College of Nurses of Ontario v. Carey Lee Varga, 2020 ONCNO 116471 — College of Nurses of Ontario Discipline Committee | minicounsel

PANEL: Sherry Szucsko-Bedard, RN Chairperson Sylvia Douglas Public Member Max Hamlyn, RPN Member Terry Holland, RPN Member Lalitha Poonasamy Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ALYSHA SHORE for College of Nurses of Ontario

and -

CAREY LEE VARGA Registration No. 9041245 JANE LETTON for Carey Lee Varga

PATRICIA HARPER Independent Legal Counsel

Heard: August 6, 2020

AMENDED 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 August 6, 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 the public disclosure of the identities of the patients in the Discipline hearing of Carey Lee Varga (the "Member") or any information that could disclose the patients' identities, including a ban on the publication or broadcasting of this information. The Member's Counsel had no objection to the order being made.

The Panel considered the submissions of the Parties and decided that there be an order preventing the public disclosure of the identities of the patients in the Discipline hearing of Carey Lee Varga or any information that could disclose the patients' identities, including a ban on the publication or broadcasting of this information.

The Allegations

The allegations against the Member as stated in the Notice of Hearing dated June 15, 2020 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 at Providence Care in Kingston, 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 on or around November 12, 2016 when providing care to [the Patient], you:

a) did not comply with the patient's care plan and/or the direction of the charge nurse and consensus of the clinical team to provide the patient with space and an opportunity to de-escalate;

b) entered the dining room contrary to the patient's care plan and/or the direction of the charge nurse and consensus of the clinical team, which contributed to an escalation in the patient's behaviour; and/or

c) fed the patient while he was flat on his back in a four-point restraint placing the patient at risk of choking; and/or

You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Act, 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 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 on or around November 12, 2016 when providing care to [the Patient], you:

a) did not comply with the patient's care plan and/or the direction of the charge nurse and consensus of the clinical team to provide the patient with space and an opportunity to de-escalate;

c) fed the patient while he was flat on his back in a four-point restraint placing the patient at risk of choking.

Member's Plea

The Member admitted the allegations set out in paragraphs #1 and #2 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

Carey Lee Varga (the "Member") obtained a baccalaureate degree in nursing from Queen's University in 1989.
The Member registered with the College of Nurses of Ontario ("CNO") as a Registered Nurse ("RN") on June 6, 1990.
The Member worked at Providence Care Hospital (the "Facility") as a float nurse from May 17, 1999 to November 30, 2016, when her employment was terminated for the incidents described below.

PRIOR HISTORY

In November 1999, the Discipline Committee found that the Member engaged in disgraceful, dishonourable or unprofessional conduct when she cheated during a job competition examination with the Correctional Services of Canada.
The Member was required to appear before the Discipline Committee panel for an oral reprimand and received a three-month suspension that would be suspended if she received counselling for stress management and other issues determined by a CNO-approved counsellor and met with a Practice Consultant. The Member completed the counselling requirements and thus did not serve a suspension.

THE FACILITY

The Facility is located Kingston, Ontario.
The Member was a casual staff nurse and was assigned to the Adult Mental Health Unit (the "Unit") as a float nurse between May 1999 and November 2016.
During the relevant period, there were 20 patients on the Unit at a time. There were typically six staff members, comprised of two RNs (one acting as a charge nurse) and four Development Service Workers ("DSW").
Each patient in the Unit has a detailed, individual care plan outlining the patient's diagnosis, behaviours, daily schedule and best practices to managing negative behaviours.
All staff who interact with patients are expected by the Facility to follow the patients' care plans.

THE PATIENT

The Patient had a psychiatric disorder, severe intellectual delay and Impulse Control Disorder.
According to the Patient's care plan, he required a consistent and regular daily routine to help manage his aggressive outbursts and negative behaviours. His care plan also made clear that if there were concerns with his behaviour, he should be monitored from a distance.
In particular, the Patient's care plan dictated that, when he became agitated, all other patients should be removed from the area and the door should be closed to reduce environmental stimulation.
Staff were to monitor the Patient from outside the door when he presented as agitated or demonstrated negative behaviours. If his behaviour escalated to physical aggression (hand biting, head banging, tearing clothing, etc.), the Patient would require four-point restraint to avoid self-harm.
According to Facility staff, the Patient would often settle down when left alone and not in the presence of staff members. Conversely, when staff were in his face or easily within his line of sight, he would become further agitated.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Failure to Comply with Patient's Care Plan and Follow Direction of the Charge Nurse

On November 12, 2016, while in the dining room, the Patient took a birthday card away from another patient. Staff members retrieved the card and returned it. A few minutes later, the Patient left the dining room in an agitated state and went to the conference room.
A DSW was assigned to the Patient's care that day. The DSW left the Patient for approximately five minutes to obtain PRN medication for agitation. While the DSW was out of the room, the Patient ripped apart a pillow with his teeth and was redirected to the dining room.
The Charge Nurse went to the nursing station and called a security guard and the Member was asked to attend by a DSW.
The Patient accepted the PRN medication from the DSW. All staff and security left the dining room and partially closed the door behind them.
The Charge Nurse consulted another RN who was very familiar with the Patient. The RN's assessment was that the Patient should be left alone as he feeds off an audience. The Charge Nurse agreed with this assessment and all staff complied, except the Member.
The Member stayed at the door, in sight of the Patient and continued to look at him. The Charge Nurse and another staff member asked the Member to step away from the door. They explained to the Member again that the Patient was more likely to de-escalate on his own if she was not visible to the Patient.
The Member backed away for a few seconds, but then went back to her prior position where she continued to be visible to the Patient.
The Member then unilaterally entered the room with a security guard. She directed the Patient to sit on his chair and stop shredding items. The Member was speaking in a non-therapeutic, demanding and firm tone. If the Member were to testify she would state that she was using a re-directive approach to avoid four-point restraints. However, she admits that this was not the approach directed by the Charge Nurse.
Following this interaction, the Patient sat on the floor, urinated and started to bite his hand - all signs of escalation for the Patient.
Staff members provided the Patient with clean clothes. Staff cleaned up the urine on the floor and tried to direct him back to his chair. He refused, spat at an RN and continued biting his hand.
While the Patient was cooperative with changing his clothes, he continued to refuse to sit in the chair. A decision was made to place the Patient in a restraint bed. If the Member were to testify she would state she did not want to place the Patient in a restraint.
If the Member were to testify, she would state that she entered the room to de-escalate the Patient. However, the Member admits that she stayed within the Patient's line of sight and entered the Patient's room contrary to the Patient's care plan and the direction from the Charge Nurse, and that, contrary to her intentions, doing so further escalated the Patient's behaviour.

Inappropriate Feeding while Patient was in a Four-Point Restraint Bed

The Member later went into the Patient's room to feed him while he was still in the four-point restraint bed.
According to the Patient's care plan, he could only eat minced turkey/poultry/pork/liver. He had a risk of choking and required supervision when eating high choking risk foods. The Patient also tended to pocket foods in his mouth.
When a patient is in four-point restraints, the Facility expects the patient's head and neck to be propped up when feeding to avoid choking.
The Member fed the Patient food while the Patient was lying on his back in four-point restraints. One of the DSW's ordered a seclusion lunch that was to be selected in accordance with the Patient's preferences. One of the DSWs was concerned that the Patient might choke and warned the Member that the Patient often pockets his food. The Member continued to feed the Patient.
The DSW voiced her concerns to the Charge Nurse.
The Charge Nurse entered the Patient's room and told the Member not to feed the Patient in that position. The Member disregarded the Charge Nurse's direction and continued feeding him. The Charge Nurse took over feeding the Patient.
If the Member were to testify she would state that she assumed the meal provided was an appropriate meal for Patient. But upon reflection, admits that she was ultimately responsible for ensuring the food she fed the Patient was consistent with his care plan. After determining it was not safe to remove one of the Patient's wrist restraints, she assisted feeding him as he indicated he was hungry, in the hopes of de-escalating him. She believed that the Patient's head and shoulders were sufficiently raised. However, upon reflection, the Member admits that she failed to follow the Facility's safe-feeding protocol by continuing to feed the Patient food while he was lying on his back in four-point restraints.

CNO STANDARDS AND PRACTICE GUIDELINES

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 provides that each nurse is accountable to the public and responsible for ensuring that her practice and conduct meets legislative requirements and the standard of the profession.
A nurse demonstrates this standard by actions such as:

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

b. assessing/describing the patient situation using a theory, framework or evidence-based tool and identifying/recognizing abnormal or unexpected client responses and acting appropriately;

c. advocating on behalf of patients;

d. seeking assistance appropriately and in a timely manner;

e. taking action in situations in which patient safety and well-being are compromised; and

f. ensuring practice is consistent with CNO's standards of practice and guidelines as well as legislation.

Therapeutic Nurse-Client Relationship Standard

CNO's Therapeutic Nurse-Client Relationship Standard ("TNCR Standard") provides guidance to nurses on establishing and maintaining appropriate relationships with patients. The TNCR Standards notes that the therapeutic relationship with patients is at the core of the practice of nursing.
The TNCR Standard places the responsibility for establishing and maintaining the therapeutic nurse-patient relationship on the nurse. Therapeutic nursing services "contribute to the [patient's] health and well-being" and the relationship is based on "trust, respect, empathy and professional intimacy, and requires the appropriate use of power inherent in the care provider's role."
The TNCR Standard specifies that nurses meet the standard for patient-centred care by working with the patient to ensure that all professional behaviours and actions meet the therapeutic needs of the patient. A nurse meets the standard by:

a. actively including the patient as a partner in care because the patient is the expert on his/her life;

b. gaining an understanding of the patient's abilities, limitations and needs related to his/her health condition and the patient's needs for nursing care or services;

c. recognizing that the patient's well-being is affected by the nurse's ability to effectively establish and maintain a therapeutic relationship; and

d. engaging the patient in evaluating the nursing care and services that the patient is receiving.

The Member admits that her failure to follow the Patient's care plan, the Charge Nurse's direction and the consensus of the clinical team by failing to provide the Patient with space and an opportunity to de-escalate, entering the dining room and feeding the Patient while flat on his back in four-point restraints was a breach of the Professional Standards and the TNCR Standard.

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 11-34 above, when she:

a. did not comply with the Patient's care plan, and the direction of the Charge Nurse, and consensus of the clinical team to provide the Patient with space and an opportunity to de-escalate;

b. entered the dining room contrary to the Patient's care plan, and the direction of the Charge Nurse, and consensus of the clinical team, which contributed to an escalation in the Patient's behaviour; and

c. fed the Patient while he was flat on his back in a four-point restraint, placing the patient at risk of choking.

The Member admits that she committed the act of professional misconduct as alleged in paragraph 2 of the Notice of Hearing, and in particular, that her conduct was disgraceful, dishonourable and unprofessional.

Counsel Submissions

College Counsel provided four cases that support the findings of professional misconduct.

CNO v. Gillette (Discipline Committee, 2015). This case dealt with a member in a mental health care setting, which involved patients that were particularly vulnerable and required practice care plans to manage their behaviours. The Gillette case deals with facts that are more extreme, and involved findings of physical and verbal abuse, which are not an issue in the current case. The member failed to comply with the care plan, which is a breach of the College's Professional Standards and the Therapeutic Nurse-Client Relationship Standard (the "TNCR Standard"). The panel in the Gillette case found that the member's actions constituted professional misconduct and would be considered by members to be disgraceful, dishonourable and unprofessional.

CNO v. Andrews (Discipline Committee, 2009). This case involved a number of allegations including physical abuse, which is not present in the current case, but also the failure to follow the established plan of care for the client when the client became agitated. Failure to follow the care plan was deemed professional misconduct in the Andrews case and the Panel was asked to make the same finding in the current case.

CNO v. Flynn (Discipline Committee, 2017). Essentially the member in this case withdrew life support from a patient without having medical authority and informed consent. Although very different from the current case, the commonality in the two cases is that both the Member and Flynn disregarded the patient care plan and took matters into their own hands, rather than addressing their disagreement with the care team. In both cases the members may have been well-intentioned, but acted in contrast to the care plan and against team members' advice, constituting professional misconduct.

CNO v. Rowe (Discipline Committee, 2017). College Counsel submitted that in allegation #1(c), the Member failed to follow facility protocols for feeding a patient in four-point restraints and acted in contrast to the advice of the care team. College Counsel submitted the Rowe case for consideration in this regard, noting the member in that case was found to have committed professional misconduct. The Rowe case involved feeding a patient whereby the member left a patient to eat independently when it was not safe to do so. The patient was at high risk of choking, such as in this case. The member was found to have breached the College standards and the panel made findings of professional misconduct. The Member in the current case did not follow the care plan and acted in contrast to the facility protocol and against concerns from her colleagues. The Rowe case included abuse, which is not the case today.

College Counsel asserted that, regarding allegation #2, the Member admitted her conduct was disgraceful, dishonourable and unprofessional. Unprofessional behaviour includes a member's serious disregard for their professional obligations. In this case the Member's actions resulted in escalating the patient on more than one occasion that day. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional, constituting dishonourable conduct. Disgraceful conduct, as is the case today, brings shame on the Member, and by extension, to the profession at large.

The Member's Counsel stressed that there are no allegations of abuse in this case, rather, professional misconduct in not meeting the College's standards. The Member's Counsel further stated that the Member recognizes the vulnerability of patients in a mental health care setting and acknowledges that the care plan was not followed appropriately.

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

Reasons for Decision

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

Allegations #1(a) and (b) in the Notice of Hearing are supported by paragraphs 11-27 and 35-42 in the Agreed Statement of Facts. The Member admitted to breaching the Professional Standards and the TNCR Standard when she did not comply with the Patient's care plan and went against the advice of her professional colleagues, causing the Patient's behaviour to escalate to self-harm, as well as putting the Patient at risk of choking while feeding him while flat on his back in four-point restraints. The Professional Standards provide that each nurse demonstrates the standard including when they provide and facilitate the best possible care for patients, advocate on behalf of patients, seek assistance when necessary and take actions in situations when patient safety and well-being are compromised. The TNCR Standard places the responsibility for establishing and maintaining the therapeutic relationship on the nurse, and that relationship is based on "trust, respect, empathy... and requires the appropriate use of power inherent in the care provider's role". The Member ought to have known that it was her responsibility to be empathetic to the Patient and to recognize that the Patient's well-being was affected by the Member's ability to effectively engage and maintain a therapeutic relationship. Furthermore, failing to provide space and an opportunity to de-escalate was a breach of both College Standards.

Allegation #1(c) in the Notice of Hearing is supported by paragraphs 28-42 in the Agreed Statement of Facts. Feeding the Patient on his back in four-point restraints, was a breach of both the Professional Standards and the TNCR Standard. The Member disregarded the Charge Nurse's direction and continued to feed the Patient in this manner, until the Charge Nurse took over the task. The Member admitted that she failed to follow the Facility's safe-feeding protocol.

Allegations #2(a), (b) and (c) in the Notice of Hearing are supported by paragraphs 11-43 in the Agreed Statement of Facts. The Panel finds that the Member's conduct in causing the Patient's behaviours to escalate 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 moral failing. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional.

Finally, the Panel finds that the Member's conduct was disgraceful as it shames the Member and by extension the profession. By escalating the Patient's behaviours and ultimately leading to his self-harm, the Member has cast serious doubt on the Member's 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 4 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 2 meetings with a Regulatory Expert (the "Expert") at her own expense and within 6 months from the date of 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 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):

Professional Standards,
Code of Conduct,
Therapeutic Nurse-Client Relationship, and
Conflict Prevention and Management;

iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, and online participation forms;

v. The subject of the sessions with the Expert will include:

the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member's 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) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify her employers of the decision. To comply, the Member is required to:

i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;

ii. Provide her employer(s) with a copy of:

the Panel's Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel's Decision and Reasons, once available;

iii. Ensure that within 14 days of the commencement or resumption of the Member's employment in any nursing position, the employer(s) forward(s) a report to the Director, in which it will confirm:

that they received a copy of the required documents, and
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession.
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.

College Counsel submitted that the over-riding concern of the College is public protection, and in meeting that concern, there are three objectives:

To meet specific deterrence, the penalty must be serious enough to have the effect of deterring the Member from engaging in similar conduct in the future. The suspension, oral reprimand and meetings with a nursing expert contribute to specific deterrence.
General deterrence is met through the significant suspension, and the terms, conditions and limitations placed upon the Member's certificate. This penalty will have the effect of discouraging the general nursing population from engaging in this type of conduct.
The proposed penalty provides for remediation and rehabilitation through the meetings with a nursing expert which will allow the Member to gain insight, reflect on the incidents, and take the opportunity to learn from the incident and improve her practice going forward.

Overall, the public is protected through the goals of penalty, including specific and general deterrence, remediation and rehabilitation.

The Joint Submission on Order reflects the aggravating and mitigating circumstances that are present here today.

The aggravating factors in this case were:

The offenses were very serious;
Harm was caused to the Patient when his behaviours became escalated;
The Member's actions were contrary to the Patient's care plan and against advice of the Member's colleagues;
The events brought discredit to the profession;
The Member demonstrated disregard for her professional obligations.

The mitigating factors in this case were:

The incidents were isolated to one day in the Member's nursing career;
The Member has been a member of the College for a significant period of time;
There was one other minor discipline issue prior to these events;
The Member was accountable and has taken responsibility for her actions;
The Member has engaged with the College by entering into an Agreed Statement of Facts and a Joint Submission on Order.

College Counsel referred to the cases referenced during earlier submission to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee. College Counsel reiterated that the cases are not identical and contain more serious misconduct.

CNO v. Flynn (Discipline Committee, 2017)

This was a case where the member took matters into her own hands, contrary to protocols. The stakes and implications in this case were far more severe. The member received a 5 month suspension and terms, conditions, and limitations, similar to the penalty being sought in the Joint Submission on Order.

CNO v. Rowe (Discipline Committee, 2017)

This case involved a similar patient population of vulnerable patients with like behaviours and specific care plans. The patient had a risk of choking and was left alone at meal time. There were other allegations of abuse that are not part of the issues in this case. Rowe received a 6 month suspension and similar terms, conditions and limitations on her certificate to practice as were sought in this case. In Rowe, the conduct was more serious and warranted a longer suspension.

CNO v. Andrews (Discipline Committee, 2009)

In this case, the member failed to comply with care plans for patients when dealing with agitated behaviours. The care setting was analogous with a similar patient population in a mental health facility. There were additional issues in the Andrews case that included failure to assess and document injuries. The member was given a 7 month suspension which takes into account an appropriate distinction based on the seriousness of the allegations.

College Counsel concluded that there has been an agreement between Counsel, the penalty achieves all of the objectives, and is consistent with prior decisions of the Discipline Committee.

The Member's Counsel indicated that she agreed with those submissions of College Counsel and asked that the Joint Submission on Order be accepted.

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 4 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:

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;

Professional Standards,
Code of Conduct,
Therapeutic Nurse-Client Relationship, and
Conflict Prevention and Management;

iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, and online participation forms;

v. The subject of the sessions with the Expert will include:

the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member's 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;

b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify her employers of the decision. To comply, the Member is required to:

i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;

ii. Provide her employer(s) with a copy of:

the Panel's Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel's Decision and Reasons, once available;

iii. Ensure that within 14 days of the commencement or resumption of the Member's employment in any nursing position, the employer(s) forward(s) a report to the Director, in which it will confirm:

that they received a copy of the required documents, and
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession.
All documents delivered by the Member to the CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.

Reasons for Penalty Decision

The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The Panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly.

The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility. The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection. Specific deterrence is met through the Member's oral reprimand and suspension, as well as employer notification. General deterrence is met through the suspension and terms, conditions and limitations on the Member's certificate. The message that is sent to the membership is that this type of conduct will never be tolerated and there are serious consequences as a result. Rehabilitation and remediation are established through the Member's meetings with the nursing expert, as well as the terms, conditions and limitations placed upon the Member's certificate of registration. Public protection is met through all of these aspects of the penalty enabling the Member to learn from the experience and improve in her future practice, and through the substantial 12 month employer notification.

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

I, Sherry Szucsko-Bedard, 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.