DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Grace Fox, NP Chairperson
Sylvia Douglas Public Member
Catherine Egerton Public Member George Rudanycz, RN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) DENISE COONEY for ) College of Nurses of Ontario
- and - )
BONNIE LYNN HUGHES ) JANE LETTON for Registration No. 9001546 ) Bonnie Lynn Hughes
) CHRISTOPHER WIRTH
) Independent Legal Counsel
) Heard: April 13, 2020
DECISION AND REASONS
This matter came on for hearing before a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on April 13, 2020 via conference call.
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 public disclosure and banning publication or broadcasting of the names, or any information that could disclose the identities, of the patients referred to orally or in any documents presented in the Discipline hearing of Bonnie Lynn Hughes.
The Panel considered the submissions of the parties and decided that there be an order preventing public disclosure and banning publication or broadcasting of the names, or any information that could disclose the identities, of the patients referred to orally or in any documents presented in the Discipline hearing of Bonnie Lynn Hughes.
The Allegations
The allegations against Bonnie Lynn Hughes (the “Member”) as stated in the Notice of Hearing dated March 3, 2020, as amended are as follows:
IT IS ALLEGED THAT:
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that while you were employed as a Registered Nurse in the role of Director of Resident Care at Chesley Park Oxford Long-Term Care in London, Ontario (the “Facility”), you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession in that:
(a) you failed to ensure appropriate mechanisms were in place for the hiring, education, and/or supervision of Personal Support Worker [the PSW] in 2015 and 2016;
(b) you failed to review and compile required monthly nursing reports at the Facility between January and October 2016;
(c) you failed to sign acknowledging receipt with respect to the Medication Incident Reports set out in Appendix “A”;
(d) you failed to ensure that appropriate follow-up and/or investigations were conducted in relation to the Medication Incident Reports set out in Appendix “B”;
(e) you failed to report a Critical Incident with respect to [Patient JJ] on May 30, 2016, to the Ministry of Health and Long-Term Care;
(f) you failed to ensure that appropriate follow-up and/or investigations were conducted in relation to the Critical Incidents set out in Appendix “C”;
(g) you failed to appropriately document the following Critical Incidents set out in Appendix “D” in the Facility’s Critical Incidents log;
(h) you failed to appropriately document, report, follow-up on and/or investigate a complaint received in relation to the care provided to [Patient GGG], in or around March 2016;
(i) you failed to appropriately store and/or dispose of medication related to a Medication Incident Report for [Patient YY], dated March 8, 2016;
(j) you failed to appropriately store and/or dispose of medication related to a Medication Incident Report for [Patient EE], dated April 5, 2016;
(k) you failed to conduct and/or appropriately document quarterly medication objective reviews at the Facility between April 2016 and October 2016;
(l) you failed to appropriately document, report, follow-up on and/or investigate a complaint received on or around April 27, 2016 in relation to [Patient U];
(m) you failed to appropriately report, follow-up on and/or investigate a complaint received on or around May 17, 2016 in relation to [Patient U];
(n) you failed to appropriately document, report, follow-up on and/or investigate a medication error with in relation to [Patient V] on or around May 19, 2016;
(o) you failed to appropriately respond to, report and/or investigate a report that [Patient HH] had been sexually assaulted on or around August 23, 2016; and/or
(p) you referred to [the Former Restorative Aide], a former restorative aide at the Facility, using unsuitable language on or around September 2, 2016.
- 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 paragraph 1(13) of Ontario Regulation 799/93, in that, while employed as a Registered Nurse at the Facility, you failed to keep records as required, in that:
(a) you failed to review and compile required monthly nursing reports at the Facility between January and October, 2016;
(b) you failed to sign acknowledging receipt with respect to the Medication Incident Reports set out in Appendix “A”;
(c) you failed to appropriately document the Critical Incidents set out in Appendix “D” in the Facility’s Critical Incidents log;
(d) you failed to appropriately document a complaint received in relation to the care provided to [Patient GGG], in or around March 2016 in the Facility’s complaints log;
(e) you failed to appropriately document quarterly medication objective reviews conducted at the Facility between April 2016 and October 2016;
(f) you failed to appropriately document a complaint received on or around April 27, 2016 in relation to [Patient U] in the Facility’s complaints log; and/or
(g) you failed to appropriately document a medication error in relation to [Patient V] in or around May 19, 2016.
- 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(25)(i) of Ontario Regulation 799/93, in that while employed as a Registered Nurse at the Facility, you failed to report an incident of unsafe practice or unethical conduct of a health care provider to the employer or other authority responsible for the health care provider, as follows:
(a) you failed to report the following Critical Incidents to the Ministry of Health and Long-Term Care:
(i) [Patient JJ] on or around May 30, 2016;
(ii) [Patient V] on or around May 19, 2016; and/or
(iii) [Patient HH] on or around August 23, 2016;
(b) you failed to report concerns about the care RN [the RN] provided to [Patient GGG] in or around March 2016 to the Facility; and/or
(c) you failed to report concerns about the care [Patient U] received on or around April 27, 2016 to the Facility.
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that while employed as a Registered Nurse at the Facility, you engaged in conduct relevant to the practice of nursing that would reasonably be regarded by members as disgraceful, dishonourable or unprofessional, as follows:
(a) you failed to ensure appropriate mechanisms were in place for the hiring, education, and/or supervision of Personal Support Worker [the PSW] in 2015 and 2016;
(b) you failed to review and compile required monthly nursing reports at the Facility between January and October 2016;
(c) you failed to sign acknowledging receipt with respect to the Medication Incident Reports set out in Appendix “A”;
(d) you failed to ensure that appropriate follow-up and/or investigations were conducted in relation to the Medication Incident Reports set out in Appendix “B”;
(e) you failed to report a Critical Incident with respect to [Patient JJ] on May 30, 2016, to the Ministry of Health and Long-Term Care;
(f) you failed to ensure that appropriate follow-up and/or investigations were conducted in relation to the Critical Incidents set out in Appendix “C”;
(g) you failed to appropriately document the following Critical Incidents set out in Appendix “D” in the Facility’s Critical Incidents log;
(h) you failed to appropriately document, report, follow-up on and/or investigate a complaint received in relation to the care provided to [Patient GGG], in or around March 2016;
(i) you failed to appropriately store and/or dispose of medication related to a Medication Incident Report for [Patient YY], dated March 8, 2016;
(j) you failed to appropriately store and/or dispose of medication related to a Medication Incident Report for [Patient EE], dated April 5, 2016;
(k) you failed to conduct and/or appropriately document quarterly medication objective reviews at the Facility between April 2016 and October 2016;
(l) you failed to appropriately document, report, follow-up on and/or investigate a complaint received on or around April 27, 2016 in relation to [Patient U];
(m) you failed to appropriately report, follow-up on and/or investigate a complaint received on or around May 17, 2016 in relation to [Patient U];
(n) you failed to appropriately document, report, follow-up on and/or investigate a medication error with in relation to [Patient V] on or around May 19, 2016;
(o) you failed to appropriately respond to, report and/or investigate a report that [Patient HH] had been sexually assaulted on or around August 23, 2016; and/or
(p) you referred to [the Former Restorative Aide], a former restorative aide at the Facility, using unsuitable language on or around September 2, 2016.
APPENDIX “A”
Date of Medication Incident Report
Patient
January 9, 2016
[Patient A]
January 28, 2016
[Patient B]
January 29, 2016
[Patient C]
February 1, 2016
[Patient D]
February 3, 2016
[Patient E]
February 3, 2016
[Patient F]
February 4, 2016
[Patient G]
March 1, 2016
[Patient E]
March 8, 2016
[Patient H]
June 29, 2016
[Patient I]
July 26, 2016
[Patient J]
July 14, 2016
[Patient K]
Date of Medication Incident Report
Patient
October 21, 2016
[Patient L]
October 25, 2016
[Patient M]
October 27, 2016
[Patient N]
October 28, 2016
[Patient O]
October 30, 2016
[Patient P]
October 30, 2016
[Patient M]
October 31, 2016
[Patient Q]
APPENDIX “B”
Date of Medication Incident Report
Patient
January 9, 2016
[Patient A]
January 18, 2016
[Patient R]
January 19, 2016
[Patient S]
January 24, 2016
[Patient T]
January 28, 2016
[Patient B]
January 29, 2016
[Patient C]
January 30, 2016
[Patient U]
February 1, 2016
[Patient D]
February 3, 2016
[Patient E]
February 3, 2016
[Patient F]
February 4, 2016
[Patient G]
February 6, 2016
[Patient V]
February 20, 2016
[Patient W]
February 25, 2016
[Patient A]
March 1, 2016
[Patient E]
March 7, 2016
[Patient X]
March 8, 2016
[Patient H]
March 12, 2016
[Patient Y]
March 14, 2016
[Patient Z]
March 18, 2016
[Patient AA]
March 19, 2016
Unknown
March 23, 2016
[Patient BB]
March 26, 2016
[Patient CC]
March 29, 2016
[Patient W]
April 1, 2016
Unknown
April 3, 2016
[Patient DD]
April 5, 2016
[Patient EE]
April 5, 2016
[Patient FF]
April 7, 2016
[Patient DD]
April 14, 2016
[Patient GG]
April 24, 2016
[Patient B]
April 27, 2016
[Patient E]
May 6, 2016
[Patient HH]
May 24, 2016
[Patient II]
May 28, 2016
[Patient P]
May 30, 2016
[Patient JJ]
June 5, 2016
[Patient BB]
June 9, 2016
[Patient KK]
June 10, 2016
[Patient LL]
June 13, 2016
[Patient MM]
June 16, 2016
[Patient NN]
June 29, 2016
[Patient I]
June 30, 2016
[Patient OO]
July 4, 2016
[Patient PP]
July 8, 2016
[Patient QQ]
July 13, 2016
[Patient RR]
July 14, 2016
[Patient K]
July 22, 2016
[Patient SS]
July 25, 2016
[Patient I]
July 26, 2016
[Patient J]
July 28, 2016
[Patient S]
August 1, 2016
[Patient TT]
August 5, 2016
[Patient UU]
August 21, 2016
[Patient JJ]
September 24, 2016
[Patient VV]
September 26, 2016
[Patient WW]
September 30, 2016
[Patient XX]
October 2, 2016
[Patient YY]
October 4, 2016
[Patient F]
October 7, 2016
[Patient M]
October 10, 2016
[Patient ZZ]
October 11, 2016
[Patient M]
October 16, 2016
[Patient AAA]
October 18, 2016
[Patient A]
October 18, 2016
[Patient BBB]
October 18, 2016
[Patient OO]
October 18, 2016
[Patient CCC]
October 20, 2016
[Patient DDD]
October 21, 2016
[Patient EEE]
October 21, 2016
[Patient L]
October 24, 2016
[Patient JJ]
October 25, 2016
[Patient M]
October 27, 2016
[Patient N]
October 28, 2016
[Patient O]
October 30, 2016
[Patient P]
October 30, 2016
[Patient M]
October 31, 2016
[Patient Q]
APPENDIX “C”
Date of Critical Incident
Patient
March 18, 2016
[Patient AA]
May 30, 2016
[Patient JJ]
Date of Critical Incident
Patient
August 19, 2016
[Patient AA]
August 31, 2016
[Patient JJ]
September 5, 2016
[Patient JJ]
September 12, 2016
[Patient AAA]
September 23, 2016
[Patient FFF]
October 16, 2016
[Patient AAA]
APPENDIX “D”
Date of Critical Incident
Patient
May 30, 2016
[Patient JJ]
August 19, 2016
[Patient AA]
October 16, 2016
[Patient AAA]
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), #2(a), (b), (c), (d), (e), (f), (g), #3(a)(i)(ii)(iii), (b), (c) and #4(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m), (n), (o), (p) 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 as amended reads, unedited, as follows:
THE MEMBER
Bonnie Lynn Hughes (the “Member”) obtained a diploma in nursing from Fanshawe College in 1989.
The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on August 9, 1989.
The Member was employed as the Director of Resident Care (“DRC”) at Chelsey Park Oxford Long-Term Care in London, Ontario (the “Facility”) from March 25, 2011 until November 21, 2016. Her employment as DRC was terminated following the Facility’s investigation into some of the incidents below. Other incidents were discovered after the termination of her employment.
THE FACILITY
The Facility has 4 units with approximately 62 residents per unit. It has a total of 246 beds. In her role as DRC, the Member oversaw all nursing staff at the Facility.
The Facility is a long-term care facility under the Long-Term Care Homes Act, 2007, S.O. 2007, c. 8. As a result, the Facility has a number of statutory mandatory reporting obligations to the Ministry of Health and Long-Term Care (the “Ministry”).
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
Hiring and supervision of [the PSW]
In 2015, the Member signed an offer of employment to hire [the PSW] as a Personal Support Worker (“PSW”). [The PSW] suffered from a serious medical condition which did not allow him to lift certain things. He also had serious comprehension issues.
During the recruitment of [the PSW], the Member did not interview or conduct reference checks for [the PSW]; instead, she delegated this to a Scheduling Clerk. The Member also failed to comply with the Facility’s policy with respect to the hiring of an individual with accommodations.
[The RPN], an RPN, raised concerns with the Member about [the PSW] being assigned to a floor which housed patients with Alzheimer’s disease, as he was not able to manage the challenges presented by the patient population. If [the RPN] were to testify she would say she raised concerns to the Member about the peri-care [the PSW] was providing to patients. The Member told [the RPN] she had to work with [the PSW’s] limitations. If the Member were to testify she would say she confirmed with [the PSW] that he had successfully passed the PSW course. He was later removed from providing patient care, and ultimately his employment was terminated.
The Member acknowledges that she should have conducted the interview and reference checks herself during the recruitment of [the PSW]. She further acknowledges that she failed to ensure appropriate mechanisms were in place for the hiring, education and supervision of [the PSW].
Completion of monthly reports
Each month, supervisors in the Facility’s various departments submitted summary reports to the Member, along with staff meeting notes, counselling forms, medication count sheets, financial reports, and education records. The Member was required to review the information received from the supervisors and summarize the information into a Nursing Monthly Management Report. After the Member’s review, the original documents were to be returned to each supervisor in case of an audit from the Ministry.
Between January and October 2016, the Member failed to review and compile the monthly reports from the Facility’s departments into the month-end report. The documents her colleagues submitted to her over the previous 10 months were either in unopened packages in her office or at her home, rather than summarized and filed. The documents were not reviewed, compiled or returned to the appropriate departments until other staff completed the tasks, after the Member was terminated.
Completion of Medication Incident Reports
The Facility’s Policy: Medication Incidents requires the individual who discovers a medication incident to fill out a Medication Incident Report. The Medication Incident Report is then to be provided to the DRC. On the first page of the Medication Incident Report, the nurse reporting the incident provides a description. There is a section on the first page for the DRC to sign acknowledging receipt. If required, an action plan will be developed to address the outcome of the investigation and reported as required by applicable legislation. If there is an educational component for the nurse involved, the DRC is responsible for following up with that staff member and ensuring they complete the necessary remediation. Once the remediation is complete, the DRC is responsible for signing the second page of the Medication Incident Report form.
On the following 19 occasions, the Member did not sign acknowledging receipt of the Medication Incident Reports on the first page:
Date of Medication Incident Report
Patient
January 9, 2016
[Patient A]
January 28, 2016
[Patient B]
January 29, 2016
[Patient C]
February 1, 2016
[Patient D]
February 3, 2016
[Patient E]
February 3, 2016
[Patient F]
February 4, 2016
[Patient G]
March 1, 2016
[Patient E]
March 8, 2016
[Patient YY]
June 29, 2016
[Patient I]
July 26, 2016
[Patient J]
July 14, 2016
[Patient K]
October 21, 2016
[Patient L]
October 25, 2016
[Patient M]
October 27, 2016
[Patient N]
October 28, 2016
[Patient O]
October 30, 2016
[Patient P]
October 30, 2016
[Patient M]
October 31, 2016
[Patient Q]
- On the following 77 occasions, the Member failed to ensure that appropriate follow up and investigations were conducted in relation to the medication incident:
Date of Medication Incident Report
Patient
January 9, 2016
[Patient A]
January 18, 2016
[Patient R]
January 19, 2016
[Patient S]
January 24, 2016
[Patient T]
January 28, 2016
[Patient B]
January 29, 2016
[Patient C]
January 30, 2016
[Patient U]
February 1, 2016
[Patient D]
February 3, 2016
[Patient E]
February 3, 2016
[Patient F]
February 4, 2016
[Patient G]
February 6, 2016
[Patient V]
February 20, 2016
[Patient W]
February 25, 2016
[Patient A]
March 1, 2016
[Patient E]
March 7, 2016
[Patient X]
March 8, 2016
[Patient YY]
March 12, 2016
[Patient Y]
March 14, 2016
[Patient Z]
March 18, 2016
[Patient AA]
March 19, 2016
Unknown
March 23, 2016
[Patient BB]
March 26, 2016
[Patient CC]
March 29, 2016
[Patient W]
April 1, 2016
Unknown
April 3, 2016
[Patient DD]
April 5, 2016
[Patient EE]
April 5, 2016
[Patient FF]
April 7, 2016
[Patient DD]
April 14, 2016
[Patient GG]
April 24, 2016
[Patient B]
April 27, 2016
[Patient E]
May 6, 2016
[Patient HH]
May 24, 2016
[Patient II]
May 28, 2016
[Patient P]
May 30, 2016
[Patient JJ]
June 5, 2016
[Patient BB]
June 9, 2016
[Patient KK]
June 10, 2016
[Patient LL]
June 13, 2016
[Patient MM]
June 16, 2016
[Patient NN]
June 29, 2016
[Patient I]
June 30, 2016
[Patient OO]
July 4, 2016
[Patient PP]
July 8, 2016
[Patient QQ]
July 13, 2016
[Patient RR]
July 14, 2016
[Patient K]
July 22, 2016
[Patient SS]
July 25, 2016
[Patient I]
July 26, 2016
[Patient J]
July 28, 2016
[Patient S]
August 12, 2016
[Patient TT]
August 5, 2016
[Patient UU]
August 21, 2016
[Patient JJ]
September 24, 2016
[Patient VV]
September 26, 2016
[Patient WW]
September 30, 2016
[Patient XX]
October 2, 2016
[Patient YY]
October 4, 2016
[Patient F]
October 7, 2016
[Patient M]
October 10, 2016
[Patient ZZ]
October 11, 2016
[Patient M]
October 16, 2016
[Patient AAA]
October 13, 2016
[Patient A]
October 18, 2016
[Patient BBB]
October 18, 2016
[Patient OO]
October 18, 2016
[Patient CCC]
October 20, 2016
[Patient DDD]
October 21, 2016
[Patient EEE]
October 21, 2016
[Patient L]
October 24, 2016
[Patient JJ]
October 25, 2016
[Patient M]
October 27, 2016
[Patient N]
October 28, 2016
[Patient O]
October 30, 2016
[Patient P]
October 30, 2016
[Patient M]
October 31, 2016
[Patient Q]
Critical Incident System Reports
The Facility is required to file a Critical Incident System (“CIS”) Report with the Ministry with respect to an occurrence that results in harm or risk of harm to the safety, security, welfare and/or health of a resident. The Facility is also required to report to the Ministry a missing or unaccounted for controlled substance within one business day.
The Facility has a detailed policy, Critical Incidents, which sets out the procedures to be followed in the case of a Critical Incident. This policy provides that the DRC is responsible for reporting such incidents to the Ministry, conducting or overseeing an investigation into the incident, amending the initial Critical Incident Report as appropriate, and submitting the amendment to the Ministry. As DRC, the Member’s responsibilities also included tracking and trending all critical incidents in the Facility and maintaining a CIS Log.
On the following eight occasions, the Member failed to follow up and initiate investigations into Critical Incidents in circumstances where an investigation was required:
Date of Critical Incident
Patient
March 18, 2016
[Patient AA]
May 30, 2016
[Patient JJ]
August 19, 2016
[Patient AA]
August 31, 2016
[Patient JJ]
September 5, 2016
[Patient JJ]
September 12, 2016
[Patient AAA]
September 23, 2016
[Patient FFF]
October 16, 2016
[Patient AAA]
- On the following three occasions, the Member failed to record a Critical Incident in the CIS Log:
Date of Critical Incident
Patient
May 30, 2016
[Patient JJ]
August 19, 2016
[Patient AA]
October 16, 2016
[Patient AAA]
- The Member also failed to make any report to the Ministry of a Critical Incident with respect to [Patient JJ] on May 30, 2016.
Failure to investigate complaint about care provided to [Patient GGG]
In March 2016, the Member received a complaint from [ ], the daughter of [Patient GGG], related to concerns about the care an RN, [the RN], had provided to [Patient GGG]. [The daughter of Patient GGG’s] complaint related to [the RN’s] failure to detect an infection that resulted in [Patient GGG] being hospitalized for a bladder infection and sepsis.
The Member failed to document an entry into the Facility’s complaint log in relation to [the daughter of Patient GGG’s] complaint. She also failed to investigate and follow up on the complaint.
Storage and disposal of medication related to Medication Incident Reports
Any narcotic related to a medication incident must be destroyed in compliance with narcotics and long-term care home standards.
Contrary to these standards, the Member placed a tablet of hydromorphcontin (a narcotic) and a tablet of Galantamine in a plastic envelope and taped it to a Medication Incident Report for [Patient YY], dated March 8, 2016. The Member also attached two Tylenol tablets to a Medication Incident Report for [Patient EE], dated April 5, 2016. The Member acknowledges that attaching medications related to a Medication Incident Report to the report is inconsistent with the Facility’s policies and practices, and safe medication disposal practices. She admits that she failed to appropriately dispose of the medication.
The two Medication Incident Reports with the medications attached were found in the Member’s office on November 2, 2016. The medications were subsequently disposed of in accordance with the Facility’s policies.
Completion of quarterly medication objective reviews
The Facility’s management company required the DRC to submit quarterly medication objective reviews. These reviews demonstrated that the DRC reviewed and identified the main issues around medication errors with registered staff, and that goals were put in place to ensure ongoing issues were corrected.
The Member did not conduct the quarterly medication objective reviews at the Facility for the three quarters beginning April, July and October 2016.
Failure to investigate complaints about [Patient U]
On April 27, 2016, [Patient U] reported that she had been ringing her call bell for 2.5 hours without a response, and that a staff member had directed inappropriate language at her. The Member filed a CIS Report with the Ministry on April 29, 2016. The Member, however, failed to provide the corresponding complaint form to the Facility until September 1, 2016. She also failed to document an entry in the Facility’s complaint log at the time of the complaint.
On May 17, 2016, [Patient U’s] son reported that staff were not responding to [Patient U’s] call bell. He also expressed concerns about care provided by a PSW. The Member filed an initial CIS Report with the Ministry on May 17, 2016, but did not update the Report with any outcome of any investigation. A subsequent Ministry inspection concluded that the Facility failed to ensure that this specific incident of alleged, suspected or witnessed incident of abuse was immediately investigated.
The Member admits that she failed to appropriately report, follow up on and conduct an investigation into the May 17 complaint.
Failure to investigate incident involving [Patient V]
[Patient V] had an order for Coumadin, which was placed on hold. Despite the hold, the Patient continued to receive Coumadin until she was in medical distress. She was transported to hospital and nearly died.
An RN at the Facility completed a Medication Incident Report with respect to this medication error on May 19, 2016, and the Member signed acknowledging receipt on May 24, 2016. The Medication Incident Report documented that the effect on the patient was “increased monitoring or intervention required”. The Member acknowledges it ought to have been “major harm or death”.
The Member’s only documented follow-up was with a pharmacy consultant. She did not conduct any further investigation or follow up with the staff involved. The Member failed to file a CIS Report with the Ministry even though the Incident resulted in harm to the patient, and as a result, the report was mandatory.
The Member admits that she failed to appropriately document, report, follow up on and investigate the medication error.
Response to report of sexual assault of involving [Patient HH]
On August 23, 2016, a visitor sexually assaulted [Patient HH]. [The Assistant Director of Care], the Assistant Director of Care, called the Member and explained to her what had happened, and asked her for advice. The Member told him not to worry about it (or something similar to that effect), as the Patient had dementia or Alzheimer’s. [The Assistant Director of Care] did not file any report with the Ministry, nor did the Member.
In September 2016, [the Assistant Director of Care] heard about another incident involving the same visitor and patient. This time he sought advice from another member of the Facility’s leadership team, and on her advice, both incidents were reported to the Ministry. The Ministry subsequently issued a Written Notice to the Facility for failing to protect residents from abuse in relation to this Incident.
The Member admits that she failed to appropriately respond to, report and investigate the incident.
Comments about restorative aide
On or around September 2, 2016, during a leadership meeting, the Member referred to a restorative aide who had worked at the Facility as a “big, tall amazon woman”.
The Member does not recall making this statement; however, she does not dispute she did, and admits that such language was inappropriate.
CNO STANDARDS
- CNO has published nursing standards to set out the expectations for the practice of nursing. CNO’s standards inform nurses of their accountabilities and apply to all nurses regardless of their role, job description, or area of practice.
Professional Standards
- CNO’s Professional Standards (“Professional Standards”) provides that “[e]ach nurse is accountable to the public and responsible for ensuring that her/his practice and conduct meets legislative requirements and the standards of the profession.” The Professional Standards sets out the indicators of accountability, including:
providing, facilitating, advocating and promoting the best possible care for [patients];
… ensuring practice is consistent with CNO’s standards of practice and guidelines as well as legislation;
taking action in situations in which [patient] safety and well-being are compromised;
taking responsibility for errors when they occur and taking appropriate action to maintain [patient] safety;
reporting to the appropriate authority any health care team member or colleague whose actions or behaviours towards [patients] are unsafe or unprofessional, or indicate abuse, in accordance with the applicable legislation, including … the Long-Term Care Homes Act, 2007.
The Professional Standards requires that “[e]ach nurse establishes and maintains respectful, collaborative, therapeutic and professional relationships.” A nurse demonstrates the standard in a number of ways, including by “recognizing the potential for [patient] abuse” and “preventing [abuse] when possible”.
As a nurse in an administrator role, the Member had specific accountabilities set out in the Professional Standards, including:
ensuring that mechanisms allow for staffing decisions that are in the best interests of patients and professional practice;
ensuring the appropriate use, education and supervision and staff;
supporting nurses to take action when patients are at risk of harm;
creating environments that promote and support safe, effective and ethical practice;
creating practice environments that support quality nursing practice; and
establishing and maintaining communication systems to support quality service and research.
Documentation
- CNO’s Documentation standard states that:
Nursing documentation is an important component of nursing practice and the interprofessional documentation that occurs within the [patient] health record. Documentation — whether paper, electronic, audio or visual — is used to monitor a [patient’s] progress and communicate with other care providers. It also reflects the nursing care that is provided to a [patient].
- The standard goes on to say that a nurse meets the standard by “ensuring their documentation of [patient] care is accurate, timely and complete.”
Medication Standard
- CNO’s Medication standard requires nurses to “promote safe care, and contribute to a culture of safety within their practice environments, when involved in medication practices”. Specifically, nurses are required to:
promote and/or implement the secure and appropriate storage, transportation and disposal of medication;
take appropriate action to resolve or minimize the risk of harm to a [patient] from a medication error or adverse reaction;
report medication errors, near misses, or adverse reactions in a timely manner
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1 of the Notice of Hearing, as described in paragraphs 6-38 above, in that the Member contravened a standard of practice of the profession or failed to meet the standard of practice of the profession.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 2 of the Notice of Hearing, as described in paragraphs 10-14, 17-18, 21, and 26-33 above, in that she failed to keep records as required.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3 of the Notice of Hearing, as described in paragraphs 19-21, and 27-36, above, and in particular, that she failed to report incidents of unsafe practice or unethical conduct of a health care provider to the authority responsible for the health care provider.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 4 of the Notice of Hearing, and in particular, that her conduct was dishonourable and unprofessional, as described in paragraphs 6-38 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), (f), (g), (h), (i), (j), (k), (l), (m), (n), (o), (p), #2(a), (b), (c), (d), (e), (f), (g), #3(a)(i)(ii)(iii), (b), (c) and #4(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m), (n), (o), (p).
As to Allegations #4(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m), (n), (o), (p) in the Notice of Hearing, the Panel finds that the Member engaged in conduct relevant to the practice of nursing that would reasonably be regarded by members as unprofessional and dishonourable.
Reasons for Decision
The Panel considered the Agreed Statement of Facts and the Member’s plea and finds that this evidence supports findings of professional misconduct as alleged in the Notice of Hearing.
The Member contravened a standard of practice of the profession or failed to meet the standard of practice of the profession.
Allegation #1(a) in the Notice of Hearing is supported by paragraphs 6, 7, 8, 9 and 39-46 in the Agreed Statement of Facts as the Member failed to ensure appropriate hiring practices were in place when hiring a Personal Support Worker in 2015 and 2016.
Allegation #1(b) in the Notice of Hearing is supported by paragraphs 10, 11 and 39-46 in the Agreed Statement of Facts as the Member failed to review and compile monthly nursing reports at the Facility in 2016.
Allegation #1(c) in the Notice of Hearing is supported by paragraphs 12, 13 and 39-46 in the Agreed Statement of Facts where the Member failed to sign acknowledging receipt of Medication Incident Reports that involved 19 patients.
Allegation #1(d) in the Notice of Hearing is supported by paragraphs 12, 14 and 39-46 in the Agreed Statement of Facts where the Member failed to ensure that appropriate follow up and investigations were conducted in relation to the Medication Incident Reports involving 77 patients.
Allegation #1(e) in the Notice of Hearing is supported by paragraphs 15, 16, 19 and 39-46 in the Agreed Statement of Facts that the Member failed to report a Critical Incident for [Patient JJ] to the Ministry of Health and Long Term Care.
Allegation #1(f) in the Notice of Hearing is supported by paragraphs 15, 16, 17 and 39-46 in the Agreed Statement of Facts where the Member failed to follow up and investigate in relation to Critical Incidents concerning 8 patients.
Allegation #1(g) in the Notice of Hearing is supported by paragraphs 15, 16, 18 and 39-46 in the Agreed Statement of Facts in that the Member failed to appropriately document Critical Incidents involving 3 patients.
Allegation #1(h) in the Notice of Hearing is supported by paragraphs 20, 21 and 39-46 in the Agreed Statement of Facts where the Member failed to document, report, follow up and investigate a complaint received in relation to care provided to [Patient GGG].
Allegations #1(i) and (j) in the Notice of Hearing are supported by paragraphs 22, 23, 24 and 39-46 in the Agreed Statement of Facts where the Member failed to appropriately store and dispose of medication for two patients, [Patient YY] and [Patient EE].
Allegation #1(k) in the Notice of Hearing is supported by paragraphs 25, 26 and 39-46 in the Agreed Statement of Facts as the Member failed to conduct and appropriately document quarterly medication objective reviews at the Facility.
Allegations #1(l) and (m) in the Notice of Hearing are supported by paragraphs 27, 28, 29 and 39-46 in the Agreed Statement of Facts as the Member failed to appropriately document, report, follow up and investigate complaints in relation to [Patient U] on two occasions in April and May 2016.
Allegation #1(n) in the Notice of Hearing is supported by paragraphs 30, 31, 32, 33 and 39-46 in the Agreed Statement of Facts where the Member failed to appropriately document, report, follow up and investigate a medication error in relation to [Patient V].
Allegation #1(o) in the Notice of Hearing is supported by paragraphs 34, 35, 36 and 39-46 in the Agreed Statement of Facts when the Member failed to respond to, report and investigate a report that [Patient HH] had been sexually assaulted.
Allegation #1(p) in the Notice of Hearing is supported by paragraphs 37, 38 and 39-46 in the Agreed Statement of Facts where the Member used unsuitable language when referring to a former worker at the Facility.
The Member failed to keep records as required.
Allegation #2(a) in the Notice of Hearing is supported by paragraphs 10, 11 and 47 in the Agreed Statement of Facts where the Member failed to complete and compile the required monthly nursing reports at the Facility.
Allegation #2(b) in the Notice of Hearing is supported by paragraphs 12, 13 and 47 in the Agreed Statement of Facts where the Member on 19 occasions failed to sign acknowledging receipt with respect to the Medication Incident Reports.
Allegation #2(c) in the Notice of Hearing is supported by paragraphs 15, 16, 18 and 47 in the Agreed Statement of Facts where the Member on 3 occasions failed to appropriately document in the Critical Incident log.
Allegation #2(d) in the Notice of Hearing is supported by paragraphs 20, 21 and 47 in the Agreed Statement of Facts where the Member failed to document a complaint received in relation to the care provided to [Patient GGG] in to the Facility’s complaint log.
Allegation #2(e) in the Notice of Hearing is supported by paragraphs 25, 26 and 47 in the Agreed Statement of Facts where the Member failed to appropriately document quarterly medication objective reviews conducted at the Facility.
Allegation #2(f) in the Notice of Hearing is supported by paragraphs 27, 28, 29 and 47 in the Agreed Statement of Facts where the Member failed to appropriately document a complaint received in relation to [Patient U] in the Facility’s complaints log.
Allegation #2(g) in the Notice of Hearing is supported by paragraphs 30, 31, 32, 33 and 47 in the Agreed Statement of Facts where the Member failed to appropriately document a medication error in relation to [Patient V].
The Member failed to report incidents of unsafe practice or unethical conduct of a health care provider to the authority responsible for the health care provider.
Allegation #3(a)(i) in the Notice of Hearing is supported by paragraphs 19 and 48 in the Agreed Statement of Facts as the Member failed to report Critical Incidents to the Ministry of Health and Long Term Care for [Patient JJ].
Allegation #3(a)(ii) in the Notice of Hearing is supported by paragraphs 30, 31, 32, 33 and 48 in the Agreed Statement of Facts as the Member failed to report Critical Incidents to the Ministry of Health and Long Term Care for [Patient V].
Allegation #3(a)(iii) in the Notice of Hearing is supported by paragraphs 34, 35, 36 and 48 in the Agreed Statement of Facts as the Member failed to report Critical Incidents to the Ministry of Health and Long Term Care for [Patient HH].
Allegation #3(b) in the Notice of Hearing is supported by paragraphs 20, 21 and 48 in the Agreed Statement of Facts as the Member failed to report concerns about care provided to [Patient GGG].
Allegation #3(c) in the Notice of Hearing is supported by paragraphs 27, 28, 29 and 48 in the Agreed Statement of Facts as the Member failed to report concerns about the care provided to [Patient U].
The Member engaged in conduct that was dishonourable and unprofessional.
With respect to Allegations #4(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m), (n), (o), (p), the Panel finds that the Member’s conduct as set out in paragraphs 6-38 in the Agreed Statement of Facts was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.
The Panel also finds that the Member’s conduct was dishonourable. It demonstrated a moral failing through 2 years of disregard for her obligations to her patients. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional. Of most concern was the persistent failure to document. This lack of documentation included a patient who was alleged to have been sexually abused, as well as a medication issue that almost led to the death of a patient in the care of the Facility.
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:
Requiring the Member to appear before the Panel to be reprimanded within three months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for seven 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 practicing class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) The Member will attend two meetings with a Regulatory Expert (the “Expert”) at her own expense and within six months from the date 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,
Mandatory Reporting: A Process Guide for Employers, Facility Operators and Nurses, and
Documentation;
iv. Before the first meeting, the Member reviews and completes the CNO’s self-directed learning package, One is One Too Many, at her own expense, including the self-directed Nurses’ Workbook;
v. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, online participation forms and Nurses’ Workbook;
vi. 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 patients, 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;
vii. 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;
viii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;
b) The Member shall not hold any managerial, supervisory or any other position of authority until the conditions in paragraph 3(a) have been satisfied;
c) For a period of 18 months from the date the Member returns to the practice of nursing, the Member will notify her employers of the decision. To comply, the Member is required to:
i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;
ii. Provide her employer(s) with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;
iii. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to the Director, in which it will confirm:
that they received a copy of the required documents, and
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession; and
All documents delivered by the Member to 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 mitigating factors in this case were:
The Member had no prior discipline history with the College;
The Member was cooperative with the College by way of an Agreed Statement of Facts and a Joint Submission on Order and thereby accepted responsibility for her conduct.
The aggravating factors in this case were:
There were serious and persistent deficiencies over an extended period of time;
Multiple repeated failures to respond;
There was risk to patients with a lack of documentation involving medication errors and sexual abuse allegations;
The Member works in a Health Care environment with vulnerable patients.
A persistent disregard for the Member’s accountabilities and professional obligations.
The proposed penalty provides for general and specific deterrence by the reprimand and a 7 month suspension.
The proposed penalty provides for general deterrence by sending a message to the membership that this type of behaviour will not be accepted.
The proposed penalty provides for remediation and rehabilitation of the Member by its terms, conditions and limitations which include 2 meetings with a Nursing Expert to review various College standards and self-reflection.
Overall, the public is protected because the penalty provides that the Member cannot hold any managerial role until the expert sessions have been completed. The public is also protected by the 18 month employer notification which starts when the Member returns to work after all the other conditions have been satisfied.
College Counsel submitted cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee.
CNO v Spiridi (Discipline Committee 2018). The member was in management as a director of care in a long term facility. She had failed to report suspicions of improper treatment of a patient for over 2 months. The Member had come to an agreement with the College by way of an Agreed Statement of Facts. Her penalty included a reprimand, a suspension of 2 months, and terms, conditions and limitations which required 2 meetings with a nursing expert but no employer notification.
CNO v Figg (Discipline Committee 2019). The member in this case was an Administrator at a facility. She hired her sister an RPN, knowing that her sister’s certificate of registration was suspended by the College. The member had come to an agreement with the College by way of an Agreed Statement of Facts. Her penalty included a reprimand, a suspension of 3 months, and terms, conditions and limitations which required 2 meetings with a nursing expert and no employer notification.
CNO v Newman (Discipline Committee 2019). The member in this case was the director and owner of a Long Term Care Home. She had failed to disclose information on her annual renewal to the College. The member had also received a salary she was not entitled to receive as well as failing compliance requirements under the Long-Term Care Homes Act. The member had come to an agreement with the College by way of an Agreed Statement of Facts. The Member was given a reprimand and the panel accepted an undertaking from the Member for her permanent resignation.
The Member’s Counsel asked the Panel to accept the Joint Submission on Order and indicated that the Member had cooperated at all stages and admitted her misconduct. The Member’s Counsel added that the cases presented may not be the same as this case as it is difficult to find exact cases to match.
Penalty Decision
The Panel accepts the Joint Submission on Order and accordingly orders:
The Member is required to appear before the Panel to be reprimanded within three months of the date that this Order becomes final.
The Executive Director is directed to suspend the Member’s certificate of registration for seven 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 practicing class.
The Executive Director is directed to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) The Member will attend two meetings with a Regulatory Expert (the “Expert”) at her own expense and within six months from the date 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,
Mandatory Reporting: A Process Guide for Employers, Facility Operators and Nurses, and
Documentation;
iv. Before the first meeting, the Member reviews and completes the CNO’s self-directed learning package, One is One Too Many, at her own expense, including the self-directed Nurses’ Workbook;
v. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, online participation forms and Nurses’ Workbook;
vi. 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 patients, 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;
vii. 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;
viii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;
b) The Member shall not hold any managerial, supervisory or any other position of authority until the conditions in paragraph 3(a) have been satisfied;
c) For a period of 18 months from the date the Member returns to the practice of nursing, the Member will notify her employers of the decision. To comply, the Member is required to:
i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;
ii. Provide her employer(s) with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;
iii. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to the Director, in which it will confirm:
that they received a copy of the required documents, and
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession; and
All documents delivered by the Member to 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 Panel noted that the 18 month employer notification in this case was needed. This Member had a number of failings and the 7 month suspension was a strong indicator that this type of persistent disregard for and lack of documentation regarding allegations of sexual assault and medication errors will not be tolerated.
I, Grace Fox, NP sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.