DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Heather Stevanka, RN Chairperson
Karen Goldenberg Public Member Natalie Montgomery Public Member Michael Schroder, NP Member
Jane Walker, RN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) DENISE COONEY for ) College of Nurses of Ontario
- and - )
OMOROUBIYE OHIEGBOMWAN ) DANIEL ETOH for Registration No.: 0503086 ) Omoroubiye Ohiegbomwan
) CHRISTOPHER WIRTH
) Independent Legal Counsel
) Heard: October 1, 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 October 1, 2020, via videoconference.
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 of the patients, or any information that could disclose the identities of the patients referred to orally or in any documents presented in the Discipline hearing of Omoroubiye Ohiegbomwan.
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 of the patients, or any information that could disclose the identities of the patients referred to orally or in any documents presented in the Discipline hearing of Omoroubiye Ohiegbomwan.
The Allegations
The allegations against Omoroubiye Ohiegbomwan (the “Member”) as stated in the Notice of Hearing dated August 13, 2020, which as amended reads, 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 practicing as a Registered Nurse, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession in that:
a. on or about May 1 and 2, 2018, while working at St. Michael’s Hospital in Toronto, Ontario (“St. Michael’s”), you failed to appropriately monitor and/or assess [Patient A];
b. on or about October 16 and 17, 2017, while working at Sunnybrook Health Sciences Centre in Toronto, Ontario (“Sunnybrook”), you failed to ensure that [Patient B] received appropriate medical treatment, including but not limited to the following:
i. you failed to assess and/or maintain appropriate documentation with respect to your assessment of [Patient B]’s urine output; and/or
ii. you failed to appropriately monitor and/or assess [Patient B]’s condition and/or failed to maintain appropriate documentation with respect to your assessment of [Patient B]’s condition.
- 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 practicing as a Registered Nurse, you failed to keep records as required, in that on or about October 16 and 17, 2017, while working at Sunnybrook, you failed to maintain appropriate documentation with respect to:
a. your assessment and/or monitoring of [Patient B]’s urine output; and/or
b. your assessment and/or monitoring of [Patient B]’s condition.
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(14) of Ontario Regulation 799/93, in that you falsified a record relating to your practice, and in particular on or about October 16 and 17, 2017, while working at Sunnybrook, you recorded [Patient B]’s urine output when you had not assessed [Patient B]’s urine output.
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 practicing as a Registered Nurse, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional, in that:
a. on or about May 1 and 2, 2018, while working at St. Michael’s, you failed to appropriately monitor and/or assess [Patient A];
b. on or about October 16 and 17, 2017, while working at Sunnybrook, you failed to ensure that [Patient B] received appropriate medical treatment, including but not limited to the following:
i. you failed to assess and/or maintain appropriate documentation with respect to your assessment of [Patient B]’s urine output;
ii. you failed to appropriately monitor and/or assess [Patient B]’s condition and/or failed to maintain appropriate documentation with respect to your assessment of [Patient B]’s condition; and/or
iii. you recorded [Patient B]’s urine output when you had not assessed [Patient B]’s urine output.
Member’s Plea
The Member admitted the allegations set out in paragraphs 1(a)(b)(i)(ii), 2(a)(b), 3, 4(a)(b)(i)(ii) and (iii) in the Notice of Hearing. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.
Agreed Statement of Facts
College Counsel and the Member’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited, as follows:
THE MEMBER
Omoroubiye Ohiegbomwan (the “Member”) obtained a diploma in nursing from the State School of Nursing in Warri (Delta State), Nigeria in November 1994.
The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on January 1, 2005.
On September 20, 2018, the Inquires, Complaints and Review Committee (“ICRC”) imposed terms, conditions or limitations (“TCLs”) on the Member’s certificate of registration on an interim basis in relation to the incidents of professional misconduct described below. The ICRC subsequently removed the TCLs on January 30, 2020. The Member is currently entitled to practice nursing without restrictions.
The incidents of professional misconduct relate to incidents which occurred at two different facilities in Toronto, Ontario: Sunnybrook Health Science Centre (“Sunnybrook”) and St. Michael’s Hospital (“St. Michael’s”).
At the time of the Sunnybrook incident, the Member was deployed as an agency nurse by Nursing and Homemakers Inc. (“NHI”). The Member remains employed by NHI, where she has worked since February 1, 2004.
At the time of the St. Michael’s Incident, the Member was deployed as an agency nurse by Saint Elizabeth Staffing Solutions (“St. Elizabeth”). The Member’s employment at St. Elizabeth was terminated in relation to the St. Michael’s incident.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
Sunnybrook Incident (October 16-17, 2017)
At the time of the Sunnybrook Incident, the Member was working on a 25-bed surgical and 11 bed short stay medical unit. The Member was assigned to provide [Patient B] with care over the 12-hour night shift October 16, 2017 19:30 to October 17, 2017 07:30. [Patient B] was a 91-year-old post-operative female.
At the time the Member started her shift on October 16, 2017 and assumed care of [Patient B], [Patient B] had low urine output and a suspected Urinary Tract Infection (“UTI”). [Patient B]’s physician’s orders required urinary output monitoring, and that the nursing staff notify the physician if urine output dropped below a certain threshold.
In light of [Patient B]’s age and condition, the physician’s orders, and Sunnybrook’s practice, the Member was required to monitor [Patient B]’s vital signs at least every four hours, with increased frequency depending on [Patient B]’s condition. She was also required to monitor [Patient B]’s urine output as frequently as necessary and look for symptoms of UTI and sepsis. The Member was required to record information about [Patient B]’s urine such as its volume, colour, consistency, smell, and any possible signs and symptoms of infection and sepsis.
The Member only documented [Patient B]’s vital signs on three occasions during her 12-hour shift: 20:30, 00:30, and 06:30.
The Member did not include narrative notations in her charting of [Patient B]. The Member’s only documentation with respect to [Patient B]’s urine was to document her urine output as “500”. There is no evidence that the Member checked [Patient B] for urosepsis symptoms or UTI progression. The Member admits and acknowledges that she did not actually assess [Patient B]’s urine output, and that did she not monitor [Patient B]’s urine output or look for symptoms of UTI and sepsis.
If the Member were to testify, she would say she failed to complete the progress note with respect to [Patient B] because the Patient’s chart was with the physician at the end of her shift. Sunnybrook is a teaching hospital and the Member’s understanding was that the chart would be used to teach students.
The Member was required to document a head to toe assessment of [Patient B]. Instead of completing and documenting the assessment of [Patient B], the Member documented arrows, apparently to indicate that the values were the same as they had been when the previous nurse had assessed [Patient B]. If the Member were to testify, she would state that although she believed other nurses drew arrows as opposed to writing separate values in charts, she recognizes that drawing arrows is not an acceptable form of documentation and that she was required to complete individual and updated assessments of [Patient B].
At shift change on October 17, 2017, the Member did not communicate any concerns about [Patient B]’s urine output and vital signs to the oncoming shift, which could have affected their level of vigilance of [Patient B]. If the Member were to testify, she would say that in her observation, [Patient B] did not show any sign of sepsis during the Member’s shift, and to her knowledge, [Patient B] was stable when the day nurse assumed care of the Patient. The Member however acknowledges that she did not appropriately monitor the Patient’s condition in reaching that conclusion.
[Patient B] was found with decreased levels of consciousness on the afternoon of October 17, 2017 and passed away a few hours later.
Due to both the absence of critical documentation about [Patient B]’s condition completed by the Member, as well as the lack of accurate documentation about the Patient’s condition completed by the Member, Sunnybrook was unable to determine whether [Patient B]’s care should have been escalated sooner.
St. Michael’s Incident (May 1-2, 2018)
The Member was assigned to the night shift on the inpatient mental health unit at St. Michael’s, from May 1, 2018 19:30 to May 2, 2018 06:00. On that shift, the Member was assigned to three patients in the intermediate step-down area of the inpatient mental health unit. Each patient on the unit was in a single room, which also had a video monitor.
One of the Member’s assigned patients was [Patient A], a 56-year-old male.
St. Michael’s policy, Nursing Rounding in the Inpatient and Mental Health and Addictions Program (the “St. Michael’s Policy”), requires nurses on the inpatient mental health unit to conduct hourly checks of patients, 24 hours a day, 7 days a week. As part of the hourly checks, nurses must enter patient rooms and make direct visual observations and assessments of patients.
The St. Michael’s Policy expressly provides that observation from a video surveillance monitor is not a substitute for direct visual assessment and supervision of a patient. The St. Michael’s Policy is posted on each patient’s door.
If the Member were to testify, she would say that she was not provided with a full orientation of the protocol and policies on the inpatient mental health unit at St. Michael’s, including the St. Michael’s Policy. She would further testify that she does not recall the St. Michael’s Policy being posted on each patient’s door. Nevertheless, the Member acknowledges that, if she felt that did not receive a complete orientation, it was her responsibility to proactively familiarize herself with the protocol and policies of the inpatient mental health unit in which she was working as an agency nurse in order to provide appropriate care and maintain the safety of the vulnerable patient population in the unit.
The Member entered [Patient A]’s room at 20:45 and 22:45 to take his vital signs.
From 22:45 until her shift ended at 06:00, the Member did not enter [Patient A]’s room and/or make direct visual observation and assessment of his condition. If the Member were to testify, she would state that she was unaware of St. Michael’s Policy. Nevertheless, the Member admits that she did not appropriately monitor and assess [Patient A] when she failed to directly observe and assess his condition while she was responsible for providing him care.
The Member’s documented assessment report of [Patient A] at 06:00 was “Pt slept until Am and no management problems” and “Pt still asleep at this time and report given to incoming nurse.” The Member had not entered [Patient A]’s room in order to complete this assessment. Rather, she relied on the video monitor to assess his condition. The Member admits that observation through video surveillance is not an appropriate substitute for direct visual observation and assessment. If the Member were to testify, she would say she understood that [Patient A] was in stable condition at the time the oncoming RN assumed care for the Patient, however she acknowledges that she did not appropriately assess the Patient before transferring care.
At approximately 12:00 on May 2, 2018, the RN who had assumed care for [Patient A] from the Member found the Patient unresponsive. [Patient A] was pronounced dead at 12:30 on May 2, 2018. The report of post-mortem examination concluded that the underlying cause of [Patient A]’s death was acute bronchopneumonia and aspirational pneumonia in a man with significant blood opioid levels.
CNO STANDARDS
CNO publishes 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.
The standards of practice of the profession required the Member to complete assessments of [Patient B] and [Patient A] at regular intervals and to appropriately and accurately document assessments and monitoring of patients’ conditions.
Professional Standards
- CNO’s Professional Standards provides that each nurse is accountable to the public and responsible for ensuring her or his practice and conduct meets legislative requirements and the standards of practice of the profession. A nurse demonstrates this standard by actions such as:
a. providing, facilitating, advocating and promoting the best possible care for clients;
b. ensuring practice is consistent with CNO’s standards of practice and guidelines, as well as legislation;
c. taking action in situations in which client safety and well-being are compromised; and
d. evaluating/describing the outcomes of specific interventions and modifying the plan/approach.
The Member admits that her failure to ensure that [Patient B] received appropriate medical treatment, including appropriately assessing, monitoring and documenting [Patient B]’s urine output and condition, breached the Professional Standards.
The Member admits that her failure to appropriately monitor and assess [Patient A] breached the Professional Standards.
Documentation Standard
- CNO’s Documentation standard provides that nurses are accountable for ensuring their documentation of client care is “accurate, timely and complete.” The standard further clarifies that a nurse meets the standard by:
a. ensuring documentation is a complete record of nursing care provided and reflects all aspects of the nursing process, including assessment, planning, intervention (independent and collaborative) and evaluation;
b. documenting in a timely manner and completing documentation during, or as soon as possible after, the care or event;
c. documenting both objective and subjective data;
d. using abbreviations and symbols appropriately by ensuring that each has a distinct interpretation and appears in a list with full explanations;
e. documenting significant communication with family members/significant others, substitute decision-makers and other care providers; and
f. ensuring that relevant client care information is captured in a permanent record.
- The Member admits that her failure to maintain appropriate documentation with respect to assessing and monitoring [Patient B]’s urine output and overall condition was a breach of the Documentation standard.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct in paragraphs 1 (a), 1(b), 4(a) and 4(b) of the Notice of Hearing, as described in paragraphs 7-25 above, in that she contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, and that this conduct was disgraceful, dishonourable and unprofessional.
The Member admits that she committed the acts of professional misconduct in paragraph 2 of the Notice of Hearing, as described in paragraphs 7-14 above, in that she failed to keep records as required when she failed to maintain appropriate documentation with respect to her assessment and/monitoring of [Patient B]’s condition and urine output.
The Member admits that she committed the acts of professional misconduct in paragraph 3 of the Notice of Hearing, as described in paragraph 11 above, in that she falsified a record relating to her practice when, on or about October 16 and 17, 2017, she recorded [Patient B]’s urine output as “500” when she had not assessed the Patient’s urine output.
Decision
The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities and based upon clear, cogent and convincing evidence.
Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1(a)(b)(i)(ii), 2(a)(b), 3, 4(a)(b)(i)(ii) and (iii) of the Notice of Hearing. As to allegations #4(a)(b)(i)(ii) and (iii), the Panel finds that the Member engaged in conduct that would reasonably be considered by members to be 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.
Allegation #1(a) in the Notice of Hearing is supported by paragraphs 17 to 25, 27, 28, 30 and 33 in the Agreed Statement of Facts. From 22:45 to 06:00 when her shift ended, the Member did not directly enter the room of [Patient A] on an hourly basis to complete direct assessments and observations as required by St. Michael’s policy. The Member relied on the video monitor to make observations and assessments which the Member subsequently admits is not an appropriate substitute for direct visual assessment and observation.
Allegation #1(b)(i) in the Notice of Hearing is supported by paragraphs 11, 12, 16, 28, 29, 32 and 33 in the Agreed Statement of Facts. Given [Patient B]’s age and condition along with the physician’s orders, and Sunnybrook practice, the Member was required to monitor [Patient B]’s urine output as frequently as necessary and look for symptoms of UTI and sepsis. The Member was required to record information about [Patient B]’s urine including volume, colour, consistency, and smell and any possible symptoms of infection or sepsis. The Member’s only documentation with respect to [Patient B]’s urine was to document her urine output as “500”.
Allegation #1(b)(ii) in the Notice of Hearing is supported by paragraphs 8 to 16, 27, 28, 29, 32 and 33 in the Agreed Statement of Facts. [Patient B] had low urinary output and a suspected UTI. The physician’s orders required urinary output monitoring and for staff to notify the physician if the urine output dropped below a certain threshold. The Member was required to monitor [Patient B]’s vital signs at least every four hours with increased frequency depending on [Patient B]’s condition. The Member only documented vital signs on three occasions during her shift. The Member did not include narrative notations in her charting for [Patient B]. The Member was required to document a head-to-toe assessment of [Patient B]. Instead of completing and documenting the assessment of [Patient B], the Member documented arrows, apparently to indicate that the values were the same as they had been when the previous nurse assessed [Patient B].
Allegation #2(a) in the Notice of Hearing is supported by paragraphs 9, 11, 32 and 34 in the Agreed Statement of Facts. The Member was required to record information about [Patient B]’s urine including volume, colour, consistency, and smell. The Member’s only documentation with respect to [Patient B]’s urine was to document her urine output as “500”.
Allegation #2(b) in the Notice of Hearing is supported by paragraphs 9 to 13, 32 and 34 in the Agreed Statement of Facts. The Member was required to monitor [Patient B]’s vital signs at least every four hours with increased frequency depending on [Patient B]’s condition. The Member only documented vital signs on three occasions during her shift. The Member did not include narrative notations in her charting for [Patient B]. The Member was required to document a head-to-toe assessment of [Patient B]. Instead of completing and documenting the assessment of [Patient B], the Member documented arrows, apparently to indicate that the values were the same as they had been when the previous nurse assessed [Patient B].
Allegation #3 in the Notice of Hearing is supported by paragraphs 11, 29 and 35 in the Agreed Statement of Facts. The Member’s only documentation with respect to [Patient B]’s urine was to document her urine output as “500”. The Member admits that she falsified a record relating to her practice when she recorded [Patient B]’s urine as “500” when she had not assessed [Patient B]’s urine output.
With respect to allegations #4(a), (b)(i)(ii) and (iii), the Panel finds that the Member’s conduct in failing to appropriately assess and monitor [Patient B] and [Patient A] 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 an element of dishonesty and deceit through recording [Patient B]’s urine as “500” while subsequently admitting and acknowledging that she did not actually assess or monitor [Patient B]’s urine output. The Member knew or ought to have known that her conduct was unacceptable and fell well below the standards of a professional.
The Member failed to appropriately monitor and assess [Patient A] and failed to appropriately monitor, assess and maintain appropriate documentation for [Patient B]. She also failed to keep records as required and falsified one documentation record. Although, the Member admitted in paragraph 33 of the Agreed Statement of Facts that her conduct was disgraceful, the Panel determined that the Member’s conduct did not meet the threshold to be considered disgraceful as it was not satisfied that the Member’s conduct cast a serious doubt on her moral fitness and inherent ability to discharge the higher obligations the public expects professionals to meet.
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 three 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 a minimum of two meetings with a Regulatory Expert (the “Expert”) at her own expense and within six months from the date that this Order becomes final. If the Expert determines that a greater number of session are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date of 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,
Documentation,
Professional Standards, and
Therapeutic Nurse-Client Relationship;
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 (where applicable);
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 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;
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) Within 12 months from the date that this Order becomes final, or a longer time period as approved by the Director, the Member shall successfully complete at her own expense, with a minimum passing grade of 65%, a nursing course with clinical or laboratory or other practical components that have received prior approval from the Director regarding: health assessment. The Member must provide the Director with proof of enrolment and successful completion of the courses with a minimum passing grade of 65%.
c) For a period of 18 months from the date the Member’s suspension ends, 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. Only practice nursing for an employer who agrees to, and does, forward a report to the Director within 14 days of the commencement or resumption of the Member’s employment in any nursing position, confirming:
that they received a copy of the required documents,
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
that they agree to perform three random spot audits of the Member’s documentation practice at the following intervals over a 12-month period and provide a report to the Director regarding the Member’s practice after each audit:
a. the first audit shall take place within four months from the date the Member begins or resumes employment with the employer,
b. the second audit shall take place within eight months from the date the Member begins or resumes employment with the employer, and
c. the third audit shall take place within 12 months from the date the Member begins or resumes employment with the employer;
iv. The audits shall, on each occasion, involve reviewing a random selection of at least five of the Member’s charts to ensure they meet both CNO and employer standards.
- 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 aggravating factors in this case included that there are two separate incidents which are similar in nature with respect to conduct and its consequences. The incidents show a serious disregard by the Member to monitor and assess patients. These incidents show a lack of engagement with her practice and professional obligations. These incidents also show the lack of obligation to care for and monitor two vulnerable patients. Both patients required heightened monitoring to determine whether increased interventions were necessary. The Member’s documentation was seriously deficient, which made it difficult for other members of the patients’ care teams to determine whether the patients’ care required escalation sooner. With [Patient B], the Member admits to documenting an assessment which she admits that she did not perform. This conduct involves dishonesty and a breach of trust. The Member’s conduct involves two patients who died shortly after the Member’s shifts, however, there is no allegation that the Member’s actions directly caused the deaths.
The mitigating factors in this case were that the Member has no prior discipline history with the College and that by agreeing to the Agreed Statement of Facts and Joint Submission on Order, the Member has accepted responsibility for her conduct.
The proposed penalty provides for general and specific deterrence through the suspension and oral reprimand. The oral reprimand will assist the Member in how her actions are perceived by both the profession and the public.
The proposed penalty provides for remediation and rehabilitation through terms, conditions, and limitations on the Member’s certificate of registration. The Member is required to complete a health assessment course and attend two meetings with a nursing expert. This will assist the Member in understanding her misconduct and how this relates to her practice. This will help to ensure that this conduct is not repeated.
Overall, the public is protected because this process will assist the Member in gaining additional insight and knowledge into her practice. This will inform her practice in the future. The public is also protected through the employer notification requirements. The Member is required to notify her employers of the Panel’s decision. The Member is also required to only practice with an employer which agrees to perform spot audits of the Member’s practice. Overall, this penalty sends a message to the public about the profession’s ability to self-regulate and to ensure this conduct is not repeated.
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. Hoare (Discipline Committee, 2018). This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member failed to appropriately triage a patient in the emergency department over the concerns of paramedics and EMS. This led to a delay in the patient seeing the physician and the patient subsequently dying in the emergency department. In this case, the penalty ordered was an oral reprimand, a three-month suspension, 2 regulatory expert meetings, and 18 months of employer notification.
CNO v. Nkwelle (Discipline Committee, 2018). This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member was employed at the Centre for Addiction and Mental Health. The member took over the 15-minute patient checks from a colleague during a break. The member failed to perform some of the patient checks and falsely documented that he had performed the patient checks and withdrew himself from care while he rested at the nursing station. The patient committed suicide during the time that the member was responsible for performing the 15-minute checks. In this case, the penalty ordered was an oral reprimand, a three-month suspension, 2 regulatory expert meetings, and 12 months of employer notification.
CNO v. Popo (Discipline Committee, 2020). This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member was assigned to care for a patient on the night shift. At around 0300, the member’s nursing colleague found the patient with decreased oxygen saturations and in response, completed a number of interventions over a 25-minute period. The member’s nursing colleague reported the interventions to the member. After receiving the report, the member did not personally assess the patient again over the night shift. The patient was found without vital signs at around 0710. The member did not make any attempts to resuscitate the patient or call a code blue. In this case, the penalty ordered was an oral reprimand, a three-month suspension, a minimum of two regulatory expert meetings, and 18 months of employer notification.
The Member’s Counsel advised the Panel that he agreed with College Counsel’s submissions, that the Member was deeply remorseful and accepted the Joint Submission on Order.
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 three 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 a minimum of two meetings with a Regulatory Expert (the “Expert”) at her own expense and within six months from the date that this Order becomes final. If the Expert determines that a greater number of session are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date of 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,
Documentation,
Professional Standards, and
Therapeutic Nurse-Client Relationship;
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 (where applicable);
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 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;
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) Within 12 months from the date that this Order becomes final, or a longer time period as approved by the Director, the Member shall successfully complete at her own expense, with a minimum passing grade of 65%, a nursing course with clinical or laboratory or other practical components that have received prior approval from the Director regarding: health assessment. The Member must provide the Director with proof of enrolment and successful completion of the courses with a minimum passing grade of 65%.
c) For a period of 18 months from the date the Member’s suspension ends, 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. Only practice nursing for an employer who agrees to, and does, forward a report to the Director within 14 days of the commencement or resumption of the Member’s employment in any nursing position, confirming:
that they received a copy of the required documents,
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
that they agree to perform three random spot audits of the Member’s documentation practice at the following intervals over a 12-month period and provide a report to the Director regarding the Member’s practice after each audit:
a. the first audit shall take place within four months from the date the Member begins or resumes employment with the employer,
b. the second audit shall take place within eight months from the date the Member begins or resumes employment with the employer, and
c. the third audit shall take place within 12 months from the date the Member begins or resumes employment with the employer;
iv. The audits shall, on each occasion, involve reviewing a random selection of at least five of the Member’s charts to ensure they meet both CNO and employer standards.
- 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 Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility and avoided the need for a contested hearing. 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. It sends a strong message to the Member and to the membership as a whole that conduct such as this will not be tolerated. Members will be reminded that they are accountable for ensuring their documentation of client care is accurate and complete. The public is protected by the fact that the Member has accepted responsibility for her actions and will be rehabilitated by the health assessment course and the meetings with a Regulatory Expert. The 18-month period of employer notification will ensure that when the Member returns to practice, she has appropriate supervision. 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 similar cases. The Panel concludes that the joint submission represents a fair and reasonable outcome based on the evidence presented.
I, Heather Stevanka, 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.