College of Nurses of Ontario v. Kristin Bridge, 2021 ONCNO 120354

PANEL: Dawn Cutler, RN Chairperson Sylvia Douglas Public Member Natalie Montgomery Public Member Martin Sabourin, RN Member Michael Schroder, NP Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) GLYNNIS HAWE for ) College of Nurses of Ontario

and - )

KRISTIN BRIDGE ) NO REPRESENTATION for Registration No. 12526028 ) Kristin Bridge

) PATRICIA HARPER ) Independent Legal Counsel

Heard: February 8, 2021

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 February 8, 2021, via videoconference.

The Allegations

The allegations against Kristin Bridge (the “Member”) as stated in the Notice of Hearing dated December 16, 2020, are as follows:

IT IS ALLEGED THAT:

You have committed an act of professional misconduct as provided by subsection 51(1)(b.0.1) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, in that you failed to cooperate with the Quality Assurance Committee or any assessor appointed by that committee, and in particular, you failed to participate after being selected by the Quality Assurance Committee for practice assessment in or around 2015 and/or 2018.
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional, in that you failed to participate after being selected by the Quality Assurance Committee for practice assessment in or around 2015 and/or 2018.

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 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

Kristin Bridge (the “Member”) obtained a baccalaureate degree in nursing from Brock University on April 25, 2012.
The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on November 7, 2012. She is currently entitled to practice nursing in Ontario without restrictions.
The Member has been employed as a full-time RN at the Hamilton Health Sciences – General Site since April 1, 2013, and at the Meadows Long-Term Care Centre in a casual RN capacity since October 1, 2012.

CNO’s Quality Assurance Program

CNO is required by the Health Professions Procedural Code to establish a quality assurance program. CNO’s Quality Assurance Committee (the “QAC”) is responsible for administering CNO’s Quality Assurance Program (the “QA Program”).
The QA Program helps nurses engage in activities that foster lifelong learning and helps nurses maintain and improve their professional competence. Participation in the QA Program is a professional requirement.
The QA Program includes three kinds of assessment: self, peer, and practice assessment.

The Incidents

The Member failed to cooperate with the QAC by not participating in the QA Program in 2015 and 2018.

The Member Failed to Participate in the 2015 QA Program

The CNO notified the Member by letter dated February 23, 2015 that she was randomly selected to participate in a 2015 Practice Assessment, as part of the QA Program. The letter stated that her participation was mandatory. The Member was given until March 29, 2015 to complete the Practice Assessment, which included the submission of a Learning Plan and the completion of online multiple-choice tests.
The Member did not respond to CNO’s letter and did not participate in the Practice Assessment.
In a letter dated April 16, 2015, the QAC provided the Member a second opportunity to complete the Practice Assessment. She was informed that the new deadline to complete the Practice Assessment was May 10, 2015.
The letter also advised the Member that if she did not complete the assigned activities by the extended deadline, it was within the QAC’s authority to report her to the Inquiries, Complaints and Reports Committee (the “ICRC”) for professional misconduct on account of having not participated in the QA Program.
The Member neither responded to CNO’s letter nor participated in the 2015 Practice Assessment by either of the deadlines.
In a letter dated May 22, 2015, the QAC notified the Member that she had been referred to the ICRC due to her lack of cooperation and participation in the 2015 QA Program. The Member was given 14 days to respond to the QAC’s decision. The Member did not respond.
None of the letters sent to the Member were returned to the CNO as undeliverable.
On July 27, 2016, a panel of the ICRC requested that an investigator be appointed to gather evidence as to whether the Member had committed an act of professional misconduct in relation to her failure to cooperate with the QAC and participate in the 2015 QA Program.
On May 11, 2017, CNO appointed [an Investigator] from the private investigation firm Benard+Associates to investigate whether the Member had committed professional misconduct.
On August 28, 2017, [the B+A Investigator] called the Member at work but was told by a receptionist that the Member was not in attendance. [The B+A Investigator] left a message with the receptionist for the Member to return her call. The Member never returned the message.
On September 25, 2017, [the B+A Investigator] called the Member at home and left a voicemail asking the Member to return her call. The Member never returned the voicemail.
On September 27, 2017, [the B+A Investigator] sent an e-mail to the Member. The Member did not reply.
On September 28, 2017, [the B+A Investigator] called the Member at work three times in a row. First, the receptionist transferred [the B+A Investigator] ’s call to the Member. Once transferred, [the B+A Investigator] spoke but there was no response on the other end and the call was ended.
[The B+A Investigator] tried calling the Member’s employer again moments later. She told the receptionist that the line did not connect or go through properly. The receptionist transferred [the B+A Investigator] to the Member again and affirmed that the Member was indeed working at the time. Once more, [the B+A Investigator] attempted to establish contact. The line was picked up but the call was then ended.
[The B+A Investigator] called the employer for a third time and spoke to the same receptionist. The receptionist indicated that she would walk the call over to the Member to ensure that the call was answered by the Member, which it was.
[The B+A Investigator] introduced herself and confirmed the Member’s identity. The Member stated that she had not received any correspondence from CNO and was not aware that she had been asked to complete a Practice Assessment in 2015.
The Member verified her telephone number, e-mail, and mailing address; however, the Member told [the B+A Investigator] that she was not certain of her post office box number. The Member stated that she would e-mail [the B+A Investigator] her post office box number because she could not remember it.
The Member also told [the B+A Investigator] that she had not received any of her e-mails. [The B+A Investigator] then sent a test e-mail to the same e-mail address while they were both on the telephone call. The Member affirmed that she received the test e-mail.
Shortly after [the B+A Investigator] concluded her call with the Member, the Member e-mailed [the B+A Investigator] explaining that she had extenuating circumstances that she did not wish to discuss in the presence of others in her workplace. The Member stated that she had not reliably received mail between 2015 and 2016 due to a family matter that led her to move out of the address that was on record with the CNO. She stated that she had not updated her address with the CNO because she had no other permanent address at the time.
[The B+A Investigator] responded to the Member’s e-mail moments later and thanked the Member for explaining herself further. [The B+A Investigator] also reiterated that she was expecting the Member to send her an email confirming her mailing address.
Minutes later, the Member responded: “Thank you, Speak with you soon.”
The Member never provided [the B+A Investigator] with an email confirming her mailing address or providing her post office box number.
The Member did not update her mailing address on file with the CNO until December 31, 2018, when she filed her annual membership renewal. The Member’s email and phone number on file with the CNO remained the same.

The Member Failed to Participate in the 2018 QA Program

In a letter dated September 4, 2018, the QAC directed the Member to complete the 2018 Practice Assessment. The letter stated that her participation was mandatory. The letter also informed the Member that if she did not complete the activities by the deadline, the QAC would review her lack of participation and could refer the matter to the ICRC or direct the Executive Director to impose terms, conditions or limitations upon her certificate of registration.
The Member was given until October 15, 2018 to complete the 2018 Practice Assessment, which included the submission of a Learning Plan and the completion of online multiple-choice tests.
The Member did not respond to CNO’s letter and did not participate in the Practice Assessment.
In a letter dated October 31, 2018, the QAC provided the Member another opportunity to complete the Practice Assessment. She was informed that the new deadline to complete the Practice Assessment was November 14, 2018.
The Member was also advised that if she did not complete the assigned activities by the new deadline, the QAC may refer her for a second time to the ICRC for professional misconduct on account of having not participated in the QA Program. The Member did not respond.
On November 6, 2018, a CNO Advanced Practice Consultant, [ ], left a voicemail for the Member asking her to call back so she could explain how to complete the 2018 Practice Assessment. The Member never returned [the CNO Advanced Practice Consultant]’s voicemail.
The Member neither responded to CNO’s outreach nor participated in the 2018 Practice Assessment.
In a letter dated November 29, 2018, the QAC notified the Member that she had been referred to the ICRC for a second time, this time due to her lack of cooperation and participation in the 2018 QA Program. The Member was given 14 days to provide written submissions in response to the QAC’s decision. The Member did not respond.
On July 31, 2019, CNO couriered the Member a disclosure package to the updated address provided by the Member on her 2019 annual renewal form.
On September 3, 2019, the package was returned, unclaimed, to CNO.
CNO Investigator [ ] left voicemails for the Member requesting callbacks, and sent e-mails to the Member requesting responses, on the following dates:

September 10, 2019 (voicemail);
September 25, 2019 (voicemail);
September 25, 2019 (e-mail); and
October 7, 2019 (e-mail).

The Member did not respond to any of [the CNO Investigator]’s outreach attempts.
On October 9, 2019, CNO re-sent the disclosure package to the Member by regular mail that had previously been returned to the CNO, unclaimed. The Member was invited to respond by October 30, 2019. The Member did not respond.
On February 11, 2020, CNO notified the Member by letter by regular mail that the investigation was being expanded to include the Member’s failure to participate in both the 2015 and 2018 Practice Assessments. The package included additional disclosure documents. The Member was invited to provide a response to CNO by March 16, 2020. The Member did not respond.
On February 23, 2020, the Member was personally served with the complete CNO disclosure package by process server.
On March 16, 2020, [the CNO Investigator] e-mailed the Member reminding her that she was sent confidential information by regular mail on February 11, 2020 and by personal service on February 23, 2020, and confirming that the Member had not provided a response to CNO, which was requested by March 16, 2020. The Member did not respond.
On April 23, 2020, [the CNO Investigator] left a voicemail for the Member. [the CNO Investigator] informed the Member that she was sending her further disclosure by e-mail as secure PDF files and that the Member needed to call her in order to be provided the password to open the documents. [the CNO Investigator] also advised the Member that her response to the further disclosure was due April 30, 2020. The Member did not call [the CNO Investigator] to obtain the password.
As per her voicemail on April 23, 2020, [the CNO Investigator] e-mailed the Member explaining that the ICRC met on March 25, 2020 to review the Member’s file. The ICRC asked that the matter be assessed for possible referral to the Discipline Committee. The Member was provided with the further disclosure relevant to the investigation by e-mail (secure PDF), including all necessary documents for her to make a fulsome response. She was given until April 30, 2020 to provide a response. The Member did not respond.
Finally, in a password-protected letter e-mailed to the Member dated May 27, 2020, CNO informed the Member that allegations of professional misconduct were being referred by the ICRC to the Discipline Committee.
If the Member were to testify, she would say that a series of personal circumstances, including housing instability, led to her failure to participate in both the 2015 and 2018 QA Program. Nevertheless, the Member acknowledges that, despite any circumstances impacting her personal life, she had a professional obligation to participate in the QA Program, and to respond to communications from CNO. If the Member were to further testify, she would state that she understands the importance of accountability to CNO as a member of a regulatory body, as well as her duty to participate in the statutorily mandated QA Program.

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, in that she failed to cooperate with the Quality Assurance Committee and, in particular, failed to participate in the 2015 and 2018 QA Program Practice Assessment, as described in paragraphs 7-50 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 2 of the Notice of Hearing and that her conduct was unprofessional, as described in paragraphs 7-50 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 and 2 of the Notice of Hearing. As to allegation #2, the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be unprofessional.

Reasons for Decision

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

Allegation #1 in the Notice of Hearing is supported by paragraphs 7-51 in the Agreed Statement of Facts. On February 23, 2015, the Member was advised by the College that she was randomly selected to participate in the 2015 Quality Assurance Program. Participation in the Quality Assurance Program is mandatory if a member is selected. The Member did not respond to the written correspondence. On April 16, 2015, the Member was afforded a second opportunity to complete the Quality Assurance Program. The Member did not respond to the letter or complete the Quality Assurance Program. An investigator, [the B+A Investigator], was appointed by a panel of the ICRC to investigate whether the Member had committed professional misconduct. [The B+A Investigator] made repeated attempts to reach the Member by phone and e-mail. [The B+A Investigator] was able to speak to the Member via phone on September 28, 2017, however, the Member did not forward her post office box number as promised.

In a letter dated September 4, 2018, the Quality Assurance Committee directed the Member to complete the 2018 Practice Assessment. The Member did not complete the Practice Assessment by the deadline. Over the course of the next six months, the College made many attempts to contact the Member by phone (voicemail), email, regular mail, couriered mail and process server. The Member failed to respond to any of this correspondence.

The Panel finds that despite the Member being afforded many opportunities to complete the Quality Assurance Program over a span of many years, the Member failed to complete the Quality Assurance Program.

With respect to allegation #2, the Panel finds that the Member’s conduct in not participating in the QA Program was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.

Penalty

College Counsel and the Member advised the Panel that a Joint Submission on Order had been agreed upon. The Joint Submission on Order requests that this Panel make an order as follows:

Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for 2 months. The 2-month suspension shall take effect from April 5, 2021 and shall continue to run without interruption as long as the Member remains in a 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 6 months from the date that this Order becomes final. To comply, the Member is required to ensure that:

i. The Expert has expertise in nursing regulation and has been approved by the Director of Professional Conduct (the “Director”) in advance of the meetings;

ii. At least 7 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, and
Code of Conduct;

iv. 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;

v. 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;

vi. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;

b) The Member shall participate in CNO’s next available Quality Assurance program cycle, within 24 months from the date this Order becomes final.

All documents delivered by the Member to CNO and the Expert 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 were that this situation creates serious doubt about the Member’s governability and how seriously she takes her professional accountabilities.

The mitigating factors in this case were that the Member has cooperated with the disciplinary process. The Member has accepted responsibility and has expressed remorse. The Member has agreed to a negotiated resolution and made a joint submission to the Panel. The Member has explained that she has experienced a number of personal difficulties which interfered with her ability to complete the QA Program. The proposed penalty provides for general and specific deterrence through the oral reprimand and two-month suspension which are made public to the College’s members.

The penalty sends a clear message to the membership that failing to comply with an order of a statutory committee of the College is serious. The two-month suspension will be viewed as a serious penalty to encourage general deterrence among the membership.

The oral reprimand and suspension will discourage the Member from repeating her conduct.

College Counsel submits that the College has seen a rise in QA Program cases in the past few years and thus, a two-month suspension is appropriate as there is a need for an increased level of general deterrence to the membership for this kind of misconduct.

The proposed penalty provides for remediation and rehabilitation through the proposed education requirement and participation in the next QA Program cycle.

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. Castor (Discipline Committee, 2017). The allegations in this case were similar as the Member failed to participate in the Quality Assurance Program on two occasions in 2014 and 2015. This case proceeded on an uncontested basis by way of an Agreed Statement of Facts and a Joint Submission on Order. The penalty for this case involved an oral reprimand and a one-month suspension. There are similar terms, conditions and limitations on the member’s certificate of registration including two meetings with a Nursing Expert and participation in the College’s 2017 Quality Assurance program.

College Counsel submitted that the College has seen a significant increase in these types of cases in the past few years, and so the College has recently sought higher penalties for failure to participate in the Quality Assurance Program to provide greater general deterrence for this type of conduct as a result.

CNO v. Keating (Discipline Committee, 2020). The allegations in this case were similar in that the member failed to participate in the practice assessment component for the 2017 year. This case proceeded on an uncontested basis by way of an Agreed Statement of Facts and a Joint Submission on Order. The penalty included an oral reprimand, a two-month suspension, two meetings with a Regulatory Expert, and the requirement for the member to participate in the next Quality Assurance program.

CNO v. Rubinas (Discipline Committee, 2020). The allegations in this case were similar in that the member failed to participate in the College’s Quality Assurance program and failed to respond to the College’s associated correspondence. This case proceeded on an uncontested basis by way of an Agreed Statement of Facts and a Joint Submission on Order. The penalty included an oral reprimand, a two-month suspension, two meetings with a Regulatory Expert and participation in the next Quality Assurance program cycle.

CNO v. Davis (Discipline Committee, 2020). The allegations in this case were similar in that the member failed to participate in the College’s Quality Assurance program and failed to respond to the College’s associated correspondence. This case proceeded on an uncontested basis by way of an Agreed Statement of Facts and a Joint Submission on Order. The penalty included an oral reprimand, a two-month suspension, two meetings with a Regulatory Expert and participation in the next Quality Assurance program cycle.

The Member was provided with the opportunity to make submissions on penalty and indicated that she agreed with the submissions of College Counsel.

Penalty Decision

The Panel accepts the Joint Submission on Order and accordingly orders:

The Member is required to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
The Executive Director is directed to suspend the Member’s certificate of registration for 2 months. The 2-month suspension shall take effect from April 5, 2021 and shall continue to run without interruption as long as the Member remains in a 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 7 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, and
Code of Conduct;

iv. 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;

v. 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) The Member shall participate in CNO’s next available Quality Assurance program cycle, within 24 months from the date this Order becomes final.

All documents delivered by the Member to CNO and the Expert 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 through the oral reprimand, suspension, meetings with the Regulatory Expert, and participation in the next Quality Assurance program cycle. The Panel finds it reasonable and in the public interest that the commencement of the two-month suspension be deferred until April 5, 2021 due to the ongoing demand for health human resources from the COVID-19 pandemic. The penalty is in line with what has been ordered in previous cases.

With this penalty, Members will be reminded that they are required to obey the requirements of the College’s statutory committees. Failing to cooperate with the Quality Assurance Committee will result in disciplinary consequences.

I, Dawn Cutler, 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.