DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Tanya Dion, RN Chairperson Grace Fox, NP Member Carly Gilchrist, RPN Member Tania Perlin Public Member Richard Woodfield Public Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO JEAN-CLAUDE KILLEY for College of Nurses of Ontario
- and -
AMY RAINVILLE Registration No.: 13566722 NO REPRESENTATION for Amy Rainville
PATRICIA HARPER Independent Legal Counsel
Heard: August 1, 2019
DECISION AND REASONS
This matter came on for hearing before a panel of the Discipline Committee (the “Panel”) on August 1, 2019 at the College of Nurses of Ontario (the “College”) at Toronto.
Amy Rainville, (the “Member”) was present and not represented.
The Allegations
The allegations against the Member as stated in the Notice of Hearing dated June 25, 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 you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession, and in particular, while practising as a Registered Nurse at Saint Elizabeth Health Care in Windsor, Ontario:
(a) on or about July 27, 2017, you discontinued a physician’s order for negative pressure wound therapy for [Patient A], without taking appropriate steps to communicate with the client’s most responsible physician and/or the Local Health Integration Network with respect to your assessment of the client and discontinuation of the physician’s order;
(b) on or about July 27, 2017, you discontinued a physician’s order for negative pressure wound therapy for [Patient A], without taking appropriate steps to ensure that the client obtained advice promptly from a physician with respect to the discontinuation of the order;
(c) on or about July 27, 2017, you failed to document important aspects of your care to [Patient A], including failing to document your advice and/or directions to the client with respect to seeking follow-up medical attention, and/or failing to complete the necessary documentation to ensure that the client’s most responsible physician and/or the Local Health Integration Network was made aware of your assessment, and/or that the client’s care plan was updated to reflect your assessment, and/or failing to complete a Medical Update Report and/or an Automated Provider Report;
(d) on or about December 15, 2017, you assessed [Patient B] as requiring urgent transportation to the emergency department, without taking appropriate steps to communicate with the client’s most responsible physician and/or the Local Health Integration Network with respect to your assessment of the client; and/or
(e) on or about December 15, 2017, you failed to document important aspects of your care to [Patient B], including failing to complete the necessary documentation to ensure that the client’s most responsible physician and/or the Local Health Integration Network was made aware of your assessment, and/or that the client’s care plan was updated to reflect your assessment, and/or failing to complete a Medical Update Report and/or an Automated Provider Report;
- 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(12) of Ontario Regulation 799/93, in that you failed to advise a client to obtain services from another health professional where you knew or ought to have known that the client had a condition which was outside your scope of practice or within your scope of practice but outside your competency to treat, and in particular, while practising as a Registered Nurse at Saint Elizabeth Health Care in Windsor, Ontario:
(a) on or about July 27, 2017, you discontinued a physician’s order for negative pressure wound therapy for [Patient A], without taking appropriate steps to ensure that the client obtained advice promptly from a physician with respect to the discontinuation of the order;
- 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 you failed to keep records as required, and in particular, while practising as a Registered Nurse at Saint Elizabeth Health Care in Windsor, Ontario:
(a) on or about July 27, 2017, you failed to document important aspects of your care to [Patient A], including failing to document your advice and/or directions to the client with respect to seeking follow-up medical attention, and/or failing to complete the necessary documentation to ensure that the client’s most responsible physician and/or the Local Health Integration Network was made aware of your assessment, and/or that the client’s care plan was updated to reflect your assessment, and/or failing to complete a Medical Update Report and/or an Automated Provider Report;
(b) on or about December 15, 2017, you failed to document important aspects of your care to [Patient B], including failing to complete the necessary documentation to ensure that the client’s most responsible physician and/or the Local Health Integration Network was made aware of your assessment, and/or that the client’s care plan was updated to reflect your assessment, and/or failing to complete a Medical Update Report and/or an Automated Provider Report;
- 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 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, and in particular, while practising as a Registered Nurse at Saint Elizabeth Health Care in Windsor, Ontario:
(a) on or about July 27, 2017, you discontinued a physician’s order for negative pressure wound therapy for [Patient A], without taking appropriate steps to communicate with the client’s most responsible physician and/or the Local Health Integration Network with respect to your assessment of the client and discontinuation of the physician’s order;
(b) on or about July 27, 2017, you discontinued a physician’s order for negative pressure wound therapy for [Patient A], without taking appropriate steps to ensure that the client obtained advice promptly from a physician with respect to the discontinuation of the order;
(c) on or about July 27, 2017, you failed to document important aspects of your care to [Patient A], including failing to document your advice and/or directions to the client with respect to seeking follow-up medical attention, and/or failing to complete the necessary documentation to ensure that the client’s most responsible physician and/or the Local Health Integration Network was made aware of your assessment, and/or that the client’s care plan was updated to reflect your assessment, and/or failing to complete a Medical Update Report and/or an Automated Provider Report;
(d) on or about December 15, 2017, you assessed [Patient B] as requiring urgent transportation to the emergency department, without taking appropriate steps to communicate with the client’s most responsible physician and/or the Local Health Integration Network with respect to your assessment of the client; and/or
(e) on or about December 15, 2017, you failed to document important aspects of your care to [Patient B], including failing to complete the necessary documentation to ensure that the client’s most responsible physician and/or the Local Health Integration Network was made aware of your assessment, and/or that the client’s care plan was updated to reflect your assessment, and/or failing to complete a Medical Update Report and/or an Automated Provider Report.
Member’s Plea
The Member admitted the allegations set out in paragraphs 1(a), (b), (c), (d), (e); 2(a); 3(a), (b); and 4(a), (b), (c), (d), (e) 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, unedited, as follows:
THE MEMBER
Amy Rainville (the “Member”) obtained a baccalaureate degree in nursing from the University of Windsor in 2013.
The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on September 19, 2013.
The Member was employed as a wound care specialist with St. Elizabeth Healthcare, a home healthcare agency in Windsor, Ontario (the “Agency”), from September 19, 2013 until December 27, 2017, when she was terminated as a result of the conduct described below.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
[Patient A]: Discontinuing a Physician’s Order and Failing to Document
[Patient A] had previously broken his left ankle, resulting in surgery. He had a skin graft in place over the wound on his left ankle (the “Wound”), and his recovery was complicated by preexisting comorbidities. Among other conditions, [Patient A] had a previous history of amputation of his right foot, unrelated to the events described below.
On or about July 25, 2017, hospital staff had applied dressing to the Wound. On that date, [the Doctor]ordered negative pressure wound treatment (“NPWT”), and for care providers to change the dressing and rinse the Wound every Monday and Thursday.
[Patient A] was admitted to the Agency for home care on July 25, 2017, following [the Doctor]’s orders.
The Member attended [Patient A]’s home on July 27, 2017, a Thursday. She was the first care provider to change the dressing on the Wound after it was applied in hospital.
During that visit, the Member recorded in [Patient A]’s Progress Notes that she was discontinuing NPWT. In addition, she changed the frequency of home visits, from Monday and Thursday, to daily visits, until the following Monday.
The Member did not record any rationale for her decisions in the Progress Notes, and did not record any actions to follow-up.
The Member also completed a form entitled “K2P Initial Wound Assessment” (“Wound Assessment”) in relation to her assessment of [Patient A]’s Wound.
In the Wound assessment, the Member recorded that [Patient A] had been walking on his foot, and had not kept his weight off as recommended. She noted her observation that the skin graft had “disintegrated under the NPWT dressing”, and that pieces of the graft tissue had become lodged in the granulation foam.
The Member noted that she explained to [Patient A] that the graft site had failed, and that she had decided not to replace the NPWT dressing over the Wound as a result of its appearance.
The Member documented a recommended course of “normal” wound care, contrary to the ordered use of the NPWT, and recorded that the Enterostomal Therapist (“ET”), a type of health care provider with specific wound care specialisation, was aware.
The Member had spoken with an ET at the Agency about the status of [Patient A]’s wound. The ET was of the view, based on the Member’s description of the wound, that the Member’s assessment to discontinue NPWT was appropriate in the circumstances. The ET specifically advised the Member to ensure that she communicated her assessment – and the discontinuation of [the Doctor]’s order for NPWT – to [Patient A]’s most responsible physician.
In addition to the Member having been advised to do this by the ET, it was a requirement of the standards of practice of the profession that the Member notify [Patient A]’s most responsible physician of the discontinuation by the Member of a physician’s order with respect to the patient.
It was also a requirement of the standards of practice of the profession that the Member ensure that [Patient A] was assessed as soon as possible by a physician, following the discontinuation by the Member of the physician’s order for NPWT.
The Member did not, however, take any steps to communicate her assessment or her discontinuation of [the Doctor]’s order to the most responsible physician, or to ensure that it was communicated to the most responsible physician.
The Member also failed to advise [Patient A] to be seen as soon as possible by a physician, or take any other steps to ensure that outcome. If the Member were to testify, she would say that she advised [Patient A] to visit the hospital if there was any change in his condition, but would also acknowledge that she did not document having given this advice.
Because the Member had assessed a material change to [Patient A]’s medical status, she was required by the Agency’s policies to complete a Medical Update Report (“MUR”) and to transmit this report to [Patient A]’s most responsible physician. Had she done this, this would have satisfied the requirement of the standards of practice for the Member to inform the patient’s most responsible physician of his change in condition. However, the Member did not complete a MUR.
Because the Member had discontinued a physician’s order for NPWT, she was also required by the Agency’s policies to complete an Automated Provider Report Interim Report (“APR Interim Report”) form to provide to the Local Health Integration Network (“LHIN”), which was responsible for coordinating and funding the patient’s home care including his NPWT equipment. The Member did not complete an APR Interim Report. If the Member were to testify she would say that the policies on reporting to the LHIN were new and staff were still in the process of being trained on them, and she was not specifically aware of which reports needed to be completed at the time. Regardless, the Member acknowledges that it is her responsibility to ensure that she is knowledgeable about the Agency’s policies and procedures, and to seek guidance to clarify any uncertainty.
As a result, the patient’s most responsible physician did not become aware of the patient’s change in condition and the discontinuation of the NPWT order until July 31, 2017. Complications arising from the failure of the patient’s wound to heal properly eventually required that the patient’s left leg be amputated below the knee.
As a result of this incident, the Agency required the Member to complete some remediation that included a reflective practice statement, which the Member did on October 2, 2017. In that statement to her employer, the Member wrote: “I will communicate to the most responsible practitioner of my assessment and plan of care for the client if there is a change in status, I will also continue to communicate these changes to the LHIN, and team members at SEHC. I will start this practice immediately, and utilize blank MUR forms if my tablet is not working, and if I need an MUR to be sent immediately I will ask a supervisor to send one on my behalf if I need the MD to know details immediately.”
[Patient B]: Wound Care and Failing to Document
[Patient B] was admitted to the Agency for homecare on December 7, 2017. He had two wounds that required daily care.
On December 15, 2017, the Member was not the nurse assigned to care for [Patient B], but because of her expertise in wound care, had been asked by [Patient B]’s assigned [Registered Nurse], to attend and assist with providing care to [Patient B].
The Member arrived at [Patient B]’s home before [the Registered Nurse], and began her assessment and treatment of [Patient B] without [the Registered Nurse] present.
The Member engaged in non-routine and fairly complex care of [Patient B]’s wound, probing the closed incision 3 times in order to locate the base of the wound, identifying tunnels of up to 14cm in length, and expressing significant amounts of draining.
The Member then advised [Patient B] that he needed to attend the emergency department to seek medical attention for his wound.
At about this time, [the Registered Nurse] arrived at [Patient B]’s home. By this point the Member had closed and re-dressed [Patient B]’s wound.
The Member reported to [the Registered Nurse] that [Patient B]’s wound was draining quite a lot, and that he needed to be taken by ambulance to the emergency department for administration of intravenous antibiotics. The Member asked [the Registered Nurse] to call 911 for [Patient B], and then left.
The Member documented her care to [Patient B] in the progress notes. However, the Member did not complete, and instead expected [the Registered Nurse] to complete, the MUR that would accompany [Patient B] to the hospital and that would inform [Patient B]’s most responsible physician, as well as the paramedics and emergency room staff treating [Patient B] in the course of his visit to the hospital, about the Member’s assessment of [Patient B]’s condition.
It was inappropriate for the Member to expect and/or allow [the Registered Nurse] to complete the MUR that was required as part of the Member’s assessment of [Patient B]’s condition, when [the Registered Nurse] was not present for the assessment or care of [Patient B].
The Member did not take any steps to otherwise ensure that [Patient B]’s most responsible physician, or the LHIN, was advised of the change in his status. If the Member were to testify she would say that she believed that because [Patient B] was being sent to the hospital, his most responsible physician would become aware of his change in status. She now recognizes that she was accountable to ensure the complete and accurate documentation and transmission of information to the most responsible physician and to the LHIN, which she failed to do in this case.
STANDARDS OF PRACTICE OF THE PROFESSION
- In addition to the standards of practice that are described above, CNO has published a practice standard titled, Professional Standards, Revised 2002, which describes, in broad terms, the professional expectations of nurses. Among other things, that document indicates that nurses meet the standard of practice by:
demonstrating knowledge of and respect for each other’s roles, knowledge, expertise and unique contribution to the health care team, and
sharing knowledge with others to promote the best possible outcomes for [patients].
- CNO published practice standard titled, Decisions About Procedures and Authority, describes the expectations of a nurse when making a decision about performing a procedure. Among other things, that document indicates that nurses meet the standard of practice by:
advocating for the appropriate health care provider to perform the procedure,
ensuring that [patient] records reflect the procedures that were performed,
consulting when she/he reaches the limits of her/ his knowledge, skill and judgment, and
communicating with other health care team members as necessary for safe, effective and ethical [patient] care.
- CNO’s published practice standard titled, Documentation, describes the regulatory and legislative requirements for nursing documentation. It provides that, among other things, nurses meet the standard by “ensuring that 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.”
ADMISSIONS OF PROFESSIONAL MISCONDUCT
- The Member admits that she committed the acts of professional misconduct as described in paragraphs 4 to 35 above, and as alleged in the Notice of Hearing as follows:
1 (a), in that the Member contravened a standard of practice of the profession on July 27, 2017 when she discontinued a physician’s order for NPWT for [Patient A] without taking appropriate steps to communicate with [Patient A]’s most responsible physician and the LHIN with respect to her assessment and discontinuation of the order;
1(b) and 2(a), in that the Member contravened a standard of practice of the profession and failed to advise [Patient A] to obtain services from another health professional when [Patient A] had a condition outside her scope of practice to treat when she discontinued the physician’s order for NPWT without ensuring that [Patient A] obtained advice promptly from a physician regarding the discontinuation of the order on July 27, 2017;
1(c) and 3(a), in that the Member contravened a standard of practice of the profession and failed to keep records as required when she failed to complete the necessary documentation to ensure that [Patient A]’s most responsible physician and the LHIN were made aware of the Member’s assessment, failed to update [Patient A]’s care plan to reflect the assessment and failed to complete a MUR and APR on July 27, 2017;
1(d), in that the Member contravened a standard of practice of the profession when she failed to communicate with [Patient B]’s most responsible physician and the LHIN after she assessed [Patient B] as requiring urgent transportation to the emergency department on December 15, 2017;
1(e) and 3(b), in that the Member contravened a standard of practice of the profession and failed to keep records as required when she failed to complete the necessary documentation to ensure that [Patient B]’s most responsible physician and LHIN were made aware of her assessment, failed to update [Patient B]’s care plan to reflect her assessment and failed to complete a MUR and APR on December 15, 2017.
- The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 4 (a), (b), (c), (d), and (e) of the Notice of Hearing, and in particular that she engaged in conduct that would reasonably be regarded by members as unprofessional, as described in paragraphs 4 to 35 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), (b), (c), (d), (e); 2(a); 3(a), (b); and 4(a), (b), (c), (d), (e) of the Notice of Hearing. As to Allegations 4(a), (b), (c), (d), (e), the Panel finds that the Member engaged in conduct that would reasonably be considered by members to be 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.
Allegations #1(a), (b) and (c) in the Notice of Hearing are supported by paragraphs 4-22, 33, 34 and 35 in the Agreed Statement of Facts. The Member admitted she was the first care provider to change [Patient A]’s wound dressing. The Member discontinued his Negative Pressure Wound Treatment (NPWT) and increased the frequency home visits required for his treatment. She did not document any rationale for her decisions in [Patient A]’s progress notes or any future follow up needed. The Member did speak with the Enterostomal Therapist and documented same. The Member did not advise [Patient A]’s most responsible physician about her clinical findings, discontinuation of the NPWT and need for a physician order. As such, the Member contravened or failed to meet the standards of practice of the profession.
Allegations #1(d) and (e) in the Notice of Hearing are supported by paragraphs 23-32, 33, 34 and 35 in the Agreed Statement of Facts. The Member was not assigned to [Patient B], but was asked by a co-worker to attend and assist in providing care for him. Due to his change in clinical presentation the Member advised [Patient B] that he needed to attend the emergency department to seek medical attention for his wound. The Member did document her care in the progress notes, however did not document in the Medical Update Report, which staff are to complete as per agency policy. The Member also did not take steps to ensure that [Patient B]’s most responsible physician was notified of the [patient]’s change in condition. As such, the Member contravened or failed to meet the standards of practice of the profession.
Allegation #2 in the Notice of Hearing is supported by the facts set out in paragraphs 7-22 and the reference to standards of practice in paragraphs 33 and 34 in the Agreed Statement of Facts. The Member admitted to this allegation. What a nurse knows or ought to about their scope of practice and/or competency to treat is set out in the Practice Standard, Professional Standards Revised, 2002 and Decisions About Procedures and Authority. By discontinuing the physician’s order for negative pressure wound therapy for [Patient A] without taking appropriate steps to ensure that the [patient] obtained advice promptly from a physician with respect to the discontinuance of the order, the Member 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(12) of Ontario Regulation 799/93.
Allegation #3(a) in the Notice of Hearing is supported by paragraphs 9 and 18 in the Agreed Statement of Facts. The Member acknowledges that although she documented the discontinuation of [Patient A]’s NPWT, she failed to record the rationale for her decisions in the Progress Notes. She did not record any follow-up actions required nor document any advice she gave to [Patient A].
Allegation #3(b) in the Notice of Hearing is supported by paragraphs 30 and 32 in the Agreed Statement of Facts. The Member admitted to this allegation. Although the Member documented her care to [Patient B] in the progress notes she failed to follow Agency policy by not completing a MUR, which would then accompany [Patient B] to the hospital updating the health care team of the Member’s assessment of [Patient B]’s condition.
With respect to Allegation #4, the Panel finds that the Member’s conduct in failing to meet her professional standards with regards to proper documentation, failing to notify the most responsible physician and health care team members was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.
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 3 months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for 2 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 2 meetings with a Regulatory Expert (the “Expert”), at her own expense and within 6 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 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 CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):
Code of Conduct,
Professional Standards,
Documentation, and
Decisions About Procedures and Authority;
iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, and online participation forms;
v. The subject of the sessions with the Expert will include:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s clients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards his/her report to the Director, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into her behaviour;
vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;
b) For a period of 12 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;
c) The Member shall not practice independently in the community for a period of 12 months from the date the Member returns to the practice of nursing;
- 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
Submissions were made by College Counsel.
The parties agreed that the mitigating factors in this case were that the Member has cooperated with the College, admitted to the allegations and accepts responsibility for her actions.
College Counsel submitted that there were no aggravating factors in this case. The Member’s overall conduct in question was not as serious as the conduct in many other discipline proceedings and there was no moral failure and malicious intent. The Member acted in an unprofessional manner by having a persistent disregard for her professional obligations. College Counsel also submitted that the Member’s quality of care and judgement were not being questioned thus a penalty of suspension and remediation would be of benefit to the Member and sufficient to protect the public.
College Counsel submitted the proposed penalty provides for general deterrence through the oral reprimand and two month suspension, sending a message to the profession that conduct of this nature will not be tolerated. The terms, conditions and limitations on the Member’s certificate indicate to the membership, and the public, that this behaviour is taken seriously.
The proposed penalty provides for specific deterrence through the two month suspension and oral reprimand. This will assist the Member in gaining a greater understanding of her actions professionally. The terms, conditions and limitations will provide monitoring for the Member’s professional practice.
The proposed penalty provides for remediation and rehabilitation through the two meetings with an expert, the review of the College’s publications and completion of the reflective questionnaire. These requirements will help to strengthen the Member’s awareness of her unprofessional conduct and help to ensure this will not happen again.
Overall, the public is protected because this process will assist the Member in gaining additional insight and knowledge into her practice. The twelve month employer notification will ensure that the Member’s practice is monitored when she returns to nursing practice.
The Member indicated she agreed with the submissions of College Counsel.
College Counsel submitted three cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee. College Counsel acknowledged that two of the cases did not have similar facts to this matter, but did illustrate the range of similar conduct.
CNO vs Simeone (Discipline Committee, 2017). The incidents in question happened over an extended period of time and with respect to six separate [patients]. The member failed to meet the standard of practice with multiple [patients]. The member failed to complete adequate documentation, including completing assessments on [patients], and failed to answer her phone while working on-call. The discipline panel found the member’s conduct was unprofessional and dishonourable. The panel ordered the member to receive an oral reprimand, a five month suspension and terms, conditions and limitations on the member’s certificate of registration.
CNO vs Nkwelle (Discipline Committee, 2018). The member failed to complete, and ensure that staff completed, close observation checks over a two hour period, and also failed to document that these close observation checks were completed. The discipline panel found the member’s conduct was unprofessional and dishonourable. The panel ordered the member to receive an oral reprimand, a three month suspension and terms, conditions and limitations on the member’s certificate of registration.
CNO vs Williams (Discipline Committee, 2014). The member failed to provide appropriate care to a [patient] before, during and after an anxiety attack, failed to follow a physician’s order specifically during a [patient]’s anxiety attack and failed to appropriately document observations before, during and after the anxiety attack. The member failed to provide appropriate measures when the [patient]’s vital signs were absent. The discipline panel found the member’s conduct was unprofessional. The panel ordered the member to receive an oral reprimand, two month suspension and terms, conditions and limitations of the member’s certificate of registration.
Independent Legal Counsel reminded the Panel that the goal of penalty is to protect the public, to maintain high professional standards and preserve public confidence in the nursing profession and its disciplinary process. She reiterated that the Panel should accept this carefully negotiated Joint Submission on Order unless to do so that would bring the administration of justice into disrepute or be contrary to the public interest.
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 3 months of the date that this Order becomes final.
The Executive Director is directed to suspend the Member’s certificate of registration for 2 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 2 meetings with a Regulatory Expert (the “Expert”), at her own expense and within 6 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 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 CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):
Code of Conduct,
Professional Standards,
Documentation, and
Decisions About Procedures and Authority;
iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, and online participation forms;
v. The subject of the sessions with the Expert will include:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s clients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards his/her report to the Director, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into her behaviour;
vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;
b) For a period of 12 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;
c) The Member shall not practice independently in the community for a period of 12 months from the date the Member returns to the practice of nursing;
- 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 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 penalty is in line with what has been ordered in previous cases.
I, Tanya Dion, RN, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel.