DISCIPLINE COMMITTEE

OF THE COLLEGE OF NURSES OF ONTARIO

PANEL:

Tanya Dion, RN Chairperson

Andrea Arkell Public Member

Dawn Cutler, RN Member

Sylvia Douglas Public Member

Shaneika Grey, RPN Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) NICK COLEMAN for

) College of Nurses of Ontario

• and - )

CYNTHIA RAE L. GAULT ) NO REPRESENTATION for

Registration No. 0437277 ) Cynthia Rae L. Gault

) CHRISTOPHER WIRTH

) Independent Legal Counsel

) Heard: March 17, 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 March 17, 2021, via videoconference.

Publication Ban

College Counsel brought a motion pursuant to s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, for an order preventing public disclosure and banning the publication or broadcasting of the names of the patients, or any information that could disclose their identities, referred to orally or in any documents presented in the Discipline hearing of Cynthia Rae L. Gault.

The Panel considered the submissions of College Counsel and decided that there be an order preventing public disclosure and banning the publication or broadcasting of the names of the patients, or any information that could disclose their identities, referred to orally or in any documents presented in the Discipline hearing of Cynthia Rae L. Gault.

The Allegations

The allegations against Cynthia Rae L. Gault (the “Member”) as stated in the Notice of Hearing dated February 8, 2021 are as follows:

IT IS ALLEGED THAT:

1. 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 employed as a Registered Nurse, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to the following incidents:

(a) at Muskoka Shores Care Community in Gravenhurst, Ontario:

(i) on or about March 4, 2016, you failed to document accurately a verbal order from the Nurse Practitioner to increase for a limited period the O2 administered to [Patient A], a [patient] with COPD, but instead recorded the order to apply for multiple days;

(ii) on or about March 4, 2016, you failed to document the date and time the verbal order was received from the Nurse Practitioner for [Patient A], and/or that the status of the [patient] should be checked while the increased O2 was being administered;

(iii) on or about March 7, 2016, you delegated the controlled act of administering a blood glucometer skin test to [ ], a PSW, without ensuring that the PSW was capable of performing the controlled act and/or documenting that you had delegated the controlled act;

(iv) on or about March 7, 2016, you administered overdoses of Hydromorphone 2mg/ml to [Patient B], by miscalculating the dosages, and/or altered the health record to obscure the medication errors, at or about 0900 hours and/or 1244 hours;

(v) on or about March 7, 2016, you failed to change the dressing for [Patient C], despite documenting that you had;

(vi) on or about March 7, 2016, you administered to [Patient D], the Oxazepam intended for [Patient E], and were unable to recall to whom the medication had been dispensed, at or about 1630 hours;

(vii) on or about March 8, 2016, you directed [RPN A], to administer a Ventolin nebulizer to [Patient A], three hours after the prior dose had been administered, despite the physician’s order for the Ventolin nebulizer to be administered every four hours;

(viii) on or about October 9, 2016, you failed to do a proper assessment of [Patient F], after she suffered a fall; and/or

(b) at Coleman Care Centre in Barrie, Ontario:

(i) on or about May 2, 2018, you administered Hydromorphone 1mg instead of Diazepam 2.5mg to [Patient G], at or about 0700 hours; and/or

(ii) on or about May 7, 2018, you misplaced or misappropriated a tablet of Hydromorphone 2mg intended for [Patient H], at or about 0200 hours.

2. 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(2) of Ontario Regulation 799/93, in that, on or about March 7, 2016, while employed as a Registered Nurse at Muskoka Shores Care Community in Gravenhurst, Ontario, you delegated a controlled act as set out in subsection 27(2) of the Regulated Health Professions Act, 1991, in contravention of section 5 of the Nursing Act, 1991, with respect to delegating the controlled act of administering a blood glucometer skin test to [ ], a PSW, without ensuring that the PSW was capable of performing the controlled act and/or documenting that you had delegated the controlled act.

3. 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(3) of Ontario Regulation 799/93, in that, on or about March 7, 2016, while employed as a Registered Nurse at Muskoka Shores Care Community in Gravenhurst, Ontario, you directed a member, student or other healthcare team member to perform nursing functions for which he or she was not adequately trained or that he or she was not competent to perform, with respect to delegating the controlled act of administering a blood glucometer skin test to [ ], a PSW, without ensuring that the PSW was capable of performing the controlled act and/or documenting that you had delegated the controlled act.

4. 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(13) of Ontario Regulation 799/93, in that, while employed as a Registered Nurse at Muskoka Shores Care Community in Gravenhurst, Ontario, you failed to keep records as required with respect to the following incidents:

(a) on or about March 4, 2016, you failed to document accurately a verbal order from the Nurse Practitioner to increase for a limited period the O2 administered to [Patient A], a [patient] with COPD, but instead recorded the order to apply for multiple days;

(b) on or about March 4, 2016, you failed to document the date and time the verbal order was received from the Nurse Practitioner for [Patient A], and/or that the status of the [patient] should be checked while the increased O2 was being administered;

(c) on or about March 7, 2016, you delegated the controlled act of administering a blood glucometer skin test to [ ], a PSW, without ensuring that the PSW was capable of performing the controlled act or documenting that you had delegated the controlled act;

(d) on or about March 7, 2016, you administered overdoses of Hydromorphone 2mg/ml to [Patient B], by miscalculating the dosages, and/or altered the health record to obscure the medication errors, at or about 0900 hours and/or 1244 hours;

(e) on or about March 7, 2016, you failed to change the dressing for [Patient C], despite documenting that you had; and/or

(f) on or about March 7, 2016, you administered to [Patient D], the Oxazepam intended for [Patient E], and were unable to recall to whom the medication had been dispensed and, therefore, were not able to document the medication accurately, at or about 1630 hours.

5. 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, while employed as a Registered Nurse at Muskoka Shores Care Community in Gravenhurst, Ontario, you falsified a record relating to your practice with respect to the following incidents:

(a) on or about March 7, 2016, you administered overdoses of Hydromorphone 2mg/ml to the [Patient B], by miscalculating the dosages, and altered the health record to obscure the medication errors, at or about 0900 hours and/or 1244 hours; and/or

(b) on or about March 7, 2016, you failed to change the dressing for [Patient C], despite documenting that you had.

6. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that, while employed as a Registered Nurse, 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 with respect to the following incidents:

(a) at Muskoka Shores Care Community in Gravenhurst, Ontario:

(i) on or about March 4, 2016, you failed to document accurately a verbal order from the Nurse Practitioner to increase for a limited period the O2 administered to [Patient A], a [patient] with COPD, but instead recorded the order to apply for multiple days;

(ii) on or about March 4, 2016, you failed to document the date and time the verbal order was received from the Nurse Practitioner for [Patient A], and/or that the status of the [patient] should be checked while the increased O2 was being administered;

(iii) on or about March 7, 2016, you delegated the controlled act of administering a blood glucometer skin test to [ ], a PSW, without ensuring that the PSW was capable of performing the controlled act and/or documenting that you had delegated the controlled act;

(iv) on or about March 7, 2016, you administered overdoses of Hydromorphone 2mg/ml to [Patient B], by miscalculating the dosages, and/or altered the health record to obscure the medication errors, at or about 0900 hours and/or 1244 hours;

(v) on or about March 7, 2016, you failed to change the dressing for [Patient C], despite documenting that you had;

(vi) on or about March 7, 2016, you administered to [Patient D], the Oxazepam intended for [Patient E], and were unable to recall to whom the medication had been dispensed, at or about 1630 hours;

(vii) on or about March 8, 2016, you directed [RPN A], to administer a Ventolin nebulizer to [Patient A], three hours after the prior dose had been administered, despite the physician’s order for the Ventolin nebulizer to be administered every four hours;

(viii) on or about October 9, 2016, you failed to do a proper assessment of [Patient F], after she suffered a fall; and/or

(b) at Coleman Care Centre in Barrie, Ontario:

(i) on or about May 2, 2018, you administered Hydromorphone 1mg instead of Diazepam 2.5mg to [Patient G], at or about 0700 hours; and/or

(ii) on or about May 7, 2018, you misplaced or misappropriated a tablet of Hydromorphone 2mg intended for [Patient H], at or about 0200 hours.

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), 1(b)(i), (ii), 2, 3, 4(a), (b), (c), (d), (e), (f), 5(a), (b), 6(a)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), 6(b)(i) and (ii) 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 as amended reads, unedited, as follows:

THE MEMBER

1. Cynthia Rae L. Gault (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on January 18, 1995. She was suspended for non-payment of fees from April 10, 2007 until she resigned her RPN certificate on February 1, 2013.

2. The Member registered with CNO as a Registered Nurse (“RN”) on October 12, 2004.

3. The Member’s RN certificate was administratively suspended for non-payment of fees and failure to provide information from February 19, 2020 until March 8, 2020, and once again from February 17, 2021 until she resigned her RN certificate on March 15, 2021.

INCIDENTS RELATING TO MUSKOKA SHORES CARE COMMUNITY (FACILITY A)

BACKGROUND

4. Muskoka Shores Care Community (“Facility A”) is a long-term care home located in Gravenhurst, Ontario.

5. Facility A has three floors comprised of seven units and 206 beds. The first and second floor hold open units. The third floor is locked down for residents with dementia. Each floor consists of two units, North and South, with approximately 30 residents each. The seventh unit is a convalescent unit with approximately 20 residents.

6. Staffing at Facility A is comprised of the following:

a. Personal Support Workers (“PSW”): On days and evenings, there are six for each floor. On nights, there are two on the first and second floors and three on the third floor. PSWs provide general personal care, i.e. changing briefs, washing, bathing, dressing and assisting at mealtimes.

b. RPNs: One on each unit for days and evenings (seven in total). One on each floor for nights (four in total). RPN shifts are 0600-1400, 1400-2200 and 2200-0600. RPNs complete a variety of tasks including medication pass, dressing changes, vital checks, etc.

c. RNs: One RN as the Charge Nurse for the entire Facility for days, evenings and nights. RN shifts are 0700-1500, 1500-2300 and 2300-0700. RNs are responsible for assignments, scheduling, assisting RPNs with care decisions, particularly if a resident is de-stabilizing, and speaking with doctors or Nurse Practitioners when necessary to obtain orders.

7. In addition to the above, there is always a member of the management team (“Facility Managers”) on-call for the RNs working evening and night shifts.

8. Due to RPN staffing shortages, RNs could pick-up RPN shifts for additional hours.

9. The Member worked as a casual day-shift RN at Facility A from February 2015 to October 2016.

10. The Member completed an orientation prior to commencing work at Facility A.

11. As the day shift RN, the Member would arrive at Facility A in the morning and receive a report from the RN on the previous shift. The report was both written and verbal and would include any pertinent information from each floor.

12. After receiving report, the Member would attend the morning meeting with all Facility Managers. Generally, they would discuss what was occurring at the Facility and the Member would provide any necessary report received from the night RN.

13. The Member would then start rounds. This would include checking on each RPN, residents, bloodwork/lab results, orders and making sure everything was running smoothly on each unit.

INCIDENTS AT FACILITY A

[Patient A]

Verbal Order

14. [Patient A] was a 74-year-old man suffering from Chronic Obstructive Pulmonary Disease (“COPD”), type 2 diabetes, congestive heart failure, among other medical conditions.

15. On Friday, March 4, 2016, [Patient A] was experiencing a shortness of breath (“SOB”) episode. The Nurse Practitioner (“NP”) was visiting Facility A that day. The Member asked the NP to assess [Patient A].

16. The NP observed that [Patient A’s] vitals were low. The NP instructed the Member to increase [Patient A’s] oxygen level from 3 litres to 4 litres to see if that assisted. Specifically, the NP told the Member to turn up the oxygen for a few minutes and see if that improves [Patient A’s] vitals. She also reminded the Member that [Patient A] has COPD and likely is a CO2 retainer. As a result, his oxygen level cannot remain high for too long or it will cause more problems. The NP told the Member to only turn up the oxygen for a few minutes, once his oxygen saturation improves, the oxygen should be turned down again.

17. The Member documented a verbal order relating to the oxygen as follows: “O2 @ 4L np [nasal prongs] until Monday when R/A [reassessed] by NP. VP [verbal order]”. The Member did not document the date and time of the verbal order. The NP did not see the Member’s transcribed order and did not sign it. If the NP were to testify, she would state she would never give such an order for a COPD patient.

18. [Patient A’s] O2 level stayed at 4 litres until March 8, 2016, when the RPN on duty (“RPN A”) concluded that [Patient A] was in respiratory distress and called the Director of Care (the “DOC”) and the Member (who was the RN on shift) to assess [Patient A].

19. The DOC questioned why [Patient A’s] oxygen was at 4 litres. A new order was given to keep oxygen between 3 to 3.5 litres to maintain oxygen saturation between 90-92%.

Ventolin Nebulizer

20. On March 4, 2016, the Member also documented an order from the NP relating to a Ventolin nebulizer for [Patient A]. The order provided for the Ventolin nebulizer to be administered every 4 hours.

21. On March 8, 2016, when [Patient A] was in respiratory distress, the Member instructed RPN A to administer the Ventolin nebulizer at 1450 even though his next dose was not scheduled until 1630. The DOC was present and disagreed. The DOC called the doctor for instructions regarding the Ventolin nebulizer. The doctor provided an order that it could be administered immediately, which was done at approximately 1500.

Blood Glucometer – Improper Delegation of a Controlled Act

22. On March 7, 2016, the Member provided [the PSW] with the Capillary Blood Glucose (“CBG”) monitor and instructed [the PSW] to obtain a blood glucose reading for [Patient A]. The blood glucose reading required a procedure below a dermis, which is a controlled act.

23. RPN A overheard the conversation and advised the Member that she did not think PSWs were permitted to perform such an act at Facility A.

24. The Member disagreed and advised that they were permitted to do so and continued to instruct the PSW to perform the test.

25. [The PSW] advised that she was in school and knew how to conduct the test.

26. [The PSW] entered [Patient A’s] room and subsequently returned with a reading.

27. The Member did not document the delegation of the act in [Patient A’s] chart or elsewhere.

28. Facility A has a policy entitled “Diabetes Management – Blood Glucose Monitoring” that provides that registered staff are to conduct such tests on the residents.

[Patient B]

29. [Patient B] was an 85-year-old man with Parkinson’s disease, a cardiac pacemaker, and squamous cell carcinoma, among other medical conditions.

30. On March 6, 2016, the Member documented a verbal order from the physician. She recorded: “↑ Hydromorphone to 0.75mg Q/D d/c previous order. May have additional 0.25mg Hydromorphone SC prior to dressing (neck) change.”

31. The order was then added to [Patient B’s] MAR as: “Hydromorphone HCI Solution 2 MG/ML. Inject 0.75 mg subcutaneously four times a day for pain (may have additional 0.25mg prior to dressing [neck] change)”.

32. The order did not provide the amount of medication in millilitres (“ml”) even though it was a liquid injectable. The conversion is 2mg/1ml.

33. An RPN documented on [Patient B’s] MAR that she administered this medication on March 6, 2016 at 2200.

34. The Member worked an RPN shift on March 7, 2016. The Member documented on [Patient B’s] MAR that she administered the medication on March 7, 2016 at 0730 and 1130.

35. In addition to the MAR, the Member documented the administration on the Narcotic and Controlled Substance Administration Record (“Narcotic Record”).

36. Initially, the Member documented on the Narcotic Record that she administered the Hydromorphone to [Patient B] at 0900 and 1244, in the amount of 0.75 ml. This volume of medication equated to 1.5 mg.

37. At shift change, the RPN A noticed the Member’s documentation on the Narcotic Record. RPN A sought the Member’s clarification about the dosage and what had been administered to [Patient B].

38. The Member and RPN A proceeded to complete handwritten calculations of the conversion from mg to ml. RPN A calculated the conversion to be between 0.37 to 0.38 ml. The Member calculated the conversion to be 0.266 or 2.66 ml, neither of which was correct.

39. The Member then proceeded to use an application on her phone to calculate the conversion. She advised RPN A that she agreed with the calculation of 0.38 ml and claimed that she administered 0.38 ml to the patient and her documentation on the Narcotic Record was solely a documentation error, not an administration error.

40. The Member then proceeded to write over her documentation on the Narcotic Record and changed the “l” for ml to a “g” for mg, thus indicating that she administered 0.75 mg, not 0.75 ml.

41. RPN A then administered 0.38ml to [Patient B] at 1630. She also continued to monitor the patient closely to ensure there were no signs of overdose.

42. When RPN A went to administer the 2000 medications, she noted that [Patient B] was not able to swallow properly and did not seem himself. She notified the RN on duty, who came to assess [Patient B].

43. The RN called the doctor who ordered Narcan be administered. The doctor also came to Facility A to assess the patient directly. The RN stayed with [Patient B] throughout the night to administer Narcan and monitor him closely.

[Patient C]

44. [Patient C] had an order for antibiotic ointment to be administered twice daily (1000 and 2000) with a cover of a non-adherent dressing.

45. At Facility A, when dressings are changed, nurses write the date of the dressing change directly on the dressing itself, in addition to documenting the care in the patient’s treatment administration record (“TAR”)

46. On March 7, 2016, the Member was working an RPN day shift. She documented on [Patient C’s] TAR that she applied the ointment and changed the dressing at 1000.

47. Later that day, RPN A went to change [Patient C’s] dressing at or around 2000, the last dressing of [Patient C’s] wound was dated March 6, 2016. Therefore, [Patient C’s] dressing had not been changed on March 7, 2016.

[Patient D] and [Patient E]

48. [Patient D] was a 72-year-old woman with congestive heart failure, hypertension, Parkinson’s disease, among other medical conditions. She had an order for a number of different medications to be administered at 1630.

49. [Patient E] was a 75-year-old woman with Alzheimer’s disease, among other medical conditions. She had an order for Oxazepam at 2200.

50. On March 7, 2016, the Member worked an RPN day shift. When RPN A arrived for the evening shift, the Member stayed on the floor for longer than usual after providing her report. The Member offered to review orders with RPN A.

51. At 1530, RPN A was logged into the system and was on her way to administer a medication to a resident. The Member was still at the nursing station. RPN A saw the Member go onto the computer, where RPN A was already signed in, and click on something. RPN A asked the Member what she was doing. The Member advised that she had given medication early to [Patient D] and was just documenting that in the MAR.

52. RPN A sought clarification from the Member but the Member assured her to not worry and that everything was fine.

53. Later that shift, when RPN A was doing a 1630 medication pass, she noted that [Patient D’s] 1630 medication was documented as administered. RPN A saw that her initials were beside the medication administration box even though she had not done the administration for [Patient D]. RPN A checked the medication chart and found [Patient D’s] medication still in the cart.

54. By this point, the Member had left Facility A so was not available to provide clarification.

55. RPN A then went through all medications in her cart. She discovered that [Patient E’s] 2200 Oxazepam was missing, but no administration of this medication was documented on [Patient E’s] MAR to account for why it had not been administered to [Patient E] at the required time.

[Patient F]

56. At Facility A, when a patient falls, the Charge Nurse is to be notified by phone. The RN then should conduct an assessment with the RPN over the phone to determine if the RN should personally assess the patient. If the patient is experiencing pain or there is evidence of an injury, the RN is expected to assess the patient herself.

57. [Patient F] was an 89-year-old woman with dementia, among other medical conditions.

58. On October 9, 2015, the Member was working as the evening shift as the Charge Nurse.

59. RPN B was notified by a PSW that [Patient F] had fallen and was on the floor. RPN B completed an assessment of [Patient F], who was complaining of pain.

60. RPN B notified the Member and requested that she assess [Patient F] herself due to complaints of pain.

61. Without attending to the unit or assessing the patient, the Member instructed RPN B to move [Patient F] off the floor and back to her bed.

62. Subsequently, the Member attended the unit and came to the entrance of [Patient F’s] room. The Member looked at [Patient F] and said “she looks fine”. The Member did not physically assess or touch [Patient F] at that time or at any other time during the shift.

63. Two days later, [Patient F] was sent to hospital where it was determined that she had fractured her hip and required surgery.

INCIDENTS RELATING TO COLEMAN CARE CENTRE (FACILITY B)

BACKGROUND

64. Coleman Care Centre (“Facility B”) is a long-term care home located in Barrie, Ontario.

65. Facility B is equipped with 112 beds. It is a single floor with two units – East and West.

66. Facility B has three shifts: days (0615-1415), evenings (1415-2215) and nights (2215-0615).

67. Staffing at Facility B is as follows:

a. one RN Charge Nurse on duty at all times;

b. two RPNs on day and evening shifts (one per unit); and

c. 15 PSWs on days, 10 on evenings and five on nights.

68. There is also someone from management on call to support staff on evenings and nights.

69. Facility B has three medication carts used for medication passes on day and evening shifts. The RN manages one cart and the two RPNs each manage their own cart.

70. New staff receive training which includes one day of classroom orientation to review all policies and procedures. Staff receive a hard copy of the orientation package and all information is available electronically. Nursing staff complete nine orientation shifts (three of each shift). During orientation shifts, the new staff member shadows another nurse. Additional orientation shifts can be provided if necessary.

71. The Member was hired to be the RN Charge Nurse and commenced her orientation on March 29, 2018. She was in the midst of completing her orientation shifts when she was terminated on May 15, 2018.

72. Narcotic counts are completed at the start and end of every shift. The count is completed by the nurse finishing her shift and the nurse starting her shift. Both nurses must sign off on the count.

INCIDENTS AT FACILITY B

[Patient G]

73. ]Patient G] was a 64-year-old man with epilepsy, among other conditions. [Patient G] had an order for two narcotics: Diazepam in the morning at 0700 and Dilaudid at bedtime at 2000.

74. The Member was working the day shift on May 2, 2018 from 0615 to 1415.

75. The Member documented on [Patient G’s] MAR that she administered Diazepam to [Patient G] at 0700.

76. When completing the narcotic count at shift change, the oncoming evening shift RN (“RN A”) noticed that [Patient G’s] bedtime 2000 Dilaudid was missing and the morning 0700 Diazepam was still in the medication cart.

77. The Member did not provide an explanation when questioned.

78. RN A called the doctor and was instructed to hold the bedtime Dilaudid, on the assumption that [Patient G] had already received it that morning instead of the scheduled Diazepam, and administer the Diazepam at bedtime.

[Patient H]

79. [Patient H] was an 83-year-old woman. She had an order for: “Hydromorphone TAB (tablet), 2mg, GIVE 1 TABLET PO FIVE TIMES DAILY.” The MAR provided for an administration of this medication at 0200, 0630, 1100, 1600 and 2000.

80. Each Hydromorphone tablet was in its own individual blister pack for the time of administration. [Patient H] was the only patient who received scheduled medication in the middle of the night.

81. On May 6-7, 2018, the Member was completing her last night orientation shift. The Member was shadowing RN B during the shift.

82. At the start of shift, the Member completed the narcotic count with evening RPN. The count for [Patient H’s] Hydromorphone was recorded as 25. The Member was provided with the key for the associated medication cart. RN B confirmed with the Member and the evening RPN that there were no issues with the count. The Member kept the medication cart key with her during the entire night shift.

83. There was no medication pass during the night shift. The only scheduled medication during the night shift was [Patient H’s] Hydromorphone at 0200.

84. The Member advised RN B that she wanted to administer [Patient H’s] medication as it was her last night orientation shift. RN B agreed. The Member went to the medication room by herself using the key she had been provided at the start of shift.

85. The Member then proceeded to Patient H’s room, again by herself. The Member documented on the patient’s MAR that she administered the medication to [Patient H] at 0200.

86. In the morning, the Member completed the narcotic count with the oncoming day shift RPN (“RPN C”).

87. During the count, RPN C noticed that the count was off. The Narcotic Record showed that on May 6, 2018 at 1415, the count was 27. [Patient H] received a dose at 1600 and 2054, bringing the count down to 25. At 2215 on May 6, the count was completed (as described above). [Patient H] then received a dose from the Member at 0200 bringing the count down to 24. When completing the count, RPN C noticed that the actual number of tablets was 23, not 24. The 0200 dose for May 8, 2018 was missing from the blister pack.

88. When questioned by RPN C, the Member did not have an explanation. She claimed that she only gave [Patient H] one tablet, not two. The Member and RPN C searched for the missing medication but were unable to find it.

89. RPN C asked [Patient H], who had no cognitive impairment issues, if she recalled receiving one or two tablets at 0200. [Patient H] confirmed that she only received the one tablet prescribed.

CNO STANDARDS OF PRACTICE

90. CNO publishes nursing standards to set out the expectations for the practice of nursing.

91. CNO’s published standards inform nurses of their accountabilities and apply to all nurses regardless of their role, job description or area of practice.

Decisions About Procedures and Authority

92. CNO’s Decisions About Procedures and Authority standard requires that nurses ensure that they have the appropriate authority before performing and/or delegating controlled procedures, and confirm that patients’ records reflect the initiated procedures. Nurses also put patients first by ensuring that the individual to whom a task is being considered for delegation is adequately trained to perform the procedure prior to formally delegating the controlled act.

93. This direction reflects section 37(1) of Ontario Regulation 275/94 under the Part V of the Nursing Act, 1991. Specifically, these sections of the legislation require nurses who delegate controlled acts to ensure that they have the authority to delegate the act and that the delegatee has the knowledge, skill and judgement to safely and ethically perform the controlled act.

Documentation

94. 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.

95. A nurse meets the standard by “ensuring their documentation of [patient] care is accurate, timely and complete.”

96. The practice standard also echoes the legislated requirements under Ontario Regulation 275/94 relating to the delegation and documentation of controlled acts by a nurse to a delegatee.

97. As stated under section 39 of Ontario Regulation 275/94, nurses who delegate controlled acts shall:

a. ensure that a written record of the particulars of the delegation is available in the place where the controlled act is to be performed before it is performed;

b. ensure that a written record of the particulars of the delegation, or a copy of the record, is placed in the patient record at the time the delegation takes place or within a reasonable period of time afterwards; or

c. record particulars of the delegation in the patient record either at the time the delegation takes place or within a reasonable period of time afterwards

Medication

98. CNO’s Medication standard requires nurses to “prepare and administer medication(s) to [patients] in a safe, effective and ethical manner.”

99. It goes on to define a medication error as, “any preventable event that may cause or lead to inappropriate medication use or [patient] harm while the medication is in the control of the health care professional, [patient] or consumer.” It sets out the expectation that nurses will report all medication errors and near misses using formal practice-setting communication mechanisms.

Professional Standards

100. CNO’s Professional Standards provides that each nurse is accountable to the public and responsible for ensuring her or his practice and conduct meets legislative requirements and the standards of practice of the profession. A nurse demonstrates this standard by actions such as:

d. recognizing limits of practice and consulting appropriately;

e. seeking assistance appropriately and in a timely manner;

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

g. evaluating/describing the outcomes of specific interventions and modifying the plan/approach.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

101. The Member admits that her conduct as set out in paragraphs 1-6 of the Notice of Hearing breached CNO’s Professional Standards, Documentation and Medication standards of practice and put multiple vulnerable patients at risk. The Member further acknowledges and admits that her improper delegation of a controlled act breached CNO’s Authority About Procedures and Authority practice standard.

102. The Member admits she committed the acts of professional misconduct as alleged in paragraph 1-6 of the Notice of Hearing. In particular, the Member admits that she:

• Contravened a standard of practice of the profession or failed to meet the standard of practice of the profession, as alleged in paragraph 1 the Notice of Hearing and described in paragraphs 14-89 above;

• Delegated a controlled act to a PSW without ensuring she was capable of performing the controlled act and without documenting the delegation of the controlled act, as alleged in paragraph 2 of the Notice of Hearing and described in paragraphs 22-28 above;

• Delegated a controlled act to a PSW that she was not competent to perform, as alleged in paragraph 3 of the Notice of Hearing and described in paragraphs 22-28 above;

• Failed to keep records as required, as alleged in paragraph 4 of the Notice of Hearing and described in paragraphs 14-55 above;

• Falsified a record relating to your practice, as alleged in paragraph 5 of the Notice of Hearing and described in paragraphs 29-47 above; and

• 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 unprofessional and dishonourable, as alleged in paragraph 6 of the Notice of Hearing and described above in paragraphs 14-89 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)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), 1(b)(i), (ii), 2, 3, 4(a), (b), (c), (d), (e), (f), 5(a), (b), 6(a)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), 6(b)(i) and (ii) of the Notice of Hearing. As to allegations #6(a)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), 6(b)(i) and (ii), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonorable and unprofessional.

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.

Allegations #1(a)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), 1(b)(i) and (ii) in the Notice of Hearing are supported by paragraphs 14 through 102 in the Agreed Statement of Facts. The Member’s conduct breached the College’s Professional Standards, Documentation, Medication and Decisions About Procedures and Authority standards of practice.

Allegation #2 in the Notice of Hearing is supported by paragraphs 22 through 28, 90 through 97 and 100 through 102 in the Agreed Statement of Facts.

Allegation #3 in the Notice of Hearing is supported by paragraphs 22 through 28, 90 through 97 and 100 through 102 in the Agreed Statement of Facts.

Allegations #4(a), (b), (c), (d), (e) and (f) in the Notice of Hearing are supported by paragraphs 14 through 55, 90, 91, 94, 95 and 100 through 102 in the Agreed Statement of Facts.

Allegations #5(a) and (b) in the Notice of Hearing are supported by paragraphs 29 through 47, 90, 91, 94, 95, 98, 99 and 100 through 102 in the Agreed Statement of Facts.

With respect to Allegations #6(a)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), 6(b)(i) and (ii), the Panel finds that the Member’s conduct in inappropriately delegating a controlled act, failing to change a dressing and failing to properly assess a patient after a fall 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 as it demonstrated an element of dishonesty, deceit and moral failing through numerous medication errors and failing to document accurately an order from a Nurse Practitioner. As well, the Member knew or ought to have known that her conduct was unacceptable and fell well below the standards of a professional.

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:

1. Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.

Penalty Submissions

Submissions were made by College Counsel.

College Counsel commended the Member for attending the hearing and participating in the proceedings.

College Counsel submitted that the Joint Submission on Order provides in Appendix “A” an Undertaking by the Member for the Member’s permanent resignation as a member of the College effective March 17, 2021. The Undertaking includes the Member’s commitment not to apply for membership with the College as a Registered Nurse or Registered Practical Nurse at any time in the future. College Counsel submitted that the Member’s permanent resignation allows for a limited penalty with no need for terms, limits or conditions or suspension of the Member’s certificate.

The aggravating factors in this case were the number and variety of allegations and the vulnerable patients involved. The Member caused harm, particularly to one patient who had suffered a fall that was not properly assessed, causing a fractured hip to go undiagnosed. The Member was supposed to change a dressing on a patient and although she documented that it had been done, it had not. The Member made numerous medication errors on several patients and failed to document appropriately.

The mitigating factors in this case were that the Member had no prior disciplinary history with the College, attended the hearing, took responsibility for her actions, did not contest the allegations and agreed to the Agreed Statement of Facts and the Joint Submission on Order.

The proposed penalty provides for general deterrence through the oral reprimand which will discourage members of the profession from engaging in similar conduct by reminding them of the importance of their professional obligations.

The proposed penalty provides for specific deterrence through the oral reprimand. The conduct to which the Member has admitted would generally attract a significant suspension, but because the Member agreed to sign an undertaking which would mean she would permanently resign as a member of the College and not ever apply for membership with the College at any time in the future no suspension is necessary in this case. There was no requirement for rehabilitation or remediation in this case because the Member agreed to sign the undertaking and never be a nurse again.

Overall the public is protected because the public portion of the Register maintained by the College will indefinitely reflect that the Member entered into an Undertaking with the Executive Director to permanently resign as a member of the College as part of an agreed resolution of allegations of professional misconduct heard by a Panel of the Discipline Committee.

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. O’Neill (Discipline Committee, 2016). This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member had signed an undertaking to permanently resign from the College. The member contravened several standards of practice which involved numerous patients and the member’s behaviour was found to be physical, emotional and verbal abuse. The panel found that having regard to all the circumstances the behaviour would reasonably be regarded by members of the profession as disgraceful, dishonourable and unprofessional. In light of the member’s undertaking, the panel ordered the member be given an oral reprimand.

CNO v. Marcano (Discipline Committee, 2020). This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order and the member had signed an Undertaking to permanently resign from the College. The professional misconduct related to several patients, several medications and lack of appropriate assessment of patients and inappropriate reporting. The member’s behaviour was found to be unprofessional. Considering the member’s undertaking to permanently resign from the College, the panel ordered the member be given an oral reprimand.

The Member had no submissions on penalty.

In providing the Panel with advice, Independent Legal Counsel (“ILC”) stated that the “primary goals of an order are to ensure the protection of the public and to maintain confidence in nursing and self-regulation”. ILC referenced the Joint Submission on Order and advised the Panel that it must accept it unless it decided that the proposed penalty was so disproportionate to the offence that to accept it would not be in the public’s interest or would bring the administration of justice into disrepute.

Penalty Decision

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

1. The Member is required to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.

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, and public protection.

As the Member has permanently resigned, it is not necessary for the penalty to address rehabilitation and remediation. Conduct by nurses that demonstrates a lack of integrity, dishonesty, abuse of power and authority, or disregard for the welfare and safety of members of the public is conduct that cannot be tolerated by the nursing profession. Nurses are accountable for conducting themselves in ways that promote respect for the profession. A nurse must demonstrate ethical conduct by creating environments that promote and support safe, effective and ethical practice.

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

I, Tanya Dion, 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.