DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Terry Holland, RPN Chairperson Sylvia Douglas Public Member Carly Gilchrist, RPN Member Tania Perlin, Public Member Heather Riddell, RN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) ALYSHA SHORE for ) College of Nurses of Ontario
- and - )
KELLY BEERSCHOTEN ) SHEILA RIDDELL for ) Kelly Beerschoten Registration No.: 9423534 )
) CHRISTOPHER WIRTH ) Independent Legal Counsel
) Heard: February 14, 2020
DECISION AND REASONS
This matter came on for hearing before a panel of the Discipline Committee (the “Panel”) on February 14, 2020 at the College of Nurses of Ontario (the “College”) at Toronto. Kelly Beerschoten (the “Member”) was present and represented.
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, including a ban on the publication or broadcasting of the identity of the patient in the Discipline hearing of Kelly Beerschoten or any information that could disclose the patient’s identity, including any reference to the patient’s name contained in the allegations in the Notice of Hearing and in any exhibits filed with the Panel.
The Panel considered the submissions of the Parties and decided that there be an order preventing the public disclosure, including a ban on the publication or broadcasting of the identity of the patient in the Discipline hearing of Kelly Beerschoten or any information that could disclose the patient’s identity, including any reference to the patient’s name contained in the allegations in the Notice of Hearing and in any exhibits filed with the Panel.
The Allegations
The allegations against Kelly Beerschoten (the “Member”) as stated in the Notice of Hearing dated February 13, 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 during your employment as a Registered Nurse for St. Joseph’s HealthCare London – Parkwood Site in London, Ontario (the “Facility”), you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession in that, when acting as Unit Leader on October 29, 2017:
a. you failed to assign the responsibility to complete hourly rounds to yourself and/or your colleagues;
b. you failed to ensure that you and/or your colleagues completed hourly rounds and/or failed to confirm that hourly rounds had been completed;
c. between 0845 and 1230, you failed to complete close observation monitoring of your patient, [the Patient], at fifteen-minute intervals as required by a physician’s order, and/or delegate this task to a colleague; and/or
d. between 0845 and 1000, you documented that you had completed close observation monitoring of your patient, [the Patient], at fifteen-minute intervals as required by a physician’s order, which you had not completed; 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 Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(14) of Ontario Regulation 799/93, in that during your employment as a Registered Nurse for the Facility, you falsified a record relating to your practice in that, when acting as Unit Leader on October 29, 2017:
a. between 0845 and 1000, you documented that you had completed close observation monitoring of your patient, [the Patient], at fifteen-minute intervals as required by a physician’s order, which you had not completed; 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 Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(15) of Ontario Regulation 799/93, in that during your employment as a Registered Nurse for the Facility, you signed or issued, in your professional capacity, a document that you knew or ought to have known contained a false or misleading statement in that, when acting as Unit Leader on October 29, 2017:
a. between 0845 and 1000, you documented that you had completed close observation monitoring of your patient, [the Patient], at fifteen-minute intervals as required by a physician’s order, which you had not completed; 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 Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that during your employment as a Registered Nurse for 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, when as acting as Unit Leader on October 29, 2017:
a. you failed to assign the responsibility to complete hourly rounds to yourself and/or your colleagues;
b. you failed to ensure that you and/or your colleagues completed hourly rounds and/or failed to confirm that hourly rounds had been completed;
c. between 0845 and 1230, you failed to complete close observation monitoring of your patient, [the Patient], at fifteen-minute intervals as required by a physician’s order, and/or delegate this task to a colleague; and/or
d. between 0845 and 1000, you documented that you had completed close observation monitoring of your patient, [the Patient], at fifteen-minute intervals as required by a physician’s order, which you had not completed.
Member’s Plea
The Member admitted the allegations set out in paragraphs 1(a), (b), (c) and (d), 2(a), 3(a) and 4(a), (b), (c) and (d) 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
Kelly Beerschoten (the “Member”) obtained a diploma in nursing from Sault College in Sault Ste. Marie, Ontario in 1994.
The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on August 26, 1994.
The Member was employed at St. Joseph’s Health Care London (and its predecessor St. Thomas Psychiatric Hospital) (the “Facility”) from June 16, 1995 to December 4, 2017. The Facility terminated the Member’s employment following the incidents described below.
If the Member were to testify, she would state that, in her 24 years as an RN up to the date of this incident, she had never been the subject of a complaint or report to CNO.
THE FACILITY AND UNIT
The Facility is a hospital located in London, Ontario.
At the time of the incidents in question, the Member worked as a full-time staff nurse on the G4 Mood Disorder Unit (the “Unit”).
The Unit is a 24-bed, adult psychiatric unit, providing care to patients with anxiety, depression, borderline personality and schizo-affective disorders. Many of the patients suffer from concurrent disorders (i.e. mental health/substance use disorders). Each patient has their own bedroom and bathroom.
During a weekday day shift, the Unit is staffed by two RNs, three Registered Practical Nurses (“RPNs”), and a third RN who acts as the Unit Lead without any patient assignment. On the weekend day shift, there are three RPNs and two RNs on the Unit, and one of the RNs is assigned the role of Unit Lead, with patient assignments.
The Unit Lead’s duties include staff assignments, overseeing the Unit, assigning hourly checks of all patients (“rounds”), and bringing issues to the attention of the duty doctor, among other things.
The Unit Lead is responsible for ensuring that all staff complete rounds for all patients. Staff complete rounds by visually accounting for all patients on the Unit.
The completion of rounds is recorded on the Unit’s hourly round sheet with checkmarks beside each patient name at the appropriate time and a signature by the staff member who completed the rounds.
Patients may also be ordered to receive increased observation as follows:
a. “constant observation” requires a nurse to remain within arms’ length and have eyes on the patient at all times;
b. “close observation” requires a nurse to lay eyes on the patient at regular intervals, normally every 15 minutes or designated multiples of 15 minutes.
- If the Member were to testify, she would say that, while nurses were assigned responsibility for specific patients, the usual practice on the Unit was to take a team nursing approach, with nurses stepping in to care for each other's patients where needed.
THE PATIENT
The Patient had a history of depression and suicide attempts.
She was admitted to the Unit on October 16, 2017 with an assessed moderate risk of suicide. She was placed on constant observation.
The Member provided care to the Patient on October 19 and 21, 2017. On both of those dates, the Member provided constant observation of the patient and charted this observation appropriately.
On October 25, 2017, the Patient was assessed by a psychiatrist and considered to be at a low risk of suicide. The psychiatrist documented that he had discussed the Patient’s progress with her psychologist, that she had a positive attitude towards her treatment and was thinking about her future. He discontinued constant observation and, in its place, ordered observation every 15 minutes (“Q15 checks”) while awake. He documented that a decision had been made to transition the Patient through a period of Q15 checks to Level 1. If the Member were to testify, she would state that her understanding was that Level 1 meant hourly checks.
The Member was assigned to care for the Patient on October 27 and 28, 2017. The Member’s notes from these shifts indicate that she “contracted” the Patient for safety, meaning she asked the Patient about her mood and thoughts of suicide and otherwise assessed her demeanour.
On October 27, 2017, the Member completed Q15 checks on the Patient from 0815 until 1900 hours, except when the Member was on break, at which time she delegated the checks to a colleague. All checks were completed and documented as required. The Member did not have any concerns for the Patient’s safety.
On October 28, 2017, the Member documented that the Patient had breakfast and medication, was visible in the day room and had contracted for safety. The Member continued with Q15 checks as required. At 1400, the Member noted that the Patient had eaten lunch, was able to settle on her bed and again contracted for safety. Again, the Member had no concerns regarding the Patient’s safety.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
The Member worked the day shift on Sunday, October 29, 2017 from 0700 to 1900 hours and was assigned as the Unit Lead. There was one other RN and three RPNs also working on the Unit during the shift.
The Member was assigned to care for the Patient for the third day in a row. She was also assigned four other patients on the Unit. The Patient remained on Q15 checks during the shift.
It was an unusually busy weekend day on the Unit. The general acuity of patients was quite high. Two other patients were in seclusion and another patient, Patient B, required an intervention in the morning.
The other RN who worked the October 29, 2017 shift with the Member later reported that she had seen the Patient that morning and the Patient “seemed to be in good spirits” and said she was not having any harmful thoughts. The RN reported that she did not see any signs of suicide, verbal or non-verbal. The same RN stated that the Member was having a difficult time that morning with another patient who would grab the Member every time she went into the nursing station. The other RN described the morning of October 29, 2017 as “overwhelming.”
That same RN, brought towels to the Patient so she could take a shower on the morning of October 29, without being asked by the Member. If the Member were to testify, she would say that this was an example of the team nursing approach on the Unit, of nurses assisting with each other's patients, when they could see the primary nurse was busy.
The Member spent a considerable amount of time in the morning assisting with Patient B, who was in crisis and who required an intervention. Patient B was not the Member’s patient but, as Charge Nurse, she accepted the added responsibility of actively assisting with this crisis situation, despite her already heavy patient load. During a period of approximately 30 minutes, there was a flurry of activity in Patient B’s room with no fewer than eleven staff involved. The Member was in Patient B’s room from 0918 until 0945 hours. According to the Member, she assigned an RPN to constant observation and called the duty doctor.
Unfortunately, Patient B’s condition worsened and a second intervention had to be called. The Member again assisted with this intervention at 1107.
The Member cannot recall if she asked a specific colleague to look in on the Patient while the Member was busy assisting with the crisis involving Patient B. The video surveillance shows that another RN entered the Patient’s room at 0947 hours to retrieve a chair. The Member was just a few steps away from the Patient’s room at that time.
If the Member were to testify, she would say that, during acutely busy times on the Unit, and especially during a crisis, the nursing staff routinely covered for each other and checked on each other’s patients. The Member assumed that staff were doing so for her, while she was engaged with Patient B.
An additional staff member was requested in the morning but did not arrive on the Unit until approximately 1140 hours.
At approximately 1145 hours, the additional staff member (“Staff A”) walked down the hallway where the Patient’s room was located. Video surveillance shows Staff A walking down the hallway turning her head side to side as she passed each room. However, Staff A did not note the completion of rounds on the Unit’s round sheet.
If the Member were to testify, she would say that after walking down the hallway, Staff A did not report to the Member that the Patient was not visible. Had the Member received such a report from Staff A, she would have taken immediate action to locate the Patient.
Approximately 30 minutes later, at 1215 hours, the Member requested that Staff A check on the Patient.
Staff A went into the Patient’s bedroom at 1217 hours. The Patient was not in her room and the bathroom door would not open. Staff A left and returned shortly thereafter with the Member and another staff. They discovered the Patient in the bathroom, unresponsive. The Member had activated a Code Blue, even before they forced open the door. She began CPR immediately and continued until paramedics arrived. The Patient was later pronounced dead, by suicide.
Hourly Rounds
Hourly rounds require setting eyes on each patient at the top of the hour.
As the Unit Lead, the Member was responsible for hourly rounds of all patients on the Unit, meaning she was responsible for either completing the rounds herself or assigning them to another staff person.
On October 29, 2017, the Member failed to complete the hourly rounds herself, assign the hourly rounds or ensure that all of these rounds were completed.
Other staff members completed some hourly rounds on their own initiative.
The Unit’s hourly round sheet for October 29, 2017 indicates that hourly rounds were completed for each patient at 0800, 0900 and 1000 hours.
The hourly round sheet has checkmarks beside the names of four patients at 1100 hours, but these entries are not signed by a staff member. The Patient is not one of these four patients.
Q15 Checks
Q15 checks require laying eyes on the patient every 15 minutes.
As the Patient’s assigned nurse on October 29, 2017, the Member was responsible for completing Q15 checks and documenting those checks on the Patient’s Special Observation Record. An assigned nurse may delegate Q15 checks. If another nurse completes the Q15 check, that nurse documents it on the patient’s record.
The Member documented in the Patient’s Special Observation Record that she completed Q15 checks on the Patient from 0800 to 1000.
However, the Member did not personally observe the Patient at each 15 minute interval as documented. If the Member were to testify, she would say that, at approximately 1000 hours, she was assured by another nurse that all patients were safe and had been checked. The Member believed, erroneously, that this assurance allowed her to document in this manner.
The Member only had one direct, conversational interaction with the Patient at approximately 0830 hours. During this interaction, the Member contracted the Patient for safety. If the Member were to testify, she would say that the Patient was in good spirits during this interaction, as she had been during the Member’s two prior shifts. The Member documented this observation in the Patient’s chart at 1000 hours, but video surveillance indicates it occurred at 0830 hours.
The Member walked down the Patient’s hallway at 0918 hours. The surveillance video shows the Member turned her head towards the Patient’s room at that time, but she cannot recall if she observed the Patient. The Member also walked down the Patient’s hallway at 0945 and 1107 hours, but cannot recall if she observed the Patient. If the Member were to testify, she would say that on previous shifts she had observed that the Patient spent most of her time on her bed and that the Patient’s bed was visible from the hallway.
Other staff members observed the Patient at various points in the morning, but none confirmed that they did so at the Member’s request or charted these interactions on the Patient’s Special Observation Record.
The Member failed to complete or delegate Q15 checks of the Patient from 0845 to 1230 hours.
If the Member were to testify, she would say that she was extremely busy on the morning of October 29, 2017, and was engaged for an extended time with Patient B. That situation, coupled with the fact that the Patient had seemed to pose a low risk every time the Member had assessed her in the previous few days, caused the Member to lose sight of the significance of her obligation to carry out, or delegate, the Q15 checks as ordered by the physician. The Member was not alert to the amount of time that passed between checks. She is intensely remorseful regarding this lapse and takes full responsibility for her failure to follow the physician’s order and to meet the standards of practice on that day.
CNO Standards
CNO’s Professional Standards provide that each nurse is accountable to the public and responsible for ensuring that their practice and conduct meets legislative requirements and the standards of the profession.
A nurse demonstrates this standard by:
providing, facilitating, advocating and promoting the best possible care for [patients];
seeking assistance appropriately and in a timely manner;
taking action in situations in which [patient] safety and well-being are compromised; and
taking appropriate action to maintain [patient] safety.
As well, each nurse is expected to continually improve the application of professional knowledge. A nurse demonstrates this standard by “using best-practice guidelines to address [patient] concerns and needs.”
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.”
ADMISSIONS OF PROFESSIONAL MISCONDUCT
Shortly after the incident with the Patient, the Member accepted responsibility for her conduct with her employer.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a), (b), (c) and (d) of the Notice of Hearing, as described in paragraphs 17 to 39 above, in that she:
a. failed to assign the responsibility to complete hourly rounds to herself or her colleagues;
b. failed to ensure that hourly rounds were completed by herself or her colleagues;
c. failed to complete or delegate the ordered Q15 checks of the Patient between 0845 and 1230, and
d. documented that she completed the Q15 checks of the Patient between 0845 and 1000 when she had not.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2 and 3 of the Notice of Hearing, as described in paragraphs 32 to 39 above, in that she falsely documented that she completed Q15 checks of the Patient from 0845 to 1000 hours when she had not in fact completed them.
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 17 to 39 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) and (d), 2(a) and 3(a) of the Notice of Hearing. As to Allegations #4(a), (b), (c) and (d), 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 the evidence supports findings of professional misconduct as alleged in the Notice of Hearing.
Allegation #1 in the Notice of Hearing is supported by paragraphs 21 to 48, 50-54 in the Agreed Statement of Facts. The Member admits to contravening a standard of practice. The Panel accepts her admission. The patient’s clinical observation had recently been decreased from constant observation to every 15 minute clinical monitoring while awake. Due to assisting with a crisis situation the Member failed to complete hourly rounds on her assigned patient, failed to assign responsibility to a colleague and failed to confirm that hourly rounds had been completed by a colleague. The Member admitted to documenting that she had completed the close monitoring of the Patient but had, in fact, not done so.
Allegation #2 in the Notice of Hearing is supported by paragraphs 32 to 45, and 57 in the Agreed Statement of Facts. The Member documented in the Patient’s Special Observation Record that she completed every 15 minute check on the Patient from 0800 to 1000. The Member did not personally observe the Patient at each 15 minute interval. At 1000hrs the Member was assured by another nurse that all patients were safe and had been checked. The Member believed, erroneously, that this assurance allowed her to document in this manner. The Member admits that she falsely documented that she completed Q15 checks of the Patient, when she had not in fact completed them. The Panel accepts the Member’s admission.
Allegation #3 in the Notice of Hearing is supported by paragraphs 32 to 45, 53 and 54 in the Agreed Statement of Facts. The Member acknowledges that she did not personally observe the Patient at each 15 minute interval and yet documented that all patients were safe and had been checked. The Member accepts and acknowledges that she ought to have known that her documentation contained false or misleading statements that included that she completed the clinical monitoring rounds when she had not.
With respect to Allegation #4, the Panel finds that the Member’s conduct would reasonably be regarded by members of the profession as dishonourable and unprofessional. In paragraph 58 in the Agreed Statement of Facts, the Member also admits that her conduct was dishonourable and unprofessional. The Member failed to assign the responsibility to complete hourly rounds, failed to complete close observation monitoring from 0845-1230hrs and falsified documentation that the same was completed. The conduct was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations. The Member’s conduct was dishonourable as it demonstrated an element of dishonesty and deceit through falsifying the clinical record. The Member knew or ought to have known that through the failure to complete clinical monitoring she was not maintaining the safety of patients. The Panel finds that her conduct was unacceptable and fell well below the standards of the profession.
Penalty
College Counsel and the Member advised the Panel that a Joint Submission on Order had been agreed upon. The Joint Submission on Order requests that this Panel make an order as follows:
Requiring the Member to appear before the Panel to be reprimanded within three months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for two 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, and
Documentation;
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; 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 and the Member’s Counsel.
College Counsel submitted that the Goals of Penalty are met through the Joint Submission on Order and that the following are mitigating factors:
The Member has a lengthy career in the nursing profession;
The Member has no discipline history with the College;
The Member has shown early acceptance of responsibility;
The Member demonstrated intense remorse for her actions and their consequences;
The Member took the initiative to seek guidance from a Nursing Expert and underwent two visits with the Nursing Expert at her own expense;
The acuity of the unit was very high on the day in question;
The Member has cooperated fully with the College;
A lengthy discipline hearing was not required;
College Counsel submitted that the following were aggravating factors:
The Member failed to complete hourly checks or fifteen minute checks on the Patient or others as per physician’s order;
The Member had documented that the safety checks were completed by herself personally;
The Member’s clinical documentation was a form of dishonesty and breach of trust;
The Member actions led to serious harm of the Patient and ultimately a devastating outcome.
The proposed penalty provides general deterrence through the two month suspension of the Member’s certificate and employer notification of the Decision for a period of 12 months. This sends a clear message to the membership that these actions fall below the standards of nursing practice and will not be tolerated.
The proposed penalty provides for specific deterrence through an oral reprimand, two month suspension, attendance and participation in Regulatory Expert meetings and completion of Reflective Questionnaires and employer notification of this decision for a period of 12 months.
The proposed penalty provides for remediation and rehabilitation through attendance and participation in Regulatory Expert meetings and completion of Reflective Questionnaires. The penalty proposed also allows the Member to self-reflect, and is designed to help the Member learn and get back to work.
Overall the public is protected by the 2 month suspension of the Member’s certificate and the terms, limitations and conditions on it, including the requirement for employer notification of this decision for 12 months.
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. Nkwelle (Discipline Committee, 2018). In this case the member failed to complete every fifteen minute close observation round and documented that he had completed the same and similar to the present case, a client was found to have committed suicide. This case was different in that this member did not attempt to initiate CPR. He was not busy when he failed to complete regular checks and he completed no remedial action before the hearing. The penalty in this case was an oral reprimand, a 3 month suspension, 2 meetings with a Nursing Expert and an employer notification of 12 months.
CNO v. Hoare (Discipline Committee, 2018). In this case the member failed to adequately triage a patient despite being urged to by paramedics. The client was found to be vital signs absent shortly after the end of his shift. This case is similar as it deals with breach of standards. The penalty in this case was an oral reprimand, a 3 month suspension, 2 meetings with a Nursing Expert and an employer notification of 18 months.
CNO v. Blum (Discipline Committee, 2019). In this case the member failed to monitor, assess, intervene and or seek assistance or appropriately document the care of a client. In particular, the member failed to observe a client who was locked in his room and engaging in self-harm and ringing his call bell. This member failed to de-escalate the client’s behavior, failed to assess the ongoing need for restraints and failed to document the client’s self-harm in his chart or complete an incident report. The member also acknowledged that she swatted or slapped the client’s hand. The member’s penalty was an oral reprimand, a 3 month suspension, 2 meetings with a Nursing Expert and an employer notification of 12 months.
The Member’s Counsel agreed that the Nkwelle case is “most on point” and similar to this Member’s case. However, counsel reinforced that this Member was trying to do her best on a very difficult day. The Member’s Counsel also pointed out that in the Nkwelle case, the member did not initiate CPR whereas this Member activated her alarm and initiated CPR. The other two cases were not similar on facts and dealt with two separate patients.
The Member’s Counsel submitted one case to the Panel to demonstrate that the proposed penalty fell within the range.
CNO v. Williams (Discipline Committee, 2014). In this case the member did not initiate constant observation despite having a physician order to do so. The member stated that he disagreed with the order for constant observation. The client was found vital signs absent, no CPR was initiated nor was a Code Blue called. The member’s penalty was an oral reprimand, a 2 month suspension, 3 meetings with a Nursing Expert and employer notification for 24 months.
The Member’s Counsel indicated the following were mitigating factors:
The Member had 25 years experience working in psychiatry;
The Member had an unblemished record with the College;
The Member has glowing references and skills;
This one incident does not define the Member’s career;
The Member was engaged with another client that was in serious distress;
The Member took responsibility for her actions, has been open and honest;
The Member has been cooperative with her employer and the College;
The Member expressed great remorse;
The Member has completed active steps to improve her practice through modules, questionnaire, arranging meetings with the Nursing Expert and completion of the homework analysing and gaining insight to improve her practice.
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 two 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, and
Documentation;
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; 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.
Members of the profession will be reminded that failure to follow hospital policies and College Standards can lead to serious, tragic and irreversible consequences and that such conduct will result in severe sanctions being imposed by panels of the Discipline Committee.
The Panel took into account the Member’s cooperation with the College and the Member taking responsibility by proactively meeting with a Nursing Expert in advance and beginning remediation activities.
The Panel considered both the mitigating and aggravating factors in this case and finds the proposed penalty strikes an acceptable balance taking into account all circumstances. The penalty is in line with what has been ordered in previous cases.
I, Terry Holland, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel.