College of Nurses of Ontario v. Juliana-Vera Stojiljkovic, 2019 ONCNO 129285

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Dawn Cutler, RN Chairperson Catherine Egerton Public Member Deborah Graystone, NP Member Richard Woodfield Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) EMILY LAWRENCE for ) College of Nurses of Ontario

• and - )

JULIANA-VERA STOJILJKOVIC ) TIM HANNIGAN for Registration No.: 9719709 ) Juliana-Vera Stojiljkovic ) CHRISTOPHER WIRTH ) Independent Legal Counsel ) Heard: September 6, 2019

AMENDED DECISION AND REASONS

This matter came on for hearing before a Panel of the Discipline Committee (the “Panel”) on September 6, 2019 at the College of Nurses of Ontario (the “College”) at Toronto.

Publication Ban

College Counsel brought a motion pursuant to s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, for an order preventing the public disclosure of the names and [patients] identifying information referred to orally or in any documents presented in the Discipline hearing of Juliana-Vera Stojiljkovic or any information that could disclose the identity of the [patients], including a ban on the publication or broadcasting of this information.

The panel considered the submissions of the Parties and decided that there be an order preventing the public disclosure of the names of the [patients] referred to orally or in any documents presented in the Discipline hearing of Juliana-Vera Stojiljkovic or any information that could disclose the identity of the [patients], including a ban on the publication or broadcasting of this information.

The Allegations

The allegations against Juliana-Vera Stojiljkovic (the “Member”) as stated in the Notice of Hearing dated June 11, 2019 are as follows:

IT IS ALLEGED THAT:

1. 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 during your employment as a Registered Nurse at the Central East Community Care Access Centre (the “Agency”) in Whitby, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession in that:

a. on or about April 2012 to March 2016, you failed to perform an adequate in-home re-assessment of [Patient A], in that your assessments did not reflect [the patient]’s circumstances as they changed over time and/or failed to document the change in [the patient]’s circumstances over time;

b. on or about September 2015 to March 2016, you failed to take prompt steps to follow up with [Patient B] after he cancelled scheduled home care appointments;

c. on or about November 2015 to April 2016, you failed to provide an assessment regarding palliative care needs for [Patient B];

d. on or about March 2016, you failed to perform an adequate assessment on [Patient C] and/or failed to complete adequate documentation in respect of that assessment;

e. on or about April 2016, you failed to follow up promptly after receiving alerts/notifications in respect of [Patient C];

f. on or about March 2016, you failed to follow up promptly after receiving alerts/notifications in respect of [Patient D];

g. on or about March to May 2016, you failed to complete an appropriate assessment of the needs of [Patient D];

h. on or about September 2013 to June 2016, you failed to perform an adequate in-home re-assessment of [Patient E] at any point after September 2013 and/or failed to complete adequate documentation in respect of that assessment;

i. on or about January 19, 2016, you failed to perform an adequate in-home assessment to identify the care needs of [Patient F] and his caregiver;

j. on or about January 2016 to May 2016, you failed to follow up with [Patient F] and his caregiver, to assess [patient] needs;

k. on or about February to March 2016 you failed to perform an adequate assessment of [Patient G] and/or you failed to complete adequate documentation in respect of that assessment;

l. on or about March 16, 2016 to June 2016, you failed to follow up with [Patient G] regarding her housing;

m. on or about 2014 to January 2016, you failed to perform prompt and adequate re-assessment of [Patient H];

n. on or about January 15, 2016, you failed to perform an adequate assessment of [Patient H] and/or failed to complete adequate documentation in respect of that assessment;

o. on or about February to May 2016, you failed to follow up promptly after receiving alerts/notifications and requests for follow up in respect of [Patient H];

p. on or about January to May 2016, you failed to ensure that the application for long-term care for [Patient I] was completed in a prompt manner;

q. on or about February 4, 2016 to March 17, 2016, you failed to conduct a home visit and assessment of [Patient J] in a timely manner;

r. on or about April to May 2016, you failed to follow up promptly after receiving alerts/notifications in respect of [Patient J];

s. on or about January 2016 to May 2016, you failed to conduct a home visit and assessment of [Patient K] in a timely manner;

t. on or about May 26, 2016, you failed to a conduct an adequate and complete re-assessment of [Patient K] in person;

u. on or about January 2016 to March 2016, you failed to conduct a home visit and assessment of [Patient L] in a timely manner;

v. on or about January 2016 to March 2016, you failed to coordinate appropriate in-home services for [Patient L] in a timely manner;

w. on or about March to May 2016, you failed to ensure that your documentation in respect of [Patient M] was uploaded into the Agency’s electronic document system in a timely manner;

x. on or about March to May 2016, you failed to ensure that you commenced the application process for long-term care for [Patient M] in a timely manner;

y. on or about May 5, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient N];

z. on or about May 12, 2016, you failed to follow-up when [Patient N] was reported as ‘not seen not found’ by a service provider and/or you failed to document the follow-up completed;

aa. on or about January 2016 to May 2016, you failed to conduct a home visit and assessment of [Patient O] in a timely manner;

bb. on or about January 2016 to May 2016, you failed to follow up after you received requests and information about the changing in-home needs of [Patient O];

cc. on or about May 2016, you failed to conduct a home visit and re-assessment of [Patient P] in a timely manner;

dd. on or about May 2016, you failed to provide counselling in-person regarding the application for long-term care to [Patient P];

ee. on or about January 27, 2016, you failed to perform an adequate assessment of [Patient Q] and/or you failed to complete adequate documentation in respect of that assessment;

ff. on or about January 27, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient Q];

gg. on or about May 12, 2016, you failed to perform an adequate assessment of [Patient R] and/or you failed to complete adequate documentation in respect of that assessment;

hh. on or about May 12, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient R];

ii. on or about March 17, 2016, you failed to perform an adequate assessment of [Patient S] and/or you failed to complete adequate documentation in respect of that assessment;

jj. on or about March 17, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient S];

kk. on or about January 29, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient T];

ll. on or about October 25, 2015, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient U];

mm. on or about August 2015 to April 2016, you failed to provide adequate follow-up to the caregiver of [Patient V];

nn. on or about April 21, 2016, you copied documentation that you completed in August 2015 into the documentation you completed on April 21, 2016 in respect of [Patient V];

oo. on or about February 18, 2016, you copied documentation that you completed in May 2015 into the documentation you completed on February 18, 2016 in respect of [Patient W];

pp. on or about March 3, 2016, you copied documentation that you completed in August 2015 into the documentation you completed on March 3, 2016 in respect of [Patient X];

qq. on or about April 7, 2016, you copied documentation that you completed in January 2016 into the documentation you completed on April 7, 2016 in respect of [Patient Y];

rr. on or about March 2, 2016, you failed to complete adequate documentation in respect of the assessment of [Patient Z];

ss. on or about March 2, 2016, you copied documentation that you completed in August 2015 into the documentation you completed on March 2, 2016 in respect of [Patient Z];

tt. on or about May 16, 2016, you copied documentation that you completed in October 2015 into the documentation you completed on May 16, 2016 in respect of [Patient AA]; and/or

uu. on or about April 7, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient BB]; and/or

2. 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 during your employment as a Registered Nurse at the Agency in Whitby, 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, in that:

a. on or about April 2012 to March 2016, you failed to perform an adequate in-home re-assessment of [Patient A] in that your assessments did not reflect [the patient]’s circumstances as they changed over time and/or failed to document the change in [the patient]’s circumstances over time;

b. on or about September 2015 to March 2016, you failed to take prompt steps to follow up with [Patient B] after he cancelled scheduled home care appointments;

c. on or about November 2015 to April 2016, you failed to provide an assessment regarding palliative care needs for [Patient B];

d. on or about March 2016, you failed to perform an adequate assessment on [Patient C] and/or failed to complete adequate documentation in respect of that assessment;

e. on or about April 2016, you failed to follow up promptly after receiving alerts/notifications in respect of [Patient C];

f. on or about March 2016, you failed to follow up promptly after receiving alerts/notifications in respect of [Patient D];

g. on or about March to May 2016, you failed to complete an appropriate assessment of the needs of [Patient D];

h. on or about September 2013 to June 2016, you failed to perform an adequate in-home re-assessment of [Patient E] at any point after September 2013 and/or failed to complete adequate documentation in respect of that assessment;

i. on or about January 19, 2016, you failed to perform an adequate in-home assessment to identify the care needs of [Patient F] and his caregiver;

j. on or about January 2016 to May 2016, you failed to follow up with [Patient F] and his caregiver, to assess [patient] needs;

k. on or about February to March 2016 you failed to perform an adequate assessment of [Patient G] and/or you failed to complete adequate documentation in respect of that assessment;

l. on or about March 16, 2016 to June 2016, you failed to follow up with [Patient G] regarding her housing;

m. on or about 2014 to January 2016, you failed to perform prompt and adequate re-assessment of [Patient H];

n. on or about January 15, 2016, you failed to perform an adequate assessment of [Patient H] and/or failed to complete adequate documentation in respect of that assessment;

o. on or about February to May 2016, you failed to follow up promptly after receiving alerts/notifications and requests for follow up in respect of [Patient H];

p. on or about January to May 2016, you failed to ensure that the application for long-term care for [Patient I] was completed in a prompt manner;

q. on or about February 4, 2016 to March 17, 2016, you failed to conduct a home visit and assessment of [Patient J] in a timely manner;

r. on or about April to May 2016, you failed to follow up promptly after receiving alerts/notifications in respect of [Patient J];

s. on or about January 2016 to May 2016, you failed to conduct a home visit and assessment of [Patient K] in a timely manner;

t. on or about May 26, 2016, you failed to a conduct an adequate and complete re-assessment of [Patient K] in person;

u. on or about January 2016 to March 2016, you failed to conduct a home visit and assessment of [Patient L] in a timely manner;

v. on or about January 2016 to March 2016, you failed to coordinate appropriate in-home services for [Patient L] in a timely manner;

w. on or about March to May 2016, you failed to ensure that your documentation in respect of [Patient M] was uploaded into the Agency’s electronic document system in a timely manner;

x. on or about March to May 2016, you failed to ensure that you commenced the application process for long-term care for [Patient M] in a timely manner;

y. on or about May 5, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient N];

z. on or about May 12, 2016, you failed to follow-up when [Patient N] was reported as ‘not seen not found’ by a service provider and/or you failed to document the follow-up completed;

aa. on or about January 2016 to May 2016, you failed to conduct a home visit and assessment of [Patient O] in a timely manner;

bb. on or about January 2016 to May 2016, you failed to follow up after you received requests and information about the changing in-home needs of [Patient O];

cc. on or about May 2016, you failed to conduct a home visit and re-assessment of [Patient P] in a timely manner;

dd. on or about May 2016, you failed to provide counselling in-person regarding the application for long-term care to [Patient P];

ee. on or about January 27, 2016, you failed to perform an adequate assessment of [Patient Q] and/or you failed to complete adequate documentation in respect of that assessment;

ff. on or about January 27, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient Q];

gg. on or about May 12, 2016, you failed to perform an adequate assessment of [Patient R] and/or you failed to complete adequate documentation in respect of that assessment;

hh. on or about May 12, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient R];

ii. on or about March 17, 2016, you failed to perform an adequate assessment of [Patient S] and/or you failed to complete adequate documentation in respect of that assessment;

jj. on or about March 17, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient S];

kk. on or about January 29, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient T];

ll. on or about October 25, 2015, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient U];

mm. on or about August 2015 to April 2016, you failed to provide adequate follow-up to the caregiver of [Patient V];

nn. on or about April 21, 2016, you copied documentation that you completed in August 2015 into the documentation you completed on April 21, 2016 in respect of [Patient V];

oo. on or about February 18, 2016, you copied documentation that you completed in May 2015 into the documentation you completed on February 18, 2016 in respect of [Patient W];

pp. on or about March 3, 2016, you copied documentation that you completed in August 2015 into the documentation you completed on March 3, 2016 in respect of [Patient X];

qq. on or about April 7, 2016, you copied documentation that you completed in January 2016 into the documentation you completed on April 7, 2016 in respect of [Patient Y];

rr. on or about March 2, 2016, you failed to complete adequate documentation in respect of the assessment of [Patient Z];

ss. on or about March 2, 2016, you copied documentation that you completed in August 2015 into the documentation you completed on March 2, 2016 in respect of [Patient Z];

tt. on or about May 16, 2016, you copied documentation that you completed in October 2015 into the documentation you completed on May 16, 2016 in respect of [Patient AA]; and/or

uu. on or about April 7, 2016, you copied the documentation of a colleague, and passed it off as if it were your own, into the documentation you completed in respect of [Patient BB]

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m), (n), (o), (p), (q), (r), (s), (t), (u), (v), (w), (x), (y), (z), (aa), (bb), (cc), (dd), (ee), (ff), (gg), (hh), (ii), (jj), (kk), (ll), (mm), (nn), (oo), (pp), (qq), (rr), (ss), (tt), (uu) and 2(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m), (n), (o), (p), (q), (r), (s), (t), (u), (v), (w), (x), (y), (z), (aa), (bb), (cc), (dd), (ee), (ff), (gg), (hh), (ii), (jj), (kk), (ll), (mm), (nn), (oo), (pp), (qq), (rr), (ss), (tt), (uu) 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’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited, as follows:

THE MEMBER

1. Juliana-Vera Stojiljkovic (the “Member”) obtained a diploma in nursing from Durham College in 1997.

2. The Member has been registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) in the General Class since July 7, 1997.

3. The Member was employed as a full-time Care Coordinator at the Central East Community Care Access Centre (“CECCAC”) from 2007 until she resigned in June 2016 after an investigation into the incidents described below.

CECCAC AND THE CARE COORDINATOR POSITION

Assessment by Care Coordinators

4. Community Care Access Centres (“CCAC”) coordinate all healthcare services in the home including nursing, occupational therapy, physiotherapy, dietician services, speech and language services, lab services, personal support worker (“PSW”) services, equipment or medical supplies and social work services. CCACs also connect patients to community resources and assess long-term care (“LTC”) needs. CCACs are funded by the Ministry of Health and Long-Term Care.

5. CECCAC covers central east Ontario. The Member worked at the Whitby branch, where there are approximately 200 Care Coordinators. She was a Care Coordinator in the long-stay program, for patients with anticipated long-term in-home needs. The Member had 129 patients in her patient load.

6. Care Coordinators coordinate the patient’s care plan and assess the patient’s needs for in-home services and/or application to LTC. They are RNs, occupational therapists, or social workers. Care Coordinators do not provide ongoing in-home services, but they determine and approve what in-home services the patient should receive.

7. Care Coordinators manage a caseload of 120-130 patients. They coordinate patient care until the patient is discharged. Care Coordinators meet with patients in their homes, first upon assignment into the CCAC, and then at least every six months thereafter (or earlier if there is a significant event).

8. On assignment to the CCAC, Care Coordinators must meet patients in their homes to complete a standardized assessment tool, called a "resident assessment instrument" ("RAI"). RAI is a nine-page electronic tool that Care Coordinators use to complete an assessment of the patient’s in-home health needs and eligibility and possible LTC needs.

9. RAI is a holistic assessment of the patient’s demographics, personal situation, health history, medication, equipment use, cognition and mental health, social and physical functioning, medications, etc. From the patient's answers, the Care Coordinator determines how much support is required; information to make this determination is embedded throughout the entire assessment. This is part of the Minimum Data Set Home Care package.

10. Care Coordinators complete the RAI by asking the patient questions, while visiting the patient in the patient’s home. RAIs are completed on a laptop. The assessment using the RAI takes at least one hour. It must be completed within 10-14 days of patient assignment to the CCAC. All Care Coordinators receive four days training on completing RAI assessments. They have yearly competency tests on the RAI as well.

11. After the initial assessment, Care Coordinators are expected to see patients every six months afterwards, and complete an RAI at those biannual visits. The reassessment using RAI takes at least 20 minutes to complete. Care Coordinators receive alerts in the electronic system to conduct these six-month assessments.

12. Care Coordinators may also see patients between biannual visits if they receive reports of a significant change from other nurses, therapists, or care providers, or from family members. Care Coordinators are alerted if a patient's health card is swiped in any emergency department to ensure that they know what is happening with their patients.

13. In order for the Care Coordinators to stay on top of biannual visits, they must do a minimum of six visits per week. This often means that Care Coordinators have two days in the community and three days in-office, either at home or at the CCAC office. The Member worked from home from September 2015 onwards, coming into the office at least once every two weeks for a full day of work.

Documentation by Care Coordinators

14. Care Coordinators use the CCAC’s CHRIS electronic document system. All documentation is time-stamped. For the RAI assessment, the Care Coordinator has uploaded a portable version onto their laptop. Their documentation will not sync with their system until they dock it back in and download it into the system. Care Coordinators have a three-day turnaround time in which they are expected to ensure they have documented after visiting a patient.

15. Issues with CHRIS are dealt with on a provincial basis, using an IT issue ticketing system. Care Coordinators plan out their week and they have a common calendar they are expected to keep up to date so that the rest of the team knows where they are. This is also a safety measure for them.

16. If the Member were to testify, she would state that it was common practice among Care Coordinators to cut and paste notes from past RAIs into current RAIs. She acknowledges that even if this was a common practice, it was not sanctioned by her employer and did not meet minimum standards of practice, as addressed in more detail below.

LTC Applications

17. In addition to conducting the initial and biannual RAI assessments and coordinating care as needed, Care Coordinators must also assess patients for LTC needs and, if appropriate, complete LTC applications.

18. To begin this process, Care Coordinators must assess the patient’s capacity to apply for LTC and obtain their consent to apply. Care Coordinators complete capacity assessments, usually along with the RAI assessment. If necessary, Care Coordinators also ensure that the patient file contains a valid written power of attorney, and document the identity of the substitute decision-maker, and/or initiates contact with the Public Guardian and Trustee. Care Coordinators then obtain written consent to complete the LTC application. This written consent is filed in their system and forms part of the application.

19. Care Coordinators also assist patients to select the LTC facilities to which they wish to apply.

20. The Care Coordinators compile the application materials, including the RAI assessment, a behavioural assessment, a health report (usually from the patient's physician, although it can be completed by another care provider), and the choice form (which sets out the patient’s five preferred LTC facilities, selected through discussion with the Care Coordinator).

21. The Care Coordinator then uploads the application and puts the patient on the list for LTC, and opens up an LTC file in the patient’s file. Waitlists could be up to three to four years, so they are continually re-assessing to see if the patient can wait to be placed or if they should be looking at other alternatives. The application process (from the patient’s first mention of their desire to apply to filing the application) should take six weeks. Thereafter, the Care Coordinator works with the LTC placement coordinators to offer beds to patients as they become available.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

CECCAC Investigation into the Member’s Conduct

22. During her employment at CECCAC, the Member was placed on learning plans regarding documentation and her ability to meet targets for the number of case assessments completed.

23. As part of her learning plans, the Member used documentation templates (in bullet points) to guide the Member’s assessment and remind her of things to consider for a patient. The templates were not scripted, but were in the form of bullet points.

24. When the incident described below emerged, the Member had successfully completed the learning plan; however, her supervisor continued to do random chart audits.

25. After the Member failed to attend a scheduled patient meeting and a patient’s family member complained, the Member’s supervisor investigated. The supervisor then reviewed the Member’s visits in the calendar against her documentation, and she contacted patients to determine if the Member had attended scheduled visits. The supervisor also reviewed the Member’s documentation for the Member’s patients.

[Patient A]

26. The Member was [Patient A]’s assigned Care Coordinator, from at least 2011. The RAIs that the Member completed from April 2012 to March 2016 for this patient indicated virtually no change in [Patient A]’s circumstances, acuity or score.

27. The Member acknowledges and agrees that the lack of change in the RAI assessment over a period of years was atypical, as the CECCAC clientele tends to be elderly, often suffer from dementia, often are nearing end of life and their needs change (usually decline) over time.

28. The Member completed her last RAI for this patient in March 2016. In May 2016, another nurse re-assessed [Patient A] and made some adjustments to the RAI and score, reducing [Patient A]’s acuity.

29. The Member admits that she failed to perform and document accurate or comprehensive RAIs and routine re-assessments for [Patient A] from April 2012 to March 2016, in that the RAIs she completed did not reflect any change in the patient’s circumstances over time. The patient’s circumstances had, in fact, changed, as demonstrated by another nurses’ reassessment.

[Patient B]

30. The Member was [Patient B]’s assigned Care Coordinator.

31. The Member completed a home visit on July 27, 2015, after [Patient B] returned from a hospital stay. [Patient B] cancelled many of his daily PSW home visits from September to December 2015. His physician deemed him to be palliative in November 2015, an event that would trigger the need for a Care Coordinator visit.

32. On January 7, 2016, there was a notation and task assigned to the Member to follow up regarding [Patient B]’s palliative status and in-home care needs.

33. [Patient B] cancelled several more PSW visits in January 2016. The Member charted that she spoke to [Patient B]’s spouse on February 2, 2016, who told her that he was “unwell” for AM care prior to dialysis and the son was to “clarify” PSW support.

34. The son agreed to put PSW support on hold on February 19, 2016. The Member followed up on February 21, 2016 and the son then advised the Member on February 22, 2016 that [Patient B] would accept PSW services three times weekly.

35. [Patient B] was later discharged from CCAC care when admitted to hospital, and passed away.

36. The Member acknowledges and admits that she failed to promptly assess [Patient B]’s palliative status between November 2015 and April 2016, when [Patient B] was admitted to hospital. She also admits and acknowledges that she failed to follow up promptly with [Patient B] after cancelled PSW appointments and after receiving a notation to follow up on January 7, 2016. She acknowledges that it was her responsibility to assess the patient’s PSW needs and that it was improper to rely on the patient’s spouse or son to assess the patient’s PSW needs.

[Patient C]

37. [Patient C] was added to the Member’s caseload in March 2016, after being followed by another Care Coordinator.

38. The Member completed a home visit and a revised RAI on March 3, 2016, which she logged in charting for a half hour (11:23 am to 11:51 am). The Member’s RAI was very similar to the prior RAI, in terms of the answers to the RAI questions. The Member cut and pasted from the patient’s prior RAI and made very few changes to the RAI.

39. In April 2016, the Member received several alerts (April 6, 14 and 16) after [Patient C] was admitted to hospital. The Care Coordinator guidelines require follow up within 72 hours post-hospital. The Member failed to follow up until April 18, although she marked the follow-up task as completed before that date. When she did follow up with [Patient C]’s daughter on April 21, she failed to chart any inquiry regarding the repeated hospital admissions. She did not follow up after another patient alert on April 22, 2016.

40. The Member acknowledges and admits that she failed to perform and document an adequate assessment on March 3, 2016, as demonstrated by her half-hour visit (when an initial assessment takes up to an hour), and her cutting and pasting of information from past RAIs. She also admits and acknowledges that she failed to follow up promptly after receiving alerts in April 2016.

[Patient D]

41. The Member was [Patient D]’s assigned Care Coordinator.

42. [Patient D] was discharged from the hospital on March 18, 2016, with a hospital-prepared care plan that included in-home nursing and PSW services. He was added to the Member’s patient load. The Member failed to follow up on two alerts (March 20 and 25). She did not complete a home visit for [Patient D] at any point after March 18, 2016.

43. On April 8, 2016, the PSW supervisor advised the Member that [Patient D] was refusing PSW appointments. The Member did not follow up with [Patient D] about this report until April 18, 2016.

44. On May 19, 2016, the Member received a report from an occupational therapist. The Member did not make any notes in the patient’s chart about this report, but check-marked the task of reviewing it as complete. The Member discharged [Patient D] the following day, which was appropriate given the patient’s health status.

45. The Member acknowledges and admits that she failed to follow up promptly after receiving alerts in March 2016, and that she failed to complete an appropriate assessment of the patient’s needs, which would have included an in-home visit for assessment and discussion about PSW visits, and a discussion with the patient about the occupational therapist report and his readiness for discharge.

[Patient E]

46. [Patient E] was discharged from the hospital in September 2013, with a referral for CECCAC services. The hospital’s Care Coordinator completed an RAI before he was discharged.

47. [Patient E] was added to the Member’s patient load in September 2013.

48. The Member completed a home visit and RAI in September 2013.

49. The Member did not complete any further re-assessment, on a biannual basis or otherwise, at any point thereafter.

50. The Member admits and acknowledges that she failed to perform an adequate in-home re-assessment at any point after September 2013 and failed to complete adequate documentation in respect of that assessment.

[Patient F]

51. The Member was [Patient F]’s assigned Care Coordinator.

52. The Member received [Patient F] onto her patient load when caseloads were rebalanced. She completed an initial home visit on January 19, 2016. The Member did not provide sufficient information to [Patient F]’s spouse about how to obtain short stay respite (assistance for caregivers).

53. [Patient F]’s spouse called on January 26 for information regarding short stay respite and received information from another colleague, as the Member was on break. [Patient F]’s spouse called again on January 28, reporting that [Patient F] had fallen on January 20 and spoke to a colleague of the Member.

54. The Member did not document any interaction with [Patient F] until May 5, 2016. Other CCAC staff handled the short stay respite application.

55. The Member acknowledges and admits that she failed to perform and document an adequate in-home assessment, which may have identified the need for a short stay respite, and that she should have provided information about short stay respite during her home visit and failed to do so. She also admits that she should have followed up when [Patient F]’s spouse expressed concerns about burnout and [Patient F] falling on January 28, 2016, and she failed to do so.

[Patient G]

56. [Patient G] was first assessed by one of the Member’s colleagues in March 2015.

57. By February 2016, the Member was this patient’s assigned Care Coordinator. The Member did a home visit in February 2016. She did not change the RAI score. In the narrative notes section, the Member cut and pasted information from the prior RAI.

58. On March 16, 2016, the Member had a telephone call with [Patient G] who told her that she was being evicted. The Member did not follow up with [Patient G] at any point prior to her resignation in June 2016. She completed no charting between March 16 and her resignation in June 2016.

59. The Member acknowledges and admits that she failed to perform and document an adequate assessment on March 16, 2016 and failed to follow up with [Patient G] regarding housing after March 16, 2016.

[Patient H]

60. The Member was [Patient H]’s assigned Care Coordinator.

61. On January 15, 2016, the Member conducted a home visit for [Patient H], for an RAI reassessment. The prior RAI was from August 2014. The Member did not update or change the content of the January 2016 RAI from the prior August 2014 RAI in any significant detail. However, she did document in CHRIS that [Patient H] has progressed to end stage of her COPD (which would suggest changes in the RAI and the patient’s acuity).

62. The Member received several alerts and requests for follow-up in February and March 2016:

a. hospital visit alerts on February 8, 20, and 26, 2016.

b. a request from the LTC placement coordinator to follow up with [Patient H]’s daughter on LTC choices on February 26, 2016; and

c. a voicemail message from an LTC placement coordinator on March 4 to follow up with [Patient H]’s daughter.

63. The Member did not contact the patient or the patient’s family until March 7, 2016 when the Member left a voicemail for [Patient H]’s daughter.

64. The Member received another hospital visit alert on May 5. [Patient H] died on May 13, 2016.

65. The Member did not do a home visit or speak to the patient or the patient’s family members between January 2016 and her death in May 2016.

66. The Member acknowledges and admits that she failed to perform prompt re-assessments between August 2014 and January 2016, and that the assessment she did in January 2016 was not an adequate assessment, nor was the documentation for that assessment adequate. She also admits that she failed to follow up promptly after receiving alerts and requests for follow up in February to May 2016.

[Patient I]

67. On January 4, 2016, [Patient I]’s daughter-in-law reported to the CCAC Team Assistant that [Patient I], who was 78 years old and had Alzheimers, intended to walk to her cottage without a coat or her medication. The Member was sent an urgent request to follow up. This event triggered the need to discuss LTC placement and open an LTC application file, which the Member admits she did not do in a prompt manner.

68. On January 6, the Member made an appointment for a home visit for January 18, which she then cancelled on January 18 and rebooked on January 27, 2016.

69. The Member eventually opened the LTC file on March 29, 2016. The Member did not ensure that the power of attorney forms and other prerequisites for the LTC application were completed in a timely way, all of which should have been initiated shortly after the January 4, 2016 call.

70. The LTC application was not completed until May 10, 2016, despite the expectation that applications will be completed within four weeks after the initial mention of need.

71. The Member acknowledges and admits that she failed to ensure that the patient’s LTC application was completed in a prompt manner.

[Patient J]

72. [Patient J] was transferred to the Member’s assignment on February 4, 2016, following a discharge from the hospital on January 28, 2016. [Patient J] had Alzheimers. His hospital-prepared care plan included nursing care, a PSW and occupational therapy.

73. If the Member were to testify, she would state that she did not realize that [Patient J] had been transferred to her until February 10, 2016.

74. In February, [Patient J] received nursing care for his catheter. The Member spoke to [Patient J] first on March 8, 2016 and conducted a home visit on March 17, 2016. She did not initiate occupational therapy or PSW support as set out in the hospital’s care plan. She did not follow up after a hospital visit and subsequent alerts on April 23, May 7, May 9, or make any documentation after March 17, 2016.

75. The Member acknowledges and admits that she should have known that [Patient J] was assigned to her and should have conducted a home visit before March 17, 2016, and failed to do so. She also admits that she failed to follow up after she received alerts/notifications of a hospital stay.

[Patient K]

76. The Member was [Patient K]’s assigned Care Coordinator.

77. The Member assessed [Patient K] in September 2015. The routine re-assessment was due March 2016, six months after the September 2015 assessment.

78. On January 15, 2016, [Patient K]’s daughter-in-law called the CCAC with a report that she suspected that [Patient K]’s spouse was abusing [Patient K]. The Member was tasked with follow-up; she checked off that she had completed the task to follow up on January 15, 2016, but she did not document follow-up until January 22, when the daughter-in-law was added as a contact and the spouse requested LTC.

79. On January 25, 2016, the Member documented that she would call back the following week to book a home visit. She did not schedule the home visit until May 24, to attend on May 26, 2016.

80. The Member attended for the home visit on May 26, 2016. She stayed for a total of 25 minutes, during which she started but did not complete the RAI and her assessment. The Member agreed to call [Patient K] to complete it. During her visit, the Member told [Patient K] and her family that she was not able to complete the RAI while the PSW was in the home, which was not CCAC policy.

81. The Member acknowledges and admits that she failed to conduct a home visit and assessment in a timely manner (being a four-month delay after a suspicion of abuse, and two months after the re-assessment was due). She also admits that she failed to complete a complete and adequate re-assessment in person, as required.

[Patient L]

82. [Patient L] was admitted to the hospital as a result of a fall on January 1, 2016. When discharged, [Patient L] was seen by a Rapid Response Nurse, a member of the CCAC team that complete post-hospital assessments and care in some circumstances. The Rapid Response Nurse determined that [Patient L] would benefit from occupational therapy on January 4, 2016, a recommendation which she also noted on January 14.

83. The Member was this patient’s assigned Care Coordinator, and took over care from the Rapid Response team.

84. On January 13, [Patient L] spoke to the Member by phone and requested occupational therapy. The Member noted a new diagnosis of pneumonia, but took no further steps to create a plan of care. She did not conduct an in-home assessment at any time.

85. The Member did not document that she had arranged for occupational therapy, although she did. The patient was discharged after a course of occupational therapy in late January, and the patient was discharged on February 2, 2016.

86. The Member acknowledges and admits that she failed to conduct a home visit and assessment in a timely manner and failed to coordinate appropriate in-home services in a timely manner.

[Patient M]

87. The Member was [Patient M]’s assigned Care Coordinator, as of March 28, 2016, following discharge from the hospital.

88. The Member first made a note in CHRIS on April 5, 2016. She completed a home visit and RAI on April 28, 2016 but did not upload it into CHRIS until May 17, 2016, contrary to the expectations that RAIs would be uploaded within 72 hours.

89. The Member did not open an LTC application file, despite discussions with the family about LTC options, between April 28 and May 16, 2016. If the Member were to testify, she would state that she was waiting on the family to decide if the patient wanted to apply. However, she acknowledges that she should have followed up to ensure that the LTC application was processed in a timely way.

90. [Patient M] was transferred to complex caseload on May 16, 2016.

91. The Member admits and acknowledges that she failed to ensure that her documentation was entered into CCAC’s electronic document system in a timely manner. She also admits that she failed to ensure that she commenced the application process for LTC in a timely manner.

[Patient N]

92. On May 5, 2016, the Member cut and pasted charting from another colleague into the charting she completed in CHRIS regarding [Patient N].

93. On May 12, 2016, an in-home care provider reported to the CCAC’s team assistant that [Patient N] was “NSNF”, which means Not Seen Not Found, or not at the residence at the time of an appointment. The team assistant sent an urgent task to the Member to follow up. The Member did not follow up. She did mark the urgent task request as completed.

94. The Member acknowledges that she had a responsibility to follow up on NSNF reports relating to patients in her patient load. She further acknowledges that she knew of the NSNF report, even if it should not have been assigned her over the lunch hour, and that she marked the task as complete when she had not actually followed up.

95. The Member acknowledges and admits that she cut and pasted a colleague’s documentation instead of doing her own documentation, and passed it off as her own. She also admits that she failed to follow up when [Patient N] was not seen not found by a service provider and failed to document her follow-up.

[Patient O]

96. [Patient O] was assigned to the Member’s caseload at some point prior to January 1, 2016. Between January and May 2016, the Member did not conduct an RAI or in-home visit.

97. During that period, [Patient O] had issues with an incision and care providers reported that she was not coping well. The Member should have conducted a home visit and completed an RAI and assessment.

98. The Member acknowledges and admits that she failed to conduct a home visit and assessment in a timely manner and failed to follow up after she received requests and information about [Patient O]’s changing in-home needs.

[Patient P]

99. The Member was [Patient P]’s assigned Care Coordinator.

100. [Patient P] had had a pending LTC application since 2013. A bed in one of her preferred facilities became available in May 2016. The Member conveyed this to [Patient P] by phone, who declined to take the bed.

101. The Member should have visited [Patient P] in person and counselled her, ensuring that [Patient P] understood the consequences of declining to take the bed, which included that [Patient P] would be placed at the bottom if she re-applied for LTC.

102. The Member did not schedule or conduct a home visit to discuss the consequences, even though a reassessment was due in May 2016. The subsequent Care Coordinator properly counselled [Patient P] in June 2016 and the Care Coordinator and [Patient P] adopted a new care plan with significant changes.

103. The Member acknowledges and admits that she failed to conduct a home visit and re-assessment in a timely manner and that she failed to provide counselling in person regarding the application for LTC.

[Patient Q]

104. The Member was [Patient Q]’s assigned Care Coordinator.

105. The Member documented a history of falls during her home visit for [Patient Q] on January 27, 2016, yet failed to put this information in her RAI assessment under falls frequency, which she documented as none. The Member did not offer a physiotherapy visit to look at equipment needs or send [Patient Q] to a falls clinic.

106. The Member cut and pasted charting from another colleague into the charting she completed in CHRIS on January 27, 2016. The specific language she copied related to “has STM [short term memory] loss due to dementia. Client recalled 1/3 after 5 mins. Son helps with decision making”, which are all areas where the Member should have conducted her own assessment and used her own words.

107. The Member acknowledges and admits that she failed to perform an adequate assessment on January 27, 2016 and to document that assessment appropriately, and that she cut and pasted documentation of a colleague, passing it off as her own.

[Patient R]

108. The Member was [Patient R]’s assigned Care Coordinator.

109. The Member charted an in-home visit for [Patient R] in CHRIS on May 12, 2016. She did not input any information in the first ten lines of the home visit documentation template, and she cut and pasted her colleague’s prior entries under “current status of patient/updated diagnosis”.

110. The Member acknowledges and admits that she failed to perform and document an adequate assessment of [Patient R] on May 12, 2016 and that she cut and pasted documentation, passing it off as her own.

[Patient S]

111. The Member was [Patient S]’s assigned Care Coordinator.

112. The Member charted her assessment of [Patient S] on March 17, 2016. She cut and pasted from earlier documentation completed by a colleague on November 5, 2012. In particular, the Member cut and pasted the reference to [Patient S] signing a DNR “13 years ago” when, in 2016, the DNR had been signed 17 years prior.

113. The Member acknowledges and admits that she failed to perform and document an adequate assessment on March 17, 2016 and that she cut and pasted documentation, passing it off as her own.

[Patient V]

114. The Member was [Patient V]’s assigned Care Coordinator.

115. The Member documented her in-home RAI assessment of [Patient V] on April 21, 2016. She noted that [Patient V]’s son reported that [Patient V]'s daughter was overwhelmed and at risk of burnout, which she had first documented in August 2015. The Member did not follow up regarding possible caregiver burnout in August 2015 or in April 2016.

116. The Member also cut and pasted her documentation from August 4, 2015 into her charting on April 21, 2016 for [Patient V].

117. The Member admits and acknowledges that she failed to follow-up and provide resources to [Patient V]’s family, and cut and pasted her prior documentation, passing it off as if it was current documentation.

[Patient W], [Patient X], [Patient Y], and [Patient AA]

118. The Member was Care Coordinator to [Patient W], [Patient X], [Patient Y] and [Patient AA]. For each, the Member cut and pasted her prior documentation, passing it off as if it was her current assessment:

a. during the Member’s routine re-assessment and RAI visit for [Patient W] on February 18, 2016, the Member cut and pasted the large majority of her May 2015 entries into her February 2016 assessment;

b. during the Member’s routine re-assessment and RAI visit for [Patient X] on March 3, 2016, the Member cut and pasted the section under “equipment” from her August 18, 2015 assessment into her March 3, 2016 assessment;

c. during the Member’s routine assessment of [Patient Y] on April 7, 2016, the Member cut and pasted the majority of her April 7, 2016 assessment from her January 5, 2016 assessment; and

d. during the Member’s routine assessment of [Patient AA] on May 16, 2016, she cut and pasted the majority of her May 16, 2016 entries from her October 28, 2015 assessment.

119. The Member admits and acknowledges that she cut and pasted her prior documentation, passing it off as if it was current documentation, for each of these patients.

[Patient Z]

120. The Member was [Patient Z]’s assigned Care Coordinator.

121. The Member charted an in-home visit in CHRIS for [Patient Z] on March 2, 2016. She did not input any information in the first ten lines of the home visit documentation template, and she cut and pasted her prior entries from her August 27, 2015 assessment for [Patient Z].

122. The Member acknowledges and admits that she failed to perform and document an adequate assessment of [Patient Z] on March 2, 2016 and that she cut and pasted her prior documentation, passing it off as if was current documentation.

Patients [Patient T], [Patient U] and [Patient BB]

123. The Member was assigned Care Coordinator for [Patient T], [Patient U] and [Patient BB]. For each, she cut and pasted documentation from other colleagues:

a. during an in-home RAI assessment for [Patient T] on January 29, 2016, the Member cut and pasted the majority of the narrative notes accompanying the RAI from her colleague’s prior entries from March 24, 2015;

b. during an in-home RAI assessment for [Patient U] on October 25, 2015, the Member cut and pasted documentation that had previously been completed by a Care Coordinator when [Patient U] had been in hospital, on January 8, 2014, including copying a reference to the patient’s estimated date of discharge from the hospital in January 2014, which is not relevant to the Member’s in-home assessment in October 2015; and

c. during an in-home RAI re-assessment of [Patient BB] on April 7, 2016, the Member cut and pasted information contained in a Care Coordinator’s intake assessment for entry into the diabetes program, dated February 11, 2016.

STANDARDS OF PRACTICE AND THEIR APPLICATION TO THE ALLEGED MISCONDUCT

124. 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. A nurse demonstrates this standard by actions such as:

a. providing, facilitating, advocating and promoting the best possible care for clients;

b. advocating on behalf of clients;

c. seeking assistance appropriately and in a timely manner;

d. taking action in situations in which client safety and well-being are compromised; and

e. evaluating/describing the outcomes of specific interventions and modifying the plan/approach.

125. 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; and

d. ensuring that relevant client care information is captured in a permanent record.

126. The standards of practice of the profession required the Member to complete in-depth assessments at regular intervals and to document those assessments in her own words.

127. The standards of practice of the profession also required the Member to take steps to follow up with patients, and to provide relevant resources and counselling to patients to address their health care needs. The standards also required the Member to complete LTC applications in a timely way.

128. The Member acknowledges that her failure to complete assessments and documentation in a timely manner, and to follow up and provide resources that her patients required resulted in her patients not receiving the care and resources they deserved and did or could have caused harm to her patients.

129. If the Member were to testify, she would state that she had personal issues including health issues at the time of the alleged misconduct.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

130. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1 (a) to (uu) of the Notice of Hearing in that she contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 22 to 128 above.

131. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2 (a) to (uu) of the Notice of Hearing, and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 22 to 128 above.

College Counsel submitted that the Member’s conduct failed to meet the Standards of Practice expected as a member of the profession and was unprofessional. College Counsel also submitted that the Member’s conduct was dishonourable as she knew or should have known that her conduct fell below the standards of care that her patients deserved.

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 (uu) in the Notice of Hearing. As to Allegations #2(a) to (uu), the Panel finds that the Member engaged in conduct that would reasonably be considered by members to be dishonourable and unprofessional.

Reasons for Decision

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

Allegation #1(a) in the Notice of Hearing is supported by paragraphs 26 to 29 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to perform and document accurate or comprehensive RAIs and routine re-assessments for [Patient A].

Allegations #1(b) and (c) in the Notice of Hearing are supported by paragraphs 30 to 36 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to promptly assess [Patient B]’s palliative status between November 2015 and April 2016 and failed to follow up promptly with [Patient B] after cancelled PSW appointments and after receiving a notation to follow up on January 7, 2016.

Allegations #1(d) and (e) in the Notice of Hearing are supported by paragraphs 37 to 40 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to perform and document an adequate assessment on March 3, 2016 by her half-hour visit (when an initial assessment takes up to an hour) and that she failed to follow up promptly after receiving alerts in April 2016.

Allegations #1(f) and (g) in the Notice of Hearing are supported by paragraphs 41 to 45 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to follow up promptly after receiving alerts in March 2016, and that she failed to complete an appropriate assessment of the [Patient D]’s needs. This would have included an in-home visit for assessment and discussion about PSW visits, and a discussion with the patient about the occupational therapist report and his readiness for discharge.

Allegation #1(h) in the Notice of Hearing is supported by paragraphs 46 to 50 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to perform an adequate in-home re-assessment for [Patient E] at any point after September 2013 and failed to complete adequate documentation in respect of that assessment.

Allegations #1(i) and (j) in the Notice of Hearing are supported by paragraphs 51 to 55 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to perform and document an adequate in-home assessment for [Patient F] which may have indemnified the need for a short stay respite, and she should have provided information about short stay respite during her home visit and failed to do so. She also admitted she should have followed up when [Patient F]’s spouse expressed concerns about burnout and [Patient F] falling on January 28, 2016, and she failed to do so.

Allegations #1(k) and (l) in the Notice of Hearing are supported by paragraphs 56 to 59 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to perform and document an adequate assessment on March 16, 2016 and failed to follow up with [Patient G] regarding housing after March 16, 2016.

Allegations #1(m), (n) and (o) in the Notice of Hearing are supported by paragraphs 60 to 66 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to perform prompt reassessments of [Patient H] between August 2014 and January 2016, and that the assessment she did in January 2016 was not an adequate assessment, nor was the documentation for that assessment adequate. She also admits she failed to follow up promptly after receiving alerts and requests for follow up in February to May 2016.

Allegation #1(p) in the Notice of Hearing is supported by paragraphs 67 to 71 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member admitted she failed to ensure that [Patient I]’s application to Long Term Care was completed in a prompt manner.

Allegations #1(q) and (r) in the Notice of Hearing are supported by paragraphs 72 to 75 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member admitted she should have known that [Patient J] was assigned to her and should have conducted a home visit before March 17, 2016 and failed to do so. She also admitted that she failed to follow up after she received alerts/notifications of a hospital stay.

Allegations #1(s) and (t) in the Notice of Hearing are supported by paragraphs 76 to 81 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member admitted she failed to conduct a home visit and assessment for [Patient K] in a timely manner (being a four-month delay after a suspicion of abuse, and two months after the reassessment was due). The Member also admitted she failed to complete a complete and adequate re-assessment in person, as required.

Allegations #1(u) and (v) in the Notice of Hearing are supported by paragraphs 82 to 86 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member admitted she failed to conduct a home visit and an assessment for [Patient L] in a timely manner and failed to coordinate appropriate in-home services in a timely manner.

Allegations #1(w) and (x) in the Notice of Hearing are supported by paragraphs 87 to 91 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member admitted she failed to ensure that her documentation for [Patient M] was entered into CCAC’s electronic document system in a timely manner. She also admitted she failed to ensure that she commenced the application process for Long Term Care in a timely manner.

Allegations #1(y) and (z) in the Notice of Hearing are supported by paragraphs 92 to 95 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member admitted she cut and pasted a colleague’s documentation instead of doing her own documentation, and passed it off as her own. She also admitted she failed to follow up when [Patient N] was not seen and not found by a service provider and failed to document her follow up.

Allegations #1(aa) and (bb) in the Notice of Hearing are supported by paragraphs 96 to 98 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member admitted she failed to conduct a home visit and assessment in a timely manner and failed to follow up after she received requests and information about [Patient O]’s changing in-home needs.

Allegations #1(cc) and (dd) in the Notice of Hearing are supported by paragraphs 99 to 103 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to conduct a home visit and re-assessment in a timely manner for [Patient P] and she failed to provide counselling in person regarding the application for Long Term Care.

Allegations #1(ee) and (ff) in the Notice of Hearing are supported by paragraphs 104 to 107 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to perform an adequate assessment for [Patient Q] on January 27, 2016 and to document the assessment appropriately, and she cut and pasted documentation of a colleague, passing it off as her own.

Allegations #1(gg) and (hh) in the Notice of Hearing are supported by paragraphs 108 to 110 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to perform and document an adequate assessment of [Patient R] on May 12, 2016 and she cut and pasted documentation, passing it off as her own.

Allegations #1(ii) and (jj) in the Notice of Hearing are supported by paragraphs 111 to 113 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to perform and document an adequate assessment for [Patient S] on March 17, 2016 and cut and pasted documentation, passing it off as her own.

Allegations #1(kk) and (ll) in the Notice of Hearing are supported by paragraphs 123 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member cut and pasted notes from colleagues for [Patient T] and [Patient U].

Allegations #1(mm) and (nn) in the Notice of Hearing are supported by paragraphs 114 to 117 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to follow up and provide resources to patient [Patient V]’s family, and cut and pasted her prior documentation, passing it off as if it was current documentation.

Allegations #1(oo), (pp), (qq) and (tt) in the Notice of Hearing are supported by paragraphs 118, 119 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member cut and pasted her prior documentation for [Patient W], [Patient X], [Patient Y] and [Patient AA] and passed it off as if it was current documentation, for each of these patients.

Allegations #1(rr) and (ss) in the Notice of Hearing are supported by paragraphs 120 to 122 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member failed to perform and document an adequate assessment of [Patient Z] on March 2, 2016 and that she cut and pasted her prior documentation, passing it of as if it was current documentation.

Allegation #1(uu) in the Notice of Hearing is supported by paragraphs 123 and 130 in the Agreed Statement of Facts. The Panel makes the finding that the Member cut and pasted documentation from other colleagues for [Patient BB] and passed it off as current documentation.

The Member’s actions, as found by the Panel in the paragraphs above, constitute professional misconduct. Her actions contravene and fail to meet the standards of practice of the profession. In particular, they contravene the College’s Professional Standards and Documentation standard.

With respect to Allegation #2(a) to (uu) in the Notice of Hearing, the Panel finds that the Member’s conduct in failing to document in an appropriate or timely manner, failing to provide home assessments or visits in a timely manner and by failing to follow up promptly after receiving alerts/notifications was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.

With respect to Allegations #2(a) to (uu) in the Agreed Statement of Facts, the Panel also finds that the Member’s conduct of copying and pasting another colleagues documentation and passing it off as her own, failing to provided home visits and assessments in a timely and appropriate manner, and failing to respond to alerts/notifications in a timely manner is also considered dishonourable. It demonstrates an element of dishonesty and deceit that other members of the profession would consider to be dishonourable.

Penalty

College Counsel and the Member’s Counsel 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:

1. Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.

2. Directing the Executive Director to suspend the Member’s certificate of registration for 3 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.

3. Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at her own expense and within 6 months from the date that this Order becomes final. If the Expert determines that a greater number of session are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date that this Order becomes final. 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 7 days before the first meeting, the Member provides the Expert with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. if available, a copy of the Panel’s Decision and Reasons;

iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):

1. Professional Standards,

2. Documentation, and

3. Code of Conduct;

iv. At least 7 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:

1. the acts or omissions for which the Member was found to have committed professional misconduct,

2. the potential consequences of the misconduct to the Member’s clients, colleagues, profession and self,

3. strategies for preventing the misconduct from recurring,

4. the publications, questionnaires and modules set out above, and

5. 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:

1. the dates the Member attended the sessions,

2. that the Expert received the required documents from the Member,

3. that the Expert reviewed the required documents and subjects with the Member, and

4. the Expert’s assessment of the Member’s insight into her behaviour;

vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;

b) For a period of 36 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:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. a copy of the Panel’s Decision and Reasons, once available;

iii. Only practice nursing for an employer who agrees to, and does, forward a report to the Director within 14 days of the commencement or resumption of the Member’s employment in any nursing position, confirming:

1. that they received a copy of the required documents,

2. 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

3. for a period of 18 months from the date the Member returns to the practice of nursing, that they agree to perform random spot audits of the Member’s practice every 3 months and provide a report to the Director after each audit regarding the results of each audit;

iv. The audits shall, on each occasion, involve the following:

1. reviewing a random selection of at least 10 patient records to ensure they meet both CNO and employer standards, and

2. discussing (by telephone or in person), with at least 3 of the Member’s patients, the care provided by the Member to ensure that the Member is utilizing appropriate communication techniques consistent with the Therapeutic Nurse-Client Relationship Standard and employer standards;

c) The Member shall not practise independently in the community for a period of 36 months from the date the Member returns to the practice of nursing.

4. All documents delivered by the Member to the CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.

Penalty Submissions

College Counsel submitted that the Member’s conduct failed to meet the Standards of Practice expected as a member of the profession and was unprofessional. College Counsel also submitted that the Member’s conduct was dishonourable as she knew or should have known that her conduct fell below the standards of care that her patients deserved.

Submissions were made by College Counsel.

The mitigating factors in this case were:

• The Member has cooperated with the College during the investigation and the discipline process;

• The Member has no prior discipline record with the College;

• The Member has admitted and acknowledged her actions.

The aggravating factors in this case were:

• The Member committed multiple incidents over several years involving a number of patients;

• The repetition of conduct over time demonstrated a pattern of disregard for her professional obligations;

• The Member failed to provide resources, follow up and appropriate documentation which could have resulted in significant harm to her patients;

• The Member was neglectful of her duties as a care co-ordinator and as a whole merits regulatory response through the discipline procedure as it discredits the profession.

The proposed penalty provides for general deterrence through the 3 month suspension of the Member’s certificate, 36 month employer notification, 18 month period of random spot audits and the inability to practice independently in the community for 36 months. This sends a message to the members of the profession that the College takes this conduct very seriously and it will not be tolerated.

The proposed penalty provides for specific deterrence through the oral reprimand, the 3 month certificate suspension, the 18 month period of random spot audits and the inability to practice independently in the community for a period of 36 months. This proposed penalty will provide opportunity for the Member to consider and improve her practice deficits.

The proposed penalty provides for remediation and rehabilitation through the terms, conditions and limitations placed on the Member’s certificate. Meetings with a Regulatory Expert completed within a 12 month period, along with completing the associated Reflective Questionnaires, online learning modules, decision tools and online forms for Professional Standards, Documentation and Code of Conduct will provide an opportunity for the Member to reflect on her conduct and make positive changes to her practice.

Overall, the public is protected because of the 36 month employer notification of this decision, 18 month period of random spot audits of the Member’s practice and the Member’s inability to practice independently in the community for a period of 36 months. These penalties will ensure the Member has rectified her practice deficiencies and allow for the maintenance of public confidence in the regulatory process.

The Member’s Counsel submitted that the Member has been co-operative with the College, has acknowledged the facts and has reflected upon these matters. The Member’s Counsel also submitted that the Member is an experienced nurse with greater than 2 decades of professional nursing practice and this is the first time she has been before the College and it will be her last. He also submitted that these events occurred over 3 years ago and she has continued to practice successfully and is committed to demonstrating that these issues have been remedied.

College Counsel submitted one case to the Panel to demonstrate that the proposed penalty fell within the range of a similar case from this Discipline Committee. College Counsel admitted there were no exact cases in which the member held a Care Co-ordinator position.

The case submitted was CNO vs Simeone (Discipline Committee 2017) and is different as this member was performing in-home bedside nursing care as compared to practising in a role of Care Co-ordinator. The failure of this member to provide appropriate nursing care caused patient harm which cannot be said in the case at hand. It was similar in the multiple incidents and number of patients affected by inappropriate assessments and documentation. The penalty in this case included a 5 month certificate suspension; 18 month employer notification; and 4 random spot audits.

The Member’s Counsel indicated that he agreed with College Counsel’s submissions.

Penalty Decision

The Panel accepts the Joint Submission on Order and accordingly orders:

1. Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.

2. Directing the Executive Director to suspend the Member’s certificate of registration for 3 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.

3. Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at her own expense and within 6 months from the date that this Order becomes final. If the Expert determines that a greater number of session are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date that this Order becomes final. 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 7 days before the first meeting, the Member provides the Expert with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. if available, a copy of the Panel’s Decision and Reasons;

iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):

1. Professional Standards,

2. Documentation, and

3. Code of Conduct;

iv. At least 7 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:

1. the acts or omissions for which the Member was found to have committed professional misconduct,

2. the potential consequences of the misconduct to the Member’s clients, colleagues, profession and self,

3. strategies for preventing the misconduct from recurring,

4. the publications, questionnaires and modules set out above, and

5. 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:

1. the dates the Member attended the sessions,

2. that the Expert received the required documents from the Member,

3. that the Expert reviewed the required documents and subjects with the Member, and

4. the Expert’s assessment of the Member’s insight into her behaviour;

vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;

b) For a period of 36 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:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. a copy of the Panel’s Decision and Reasons, once available;

iii. Only practice nursing for an employer who agrees to, and does, forward a report to the Director within 14 days of the commencement or resumption of the Member’s employment in any nursing position, confirming:

1. that they received a copy of the required documents,

2. 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

3. for a period of 18 months from the date the Member returns to the practice of nursing, that they agree to perform random spot audits of the Member’s practice every 3 months and provide a report to the Director after each audit regarding the results of each audit;

iv. The audits shall, on each occasion, involve the following:

1. reviewing a random selection of at least 10 patient records to ensure they meet both CNO and employer standards, and

2. discussing (by telephone or in person), with at least 3 of the Member’s patients, the care provided by the Member to ensure that the Member is utilizing appropriate communication techniques consistent with the Therapeutic Nurse-Client Relationship Standard and employer standards;

c) The Member shall not practise independently in the community for a period of 36 months from the date the Member returns to the practice of nursing.

4. All documents delivered by the Member to the CNO, 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 is aware that the Joint Submission on Order should be accepted unless the Panel believes that the penalty is so disproportionate to the offences that the public interest is not protected or that it would bring the administration of justice into disrepute.

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. In particular a 3 month suspension, 36 month employer notification, an 18 month period of random spot audits, the inability of this Member to practise independently in the community for 36 months along with Regulatory Expert Meetings and remediation of the Member will ensure public confidence in the College’s ability to protect the public.

The penalty is in line with what has been ordered in the previous case.

I, Dawn Cutler, 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.