. failed to document accurately the assessment related to Oxytocin infusion flow rate; and/or
g. failed to document a response to loss of the FHS Monitor signals (coincidence alarms).
- 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 London Health Sciences Centre in London, 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 your care for [the patient], on or about January 18, 2016, and in particular, you:
a. failed to complete and/or document a full assessment of [the patient] at transfer of care;
b. failed to complete and/or document [the patient]’s vital signs “q1 hour”, or as otherwise required;
c. failed to complete and/or document fluid balance or bladder assessment “q1 hour”, or as otherwise required, with respect to IV flow rate;
d. failed to address, assess and/or call for medication to support [the patient]’s complaint of nausea;
e. failed to complete and/or document assessments regarding the epidural site, lower motor block or pump at start of shift, or as otherwise required;
f. failed to complete and/or document accurately the assessment related to Oxytocin infusion flow rate;
g. failed to reposition the FHS Monitor when the signal indicated inadequate tracing or contraction patterns (coincidence alarms);
h. failed to adjust the FHS monitor and/or assess [the patient] and baby when the FHS fetal and/or maternal heart rate signals were lost (coincidence alarms);
i. failed to apply the Oxygen Saturation Monitor promptly in response to inadequate tracings of fetal and maternal heart rates (coincidence alarms);
j. failed to notify the Obstetrical Consultant/Resident, complete an assessment, and/or palpate and complete a manual heart beat assessment promptly when the FHS signals were lost (coincidence alarms); and/or
k. failed to monitor, analyze, document, and/or notify the medical team regarding the status of [the patient] and baby, resulting in a delay in urgent Obstetrical Intervention.
Member’s Plea
The Member admitted the allegations set out in paragraphs 1, 2 and 3 in the Notice of Hearing. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.
Agreed Statement of Facts
College Counsel and the Member advised the Panel that an agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads as follows:
THE MEMBER
Ne Haas (the “Member”) obtained a diploma in nursing from the Philippines.
The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on January 22, 2003.
The Member was employed at London Health Sciences Centre (the “Hospital”) from June 3, 2011 to March 10, 2016, when her employment was terminated as a result of the incident described below.
THE FACILITY
The Hospital is located in London, Ontario.
The Member worked at the Hospital as a full-time staff nurse on the Obstetrical Care Unit (the “Unit”).
THE PATIENT
[The Patient] was 26 years old at the time of the incident.
On January 18, 2016, the Patient was in active labour on the Unit.
The Member was assigned to care for the Patient, for the shift commencing at 1900 hours on January 18, 2016. The Patient had already been in labour all day by the start of the Member’s shift.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
Coincidence Alarms
The Unit used Fetal Health Surveillance (“FHS”) Monitors to track maternal and fetal heart rates during delivery. One concern regarding these monitors was the concept of “coincidence” that could arise for heart rate readings.
During a delivery, a “coincidence” occurs when the two monitored heart rates (maternal and fetal) appear to mirror one another. When this occurs, it is necessary to discern whether there are two separate, identical heart rate tracings, or if there has been a loss of the fetal heart rate.
When the FHS Monitor identifies a coincidence, an alarm will sound both on the monitor in the patient room and at the central nurse’s station. The alarm can be “acknowledged” or “silenced” from either location.
The proper response to the coincidence alarms is for the nurse to reposition the TOCO monitor pieces to ensure they are picking up the separate fetal and maternal heart rates, notify the physician if the coincidence repeats, apply an oxygen saturation monitor and check maternal heart rate using a stethoscope and/or manual check of radial pulse, ensure the doctor attends to assess [the patient] , and assist the doctor to apply a fetal scalp clip (to get a fetal heart rate), if necessary.
The Member received training and was tested in May 2015 regarding the coincidence alarms for the FHS Monitors and the appropriate steps to follow when the alarms occurred.
Member’s Care of [the Patient]
The day shift nurse caring for the Patient advised the Member that the Patient had received oxytocin, was fully dilated and actively pushing, had experienced one episode of hypotension, and had been tachycardic all day.
The FHS Monitor records show that there were repeated coincidence alarms soon after the Member assumed care for the Patient. Beginning at approximately 1915 hours and continuing until approximately 1945 hours, only a single heart rate was visible on the fetal heart strip. As well, the signal for contractions was also lost at approximately 1915 hours.
At approximately 1945 hours, what may have been two heart rates (or two signals regarding one heart rate) became visible again on the fetal heart strip and the signals for contractions resumed. However, the coincidence alarms continued to sound at short intervals for the next 30 minutes.
The Member failed to take any significant steps for at least 30 minutes (between 1915 and 1945 hours) to restore the FHS Monitor signals for both heart rates and contractions, despite the Patient’s labour status. The Member also failed to ensure that proper readings of the maternal and fetal heart rates had been restored for an additional 30 minutes (between 1945 and 2015 hours).
In addition, the Member failed to notify the medical team that the dual heart rate signals had been lost and/or could not be restored. The Member’s overall assessment and charting of the Patient’s medical status was also inadequate.
At approximately 2015 hours, a physician entered the Patient’s room to assess her and to assist with the delivery. At approximately 2020 hours, other medical staff observed the prolonged coincidence alarms at the nurses’ station and responded on an emergency basis. Since one or the other of the fetal or maternal heart rate had not registered adequately for an extended period of time, a fetal scalp clip was placed. No fetal heart rate could be traced at that time.
The medical decision was made to deliver the baby immediately using forceps. The baby was vital signs absent at birth. Resuscitation efforts were undertaken and the baby was transferred to the NICU to be maintained on ventilation and life support. Ventilation and life support were eventually removed and the baby died on January 20, 2016.
After an ultrasound, it was confirmed that the Patient had suffered an abruption of the placenta resulting in loss of blood flow to the fetus. It was not possible to determine if the abruption was sudden and catastrophic or chronic in nature over a period of time. It was also not possible to determine whether the Member’s inaction contributed to the baby’s death.
Failure to Complete Care and/or Document Care
At the time of transfer of care, the Member did not document any assessment of the Patient’s blood pressure, heart rate, respiratory rate, or temperature in either the Graphic Record or the Obstetrical Care Unit Record of Care.
The Member did not assess and/or document the Patient’s vital signs from the time she assumed care of the Patient until delivery, other than recording the Patient’s respiratory rate at 2000. The Member was required to assess and document the Patient’s blood pressure and temperature at least once at the start of her care for the Patient. The Member did not record the Patient’s heart rate in the Graphic Record. The Member documented an unusual significant range in the Patient’s heart rate on the Record of Care (“tachy 110-125 bmp”) but did not document actions taken to address the issue.
The Patient had two IV bags, one with sodium chloride and another with sodium chloride plus 20 units of oxytocin. The Member did not document the rate at which either IV was being absorbed by the Patient.
The Member did not document that the Patient was complaining of nausea while under the Member’s care. If the Patient was complaining of nausea and/or dry heaving, this should have been documented by the Member. The Member should have also documented the steps she took to address the Patient’s nausea and whether those steps were effective.
The Member did not document any assessment related to the Patient’s catheter site on the Monitoring Record, which should have been completed when the Member assumed care of the Patient. The Member also did not record her assessment of the sensory block and pump volume on the Monitoring Record, which should have been completed when she assumed care of the Patient.
The Member documented in the Graphic Record that the Patient was receiving oxytocin at 12mu/min at 1945, but she documented in the Record of Care that the Patient was receiving oxytocin at 13mu/min.
The Member did not attempt to adjust or reposition the monitor to regain tracing of the Patient’s contraction patterns when the uterine activity signal was lost for approximately half an hour from 1915 to 1945 hours. During the period where the signal was lost, there was a small amount of activity which is not consistent with the level of activity if the Member attempted to reposition the monitor to regain tracking of the Patient’s contraction patterns. The double-signal reading obtained at 1945 hours was not clear enough to ensure that the fetal as well as the maternal heart rate was registering.
The Member did not apply the Oxygen Saturation Monitor to measure the maternal pulse until approximately 1950, at which point the FHS Monitor had been tracing a single heart rate for over half an hour.
Member did not advise a physician or any other member of the medical team that the coincidence alarms were repeatedly sounding or that only a single heart rate was being recorded by the FHS Monitor. The Member did not complete an assessment as there is no documentation that indicates the Member checked the maternal pulse using the stethoscope and/or manual check of the radial pulse to compare it to the heart rate that was being recorded by the FHS Monitor.
CNO Standards
- CNO’s Professional Standards provides that each nurse is accountable to the public and responsible for ensuring her or his practice and conduct meets legislative requirements and the standards of practice of the profession. As well, each nurse is expected to continually improve the application of professional knowledge. A nurse demonstrates this standard by actions such as:
a. Seeking assistance appropriately and in a timely manner;
b. Taking action in situations in which client safety and well-being are compromised;
c. Managing multiple nursing interventions simultaneously; and
d. Evaluating/describing the outcomes of specific interventions and modifying the plan/approach.
- CNO’s Documentation standard provides that nurses are accountable for ensuring their documentation of client care is accurate, timely and complete.” The standard further clarifies that a nurse meets the standard by:
a. Ensuring documentation is a complete record of nursing care provided and reflects all aspects of the nursing process, including assessment, planning, intervention (independent and collaborative) and evaluation;
b. Documenting significant communication with family members/significant others, substitute decision-makers and other care providers;
c. Documenting in a timely manner and completing documentation during, or as soon as possible after, the care or event;
d. Indicating when an entry is late as defined by organizational policies; and
e. Ensuring that relevant client care information is captured in a permanent record.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1 (a) to (k) of the Notice of Hearing in that she failed to provide care and/or document care for the Patient, as described in paragraphs 14 to 30 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2 (a) to (g) of the Notice of Hearing in that she failed to keep records as required with respect to her care for the Patient, as described in paragraphs 14 to 30 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3(a) to (k) of the Notice Hearing, and in particular, her conduct was disgraceful, dishonourable and unprofessional, as described in paragraphs 14 to 30 above.
Decision
The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities based upon clear, cogent and convincing evidence.
Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1(a) to (k) and 2(a) to (g) of the Notice of Hearing. As to Allegation #3(a) to (k), the Panel finds that the Member engaged in conduct that would reasonably be considered by members to be disgraceful, 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. The Member contravened the Documentation and Practice Standards in Allegations #1 and #2.
Allegation #1(a) in the Notice of Hearing is supported by paragraphs #14 to #30 in the Agreed Statement of Facts. The Panel accepts that the Member did not document the patient’s vital signs at the time of transfer of care.
Allegation #1(b) in the Notice of Hearing is supported by paragraphs #15, #16, #17, #22 and #23 in the Agreed Statement of Facts. The Panel accepts that the Member failed to complete and/or document [the patient]’s vital signs “q 1 hour”, or as otherwise required.
Allegation #1(c) in the Notice of Hearing is supported by paragraphs #24 and #26 in the Agreed Statement of Facts. The Panel accepts that the Member failed to complete and/or document fluid balance or bladder assessment “q1 hour”, or as otherwise required with respect to IV flow rate.
Allegation #1(d) in the Notice of Hearing is supported by paragraph #25 in the Agreed Statement of Facts. The Panel accepts that the Member failed to address, assess and/or call for medication to support [the patient]’s complaint of nausea.
Allegation #1(e) in the Notice of Hearing is supported by paragraph #26 in the Agreed Statement of Facts. The Panel accepts that the Member failed to complete and/or document assessments regarding the epidural site, lower motor block or pump at start of shift, or as otherwise required.
Allegation #1(f) in the Notice of Hearing is supported by paragraphs #24 and #27 in the Agreed Statement of Facts. The Panel accepts that the Member failed to complete and/or document accurately the assessment related to Oxytocin infusion flow rate.
Allegation #1(g) in the Notice of Hearing is supported by paragraphs #15, #16, #17, #28, #29 and #30 in the Agreed Statement of Facts. The Panel accepts that the Member failed to reposition the FHS monitor when the signal indicated an inadequate tracing or contraction patterns (coincidence alarms).
Allegation #1(h) in the Notice of Hearing is supported by paragraphs #28, #29 and #30 in the Agreed Statement of Facts. The Panel accepts that the Member failed to adjust the FHS monitor and/or assess [the patient] and baby when the FHS fetal and/or maternal heart rate signals were lost (coincidence alarms).
Allegation #1(i) in the Notice of Hearing is supported by paragraph #29 in the Agreed Statement of Facts. The Panel accepts that the Member failed to apply the Oxygen Saturation Monitor promptly in response to the inadequate tracings of fetal and maternal heart rates (coincidence alarms).
Allegation #1(j) in the Notice of Hearing is supported by paragraphs #28 and #30 in the Agreed Statement of Facts. The Panel accepts that the Member failed to notify the obstetrical Consultant/Resident, complete an assessment, and/or palpate and complete a manual heart beat assessment promptly when the FHS signals were lost (coincidence alarms).
Allegation #1(k) in the Notice of Hearing is supported by paragraphs #15 to #30 in the Agreed Statement of Facts. The Panel accepts that the Member failed to monitor, analyze, document and/or notify the medical team regarding the status of [the patient] and baby, resulting in a delay in urgent Obstetrical intervention.
Allegation #2(a) in the Notice of Hearing is supported by paragraphs #22 and #23 in the Agreed Statement of Facts. The Panel accepts that the Member failed to document a full assessment of [the patient] at transfer of care.
Allegation #2(b) in the Notice of Hearing is supported by paragraphs #22 and #23 in the Agreed Statement of Facts. The Panel accepts that the Member failed to document [the patient]’s vital signs “q1 hour”, or as otherwise required.
Allegation #2(c) in the Notice of Hearing is supported by paragraphs #24 and #26 in the Agreed Statement of Facts. The Panel accepts that the Member failed to document fluid balance of bladder assessment “q1 hour”, or as otherwise required, with respect to IV flow rate.
Allegation #2(d) in the Notice of Hearing is supported by paragraph #25 in the Agreed Statement of Facts. The Panel accepts that the Member failed to document any response to [the patient]’s complaint of nausea.
Allegation #2(e) in the Notice of Hearing is supported by paragraph #26 in the Agreed Statement of Facts. The Panel accepts that the Member failed to document assessments regarding the epidural site, lower motor block or pump at start of shift, or as otherwise required.
Allegation #2(f) in the Notice of Hearing is supported by paragraphs #24 and #27 in the Agreed Statement of Facts. The Panel accepts that the Member failed to accurately document the assessment related to Oxytocin infusion flow rate.
Allegation #2(g) in the Notice of Hearing is supported by paragraphs #28, #29 and #30 in the Agreed Statement of Facts. The Panel accepts that the Member failed to document a response to loss of the FHS Monitor signals (coincidence alarms).
The Panel finds that the Member has committed acts 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 the Member engaged in conduct, relevant to the practice of nursing, that having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable and unprofessional.
Allegations #3(a) to (k) in the Notice of Hearing are supported by paragraphs #14 to #30 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in failing to provide care and/or document care for the patient was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.
The Panel also finds that the Member’s conduct as described in Allegations #3(a) to (k) in the Notice of Hearing was dishonourable and would reasonably be regarded by members of the profession as dishonourable. The Panel accepts that the Member’s conduct fell well below the standards of a professional when she failed to provide adequate care, intervention and documentation for the patient. The Member ought to have known her conduct was unacceptable.
Finally, the Panel finds that the Member’s conduct as described in Allegations #3(a) to (k) was disgraceful as it shames the Member and by extension the profession. The conduct of failing to adequately assess, monitor, document, request assistance, and notify the physician or other team members in order to provide a timely intervention casts serious doubt on the Member’s moral fitness and inherent ability to discharge the higher obligations the public expects professionals to meet. The FHS monitor was armed with a coincidence alarms functionality to alert nursing staff of a loss of signal. The Member had received training on the monitor including coincidence alarms, yet failed to take action. The Member’s conduct was profoundly deficient during a critical phase of labour. Although there was a catastrophic outcome, there was no established connection between the Member’s practice and the final outcome.
Penalty
College Counsel and the Member advised the Panel that a Joint Submission on Order had been agreed upon. The Joint Submission on Order 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 six 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 Regulatory 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,
Documentation
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) The Member shall not practice nursing in obstetrics until she has successfully completed at her own expense, with a minimum passing grade of 65%, a nursing course with clinical or laboratory or other practical components that has received prior approval from the Director regarding: obstetrics. The Member must provide the Director with proof of enrolment and successful completion of the courses with a minimum passing grade of 65%.
c) For a period of 18 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.
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 stating that the Panel should adopt the Joint Submission on Order unless it puts the administration of justice in disrepute or is not in the best interest of the public.
The mitigating factors in this case were:
The Member has accepted responsibility for her actions and has cooperated with the College;
The Member is present at the hearing.
The aggravating factors in this case were:
The Member failed to intervene for over one hour during the patient’s late stage of labour which demonstrated a gross deficiency in patient care;
The Member knew of her responsibilities and had received appropriate training but did not act on these responsibilities in a timely fashion.
The proposed penalty provides for general deterrence through the six month suspension of the Member’s certificate and employer notification of the Decision for a period of 18 months. This sends a clear message to the membership that these actions fall well below the standards of nursing practice and will not be tolerated.
The proposed penalty provides for specific deterrence through an oral reprimand, attendance and participation in Regulatory Expert meetings, completion of a Reflective Questionnaire, completion of a learning plan and employer notification of this Decision for a period of 18 months.
The proposed penalty provides for remediation and rehabilitation through attendance and participation in Regulatory Expert meetings, completion of a Reflective Questionnaire and completion of a learning plan. Rehabilitation is also provided through the requirement for the successful completion of an obstetrical nursing course with clinical and laboratory components with a minimum pass rate of 65% prior to any future nursing practice in obstetrics.
Overall, the public is protected by the 6 month suspension of the Member’s certificate and the requirement for employer notification of this decision for a period of 18 months. The requirement for the Member to complete an obstetrics focussed course prior to any future obstetrical nursing practice also protects the public.
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. Sircar (Discipline Committee, 2011) This case is similar in that it involved a member’s failure to adequately assess and intervene in a situation involving abnormal clinical and vital signs in a timely and effective fashion. The member’s similar inaction to seek medical intervention or additional qualified nursing assistance is comparable with a penalty of a 5 month suspension and 12 month employer notification.
CNO v. Gyasi (Discipline Committee, 2014) This case is similar in that the member failed to adequately assess, monitor and provide appropriate nursing care. The member also failed to ask for or seek assistance when required and in addition, failed to intervene in a timely fashion. The member in this case also failed to notify her employer of her lack of experience or training in assisting [patients] in labour and delivery. A similar penalty of 5 month suspension and 12 month employer notification was imposed.
The Member’s Counsel agreed with the submissions of College Counsel as to the aggravating and mitigating factors in this case.
Penalty Decision
The Panel accepts the Joint Submission on Order and accordingly orders:
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 six 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.
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 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,
Documentation
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) The Member shall not practice nursing in obstetrics until she has successfully completed at her own expense, with a minimum passing grade of 65%, a nursing course with clinical or laboratory or other practical components that has received prior approval from the Director regarding: obstetrics. The Member must provide the Director with proof of enrolment and successful completion of the courses with a minimum passing grade of 65%.
c) For a period of 18 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.
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. The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection.
The oral reprimand provides specific deterrence to the Member by providing a public and professional perspective regarding the serious implications of her actions and inactions. Regulatory Expert meetings, completion of a Reflective Questionnaire and the development of a Learning Plan satisfies both specific and general deterrence by raising the Member’s awareness, and that of others in the profession, and the importance of translating learned knowledge into nursing practice.
Rehabilitation and remediation is achieved through the Member’s attendance and participation at meetings with a Regulatory Expert and will also ensure that the Member learns and integrates this learned knowledge into her practice to ensure public safety in all aspects of nursing. Prior to any future obstetrical nursing practice, the Member’s requirement to complete an appropriate obstetrical nursing course with a minimum pass rate of 65%, will enhance public confidence in the ability of the College to regulate nurses.
The penalty of a six month suspension along with an 18 month employer notification of the Decision will provide specific and general deterrence by communicating to all members of the profession that misconduct will result in significant sanctions. It also conveys the seriousness of not acknowledging when you need assistance and the importance of ensuring the safe and appropriate care of your patient. The suspension also sends a message to all members by validating the importance of using learned knowledge and expertise with critical thinking in the provision of timely care, and that it is of utmost importance in maintaining your professional accountabilities.
The penalty is in line with what has been ordered in previous cases.
I, Terry Holland, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel.