College of Nurses of Ontario v. Ester Fernandez, 2021 CanLII 152475

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Dawn Cutler, RN Chairperson Sylvia Douglas Public Member Karen Laforet, RN Member Lalitha Poonasamy Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO Alysha Shore for College of Nurses of Ontario

• and -

ESTER FERNANDEZ Registration No. 0501072 Michael Mandarino for Ester Fernandez Christopher Wirth, Independent Legal Counsel

Heard: May 19, 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 May 19, 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 publication or broadcasting of the names of the patients, or any information that could disclose the identities of the patients referred to orally or in any documents presented in the Discipline hearing of Ester Fernandez.

The Panel considered the submissions of the Parties and decided that there be an order preventing public disclosure and banning publication or broadcasting of the names of the patients, or any information that could disclose the identities of the patients referred to orally or in any documents presented in the Discipline hearing of Ester Fernandez.

The Allegations

College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs 1(c)(i)(ii), 3(c)(i)(ii), and 4(a), (b), (c), (d), (e), (f), (g), (h) and (i) of the Notice of Hearing dated February 19, 2021. The Panel granted this request. The remaining allegations against Ester Fernandez (the “Member”), which as amended, 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 you were employed as a Registered Nurse (“RN”) at Peterborough Regional Health Centre in Peterborough, Ontario (the “Hospital”), 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. between or around March and November 2012, you failed to maintain an active glucometer barcode;

b. in relation to [Patient A]:

i. on or around October 16, 2012, you administered 7 units of Levemir as directed by the patient instead of the prescribed 14 units;

ii. on or around October 24, 2012, you administered 6 units of Levemir as directed by the patient instead of the prescribed 14 units;

iii. on or around October 25, 2012, you administered 7 units of Levemir as directed by the patient instead of the prescribed 14 units; and/or

iv. in October 2012, altered the dose of Levemir on one or more occasion without a physician order;

c.

i. [Withdrawn]; and/or

ii. [Withdrawn];

d. on or around April 16, 2014, you administered 50mg of Loxapine to [Patient B] instead of the prescribed 7.5mg;

e. on or around June 26, 2014, in relation to [Patient C], you dispensed and/or administered a dose of Baclofen at or around 16:58 hours when it was only prescribed at 08:00 hours;

f. on or around July 23, 2015, in relation to [Patient D], you failed to:

i. flush the patient’s catheter and/or G-tube properly; and/or

ii. properly administer medication through the patient’s G-tube;

g. on or around August 5, 2015, in relation to [Patient E], you failed to:

i. assess the patient when he was in respiratory distress;

ii. attend to the patient on one or more occasions when requested by the observing nurse; and/or

iii. adequately document the care you provided to the patient; and/or

1. on, between or around July 23 and August 5, 2015, you:

i. failed to apply proper sterile techniques, including but not limited to, management of central venous access devices, claves and/or insulin pens, wound dressing changes, and/or foley catheter flushes;

ii. failed to check the condition of peripherally inserted central catheter line sites and/or dressing and patency of lines before accessing;

iii. failed to properly time and/or calculate feeds and/or medication administration for diabetic patients;

iv. failed to exercise proper medication administration standards, including but not limited to, verifying the eight patient rights or three checks prior to administering medication, leaving medication poured but unattended, failing to administer ordered medication(s), failing to review the relevant medication administration record(s), attempting to administer intravenous medication directly from the fridge, and/or misinterpreting medication type abbreviation(s);

v. failed to apply proper G-tube techniques when administering medication and feeding;

vi. failed to provide an oral rinse after administering Flovent to a patient and/or did not know that such a rinse was necessary;

vii. were unable to administer a fleet enema without assistance;

viii. failed to properly conduct MRSA/VRE swabs on a patient during a wound dressing change; and/or

ix. failed to correctly conduct a weekly note/assessment of a wound dressing as ordered; and/or

2. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Act, and defined in subsection 1(13) of Ontario Regulation 799/93, in that, while employed as a RN at the Hospital, you failed to keep records as required with respect to the following incidents:

3. on or around June 26, 2014, you removed a dose of Baclofen from the Hospital’s automated medication dispensing unit for [Patient C] at or around 16:58 hours and failed to properly document the administration or wastage of that medication; and/or

4. on or around August 5, 2015, you failed to properly document the care you provided to [Patient E]; and/or

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(37) of Ontario Regulation 799/93, in that, while you were employed as a RN at the Hospital, 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. between or around March and November 2012, you failed to maintain an active glucometer barcode;

b. in relation to [Patient A]:

i. on or around October 16, 2012, you administered 7 units of Levemir as directed by the patient instead of the prescribed 14 units;

ii. on or around October 24, 2012, you administered 6 units of Levemir as directed by the patient instead of the prescribed 14 units;

iii. on or around October 25, 2012, you administered 7 units of Levemir as directed by the patient instead of the prescribed 14 units; and/or

iv. in October 2012, altered the dose of Levemir on one or more occasion without a physician order;

c.

i. [Withdrawn]; and/or

ii. [Withdrawn]

d. on or around April 16, 2014, you administered 50mg of Loxapine to [Patient B] instead of the prescribed 7.5mg;

e. on or around June 26, 2014, in relation to [Patient C], you dispensed and/or administered a dose of Baclofen at or around 16:58 hours when it was only prescribed at 08:00 hours;

f. on or around July 23, 2015, in relation to [Patient D], you failed to:

i. flush the patient’s catheter and/or G-tube properly; and/or

ii. properly administer medication through the patient’s G-tube;

g. on or around August 5, 2015, in relation to [Patient E], you failed to:

i. assess the patient when he was in respiratory distress;

ii. attend to the patient on one or more occasions when requested by the observing nurse; and/or

iii. adequately document the care you provided to the patient; and/or

1. on, between or around July 23 and August 5, 2015, you:

i. failed to apply proper sterile techniques, including but not limited to, management of central venous access devices, claves and/or insulin pens, wound dressing changes, and/or foley catheter flushes;

ii. failed to check the condition of peripherally inserted central catheter line sites and/or dressing and patency of lines before accessing;

iii. failed to properly time and/or calculate feeds and/or medication administration for diabetic patients;

iv. failed to exercise proper medication administration standards, including but not limited to, verifying the eight patient rights or three checks prior to administering medication, leaving medication poured but unattended, failing to administer ordered medication(s), failing to review the relevant medication administration record(s), attempting to administer intravenous medication directly from the fridge, and/or misinterpreting medication type abbreviation(s);

v. failed to apply proper G-tube techniques when administering medication and feeding;

vi. failed to provide an oral rinse after administering Flovent to a patient and/or did not know that such a rinse was necessary;

vii. were unable to administer a fleet enema without assistance;

viii. failed to properly conduct MRSA/VRE swabs on a patient during a wound dressing change; and/or

ix. failed to correctly conduct a weekly note/assessment of a wound dressing as ordered; and/or

5. [Withdrawn];

6. [Withdrawn];

7. [Withdrawn];

8. [Withdrawn];

9. [Withdrawn];

10. [Withdrawn];

11. [Withdrawn];

12. [Withdrawn]; and/or

13. [Withdrawn].

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a), (b)(i)(ii)(iii)(iv), (d), (e), (f)(i)(ii), (g)(i)(ii)(iii), (h)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(ix), 2(a), (b), 3(a), (b)(i)(ii)(iii)(iv), (d), (e), (f)(i)(ii), (g)(i)(ii)(iii), (h)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii) and (ix) 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

1. Ester Fernandez (the “Member”) obtained a diploma in nursing from the Philippines.

2. The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on December 29, 2004.

3. The Member was employed as a staff nurse at Peterborough Regional Health Centre (the “Hospital”) from June 9, 2009 to August 10, 2015. The Member’s employment was terminated as a result of the incidents described below.

THE HOSPITAL

4. The Hospital is located in Peterborough, Ontario.

5. The incidents leading to the Member’s termination occurred while the Member was working as a nurse on the Complex Continuing Care unit (the “Unit”) at the Hospital.

Professional Practice Recovery Process

6. In April 2015, a new manager, [ ], was assigned to the Unit. [The Unit Manager] reviewed the Member’s personnel file and noticed a long pattern of practice concerns, largely related to medication administration. As a result, he initiated a discussion with staff in Professional Practice. It was decided that a 10-day Professional Practice Recovery Process (“PPRP”) would be commenced with the Member starting on July 23, 2015.

7. The PPRP involved 10 shadowed shifts with a meeting each afternoon, involving the Member, the shadow, [the Unit Manager], the Clinical Nurse Educator, and the Manager of Professional Practice, to discuss what had gone well and to identify areas of improvement. The Member was shadowed by [the Senior Charge Nurse], RN, during the PPRP. [The Senior Charge Nurse] worked on the Unit as a senior Charge Nurse. [The Senior Charge Nurse] was instructed to observe the Member, take notes, and only step in if/when patient safety was compromised.

8. If the Member were to testify, she would state that the issues leading to her termination began to occur in or around the time [the Unit Manager] started on the Unit. The Member would further testify that there was significant management turnover which impacted the application and interpretation of certain policies and Unit practices. She would also testify that she refused to be redeployed to other units without proper orientation, which exacerbated a strained employment relationship. The Member would further testify that she feels these circumstances precipitated a review of her practice.

9. The Member is currently employed as a RN. CNO has not received any reports relating to the Member’s nursing practice from her current employer.

Automated Medication Dispensing Unit

10. Patients on the Unit require ongoing care that cannot be managed in the community, such as patients who have specialized IV infusions, G-tubes and/or PICC lines.

11. The Unit uses an automated medication dispensing unit (“ADU”). The ADU stores all patient medication along with information about each patient’s medications and times for administration. Each user, including nursing staff, have their own password associated with their name.

12. The ADU tracks who obtains medication for patients from the machine. The pharmacy loads the ADU with the medications and the patients’ medication information. When a nurse signs in, the screen lists all the nurse’s patient profiles. A patient can be selected to see all of the patient’s ordered medications.

13. If a nurse requests to remove a medication from the ADU, the appropriate drawer will open to allow removal of the medication. The nurse would then remove the necessary number of tablets/doses and scan them into the system. The ADU does not track how many pills are physically removed from the drawer. The user must scan each of the removed tablets in order for the ADU to properly track the number of tablets/doses that were removed. The ADU tries to ensure the correct dose is removed. For example, if a patient is prescribed two tablets and only one is removed and scanned into the ADU, the user will be prompted with words to the effect of “are you sure?”

14. The ADU is stored in a dedicated room. Nurses go into the room during rounds with the medication administration record (“MAR”) book. When a physician adds an order for a patient, the nurse writes it into the MAR and the pharmacist enters it into the computer (which in turn gets uploaded to the ADU). It is the nurse’s responsibility to check the MAR against the ADU for correctness.

15. Nurses are expected to only dispense the medications needed for a patient at that particular time of day as opposed to dispensing the medications for the entire day at one time.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

March to November 2012 – Active Glucometer Barcode

16. A significant portion of patients on the Unit are diabetic and require blood glucose levels to be tested.

17. Nurses at the Hospital use glucose meters to check patients’ blood glucose levels. Every nurse has a barcode sticker that they scan which gives them access to the glucose meter. Typically, the nurses put the sticker on the back of their identification card. A nurse receives his or her individual barcode sticker after completing the requisite training. Every year a nurse must complete certain training and checks to maintain an active barcode. The requisite training involves a LearnFlex online learning module, five Quality Assurance checks, testing the meters to make sure they adhere to lab quality guidelines and five patient tests. Each nurse is responsible for completing these requirements every year.

18. If a barcode expires, the nurse will not be able to scan it, which is required to turn on the glucose meter. As a result, if a nurse’s barcode expired, he or she would need to ask a colleague to do the blood glucose tests on patients each time one was needed.

19. The Hospital advised all nurses on April 5, 2012 that that Glucose Meter Recertification 2012 module in LearnFlex was to be completed by May 18, 2012 as one of the requirements for the annual glucose recertification. On May 25, 2012, a second email reminder was sent out to the individual nurses who had not yet completed the module. As of June 25, 2012, the Member had not yet completed the LearnFlex module required to recertify her barcode. As a result, she was locked out of the glucose meters. The Member’s then manager, [the Former Manager], was advised of this failure.

20. If the Member were to testify, she would state that she was on a medical leave when the Hospital sent out its notices regarding recertification for the glucometer in order to get the barcode required to use the glucometer and, as a result, she did not receive notice of the recertification process and missed the recertification process deadline. The Member would further testify that her manager was notified that she did not recertify yet there was no follow up by the manager at that time to remind or advise the Member of the process she missed. The Member nevertheless acknowledges that she had a responsibility to ensure all of her certifications were up to date.

21. In early 2013, the Member received education on diabetes/hypoglycemia from [ ], Nurse Educator. [The Nurse Educator] noted the Member advised that her barcode for her glucose meter had expired. The Member explained that when she needed a test done for her patients, she asked her colleagues to do it for her. The Member’s barcode was subsequently activated.

22. The Member’s reliance on other nurses’ barcodes was inefficient and prevented a proper log of the tests.

October 2012 – Patient [A]

23. Patient [A] was a 68-year-old diabetic man at the time of the incident.

24. Patient [A]’s Routine Diabetes MAR listed an order of 14 units of Levemir in the pm. In October 2012, the Member failed to administer the correct dose of Levemir to Patient [A] on three occasions, as outlined below.

• On October 16, 2012, the Member administered 7 units of Levemir to Patient [A] instead of the prescribed 14 units. The MAR confirms that Patient [A] received 7 units and the Shift to Shift Summary Report and progress notes state that the patient requested 7 units instead of 14 units of Levemir.

• On October 24, 2012, the Member administered 6 units of Levemir to Patient [A] instead of the prescribed 14 units. The MAR confirms that Patient [A] received 6 units and the Shift to Shift Summary Report states that the patient requested 6 units instead of 14 units of Levemir.

• On October 25, 2012, the Member administered 7 units of Levemir to Patient [A] instead of the prescribed 14 units. The MAR confirms that Patient [A] received 7 units and the Shift to Shift Summary Report and progress notes state that the patient requested 7 units instead of 14 units of Levemir.

25. On October 29, 2012, [the Former Manager] sent an email to the Member about her administration of Patient [A]’s Levemir. [The Former Manager] explained that the Member is not permitted to adjust insulin dosage based solely on a patient request and there must be either a physician or nurse practitioner (“NP”) order to that effect. RNs do not have the knowledge or authority to prescribe medication. [The Former Manager] reminded the Member that if she was concerned about the amount of insulin prescribed, she must contact a physician or NP to adjust the order. Finally, [the Former Manager] offered the Member further insulin education with [the Nurse Educator].

26. If the Member were to testify, she would state that she admits that she did not give the prescribed doses as ordered; however, she did so because Patient [A] refused to accept the full amount. The Member would further testify that she did not want to force the medication on a patient that had full autonomy or capacity to refuse medications. Nevertheless, the Member acknowledges that she did not administer the medication as ordered and did not advise any staff or physicians of Patient [A]’s refusal and/or medication preferences.

27. As noted above, in January 2013, the Member received education on insulin management from [the Nurse Educator]. [The Nurse Educator] wrote a report regarding their session which noted that the Member told her that she had a patient who wanted less Levemir than prescribed and the Member followed the patient’s request. [The Nurse Educator] explained to the Member why she was not permitted to adjust the patient’s dosage without an order from a physician and that by providing a different dose the Member was acting outside of her scope of practice. [The Nurse Educator] recalls that the Member was receptive to the feedback and educational information.

April 2014 - Patient [B]

28. Patient [B] was a 64-year-old man with dementia at the time of the incident.

29. On April 14, 2014, Patient [B] received an order for 7.5 mg of Loxapine every 4 hours PRN. On the MAR, beside the name of the drug, there was a description of the potency of the drug (if liquid) or size of the tablet (if pill form). The dosage for the patient was listed on the line below. With respect to the Loxapine order, beside the name of the drug was 50 mg/mL and then below in handwriting the dosage of 7.5mg.

30. On April 16, 2014, the Member administered 50mg of Loxapine to Patient [B] instead of the prescribed 7.5mg.

31. The Member prepared an incident report in which it was noted that the MAR was confusing, and she accidentally gave the patient 50mg of Loxapine. The Member thought that a vial contained 5mg and thus she would need to provide 2.5mg from a secondary vial. The Member gave the patient the entire 50mg vial. The Member realized the error and immediately self-reported to her managers and acknowledged her error.

32. Patient [B] was incapacitated and slept for many hours. He was monitored but did not require any further medical intervention.

33. Following the incident, the Member completed a reflective practice exercise. This was the fifth reflective practice relating to medication for the Member. In the reflective practice module, the Member admitted that she gave the wrong dose and was confused by the MAR.

June 2014 - Patient [C]

34. Patient [C]’s order sheet provides for 5mg of Baclofen daily.

35. On June 26, 2014 the Member dispensed and/or administered a dose of Baclofen to Patient [C] at or around 16:58 when it was prescribed for 08:00 only.

36. Patient [C]’s MAR for June 26, 2014, indicates that the Member administered Baclofen at 08:00.

37. On June 27, 2014, [the Senior Charge Nurse] completed the incident report relating to Patient [C]. In the report, [the Senior Charge Nurse] stated that she was not able to obtain Patient [C]’s 08:00 dose of Baclofen on June 27, 2014 from the ADU. The ADU indicated that Baclofen had been taken from the machine at 08:00 and 16:00, even though it was only prescribed once daily.

38. The pharmacist reviewing the incident report noted that on June 26, 2014, Baclofen was taken from the ADU at 08:15 and 16:58 hours. As a result, the machine would not dispense another dose of Baclofen on June 27, 2014 for the 08:00 administration. The ADU records support the above withdrawals were made by the Member.

39. The Member would have been able to remove the second dose of Baclofen from the ADU even though it was only ordered once a day. The ADU would likely have prompted the Member to explain why she was obtaining a dose at this time and required her to provide an answer from a list of approximately 20 possible answers. There is also the option to override the ADU, which also requires an explanation from the user.

40. There was nothing in the patient’s MAR or progress notes about the second withdrawal. It is possible that the Member removed the second dose of Baclofen in error and did not actually administer it to the patient. If that is the case, the Member could have logged back into the ADU and returned the medication if it had not yet been opened. If the medication had already been opened, the Member should have wasted it. The ADU has a function to do so, prompting the user to provide an explanation. It was common practice on the Unit to note the wastage in the MAR and not on the ADU. The medication is then disposed of in the sharps container and later incinerated. There is nothing in the MAR to indicate that the Member wasted the medication.

41. If the Member were to testify, she would state that she properly administered and documented the 0800 dose but did not administer the 1600 dose notwithstanding the withdrawal at 1600. She does not recall how the medication got withdrawn/dispensed, and acknowledges that if she did dispense a dose at 1600 she did not properly waste or re-enter it into the system.

July 2015 - Patient [D]

42. On July 23, 2015, the Member was assigned to Patient [D]. Patient [D] had a feeding tube called a G-tube. G-tubes are common on the Unit.

43. During the first day of the PPRP, [the Senior Charge Nurse] noted that when administering medication to Patient [D] through his G-tube, the Member crushed all the medications together and gave them at the same time. The Member also did not use the correct amount of water when cleaning the G-tube and administering medication.

44. Each medication was to be given independently with 15 ml of water before and after. If all medications are administered at one time, it can plug the G-tube. Also, mixing various medications together could cause an unintended adverse reaction. The G-tube must also be rinsed with 15 ml of water before and after each medication is administered. The amount of water given to patients is calculated by a dietician based on the number of medications prescribed as it can have an impact on the patient’s sodium and electrolyte levels.

45. During the daily PPRP meeting on July 23, 2015, the Member stated that she did not know that medications should not be given all at once in the G-tube. If the Member were to testify, she would acknowledge that she gave all the medications at once. She would further testify that it was her understanding per Unit practices that certain medications can be administered at once if the nurse was aware of prior reactions to the medications. The Member would also testify that Patient [D] was a long-time patient on the Unit. As a result, the Member felt confident that he would have no reactions to the medications being mixed.

46. The Member nevertheless acknowledges that mixing the medications together in the G-tube was shortcut that was not consistent with the standards of practice of the profession.

July to August 2015 – Various Patients

47. Between July 23 and August 5, 2015, there were numerous issues noted with the Member’s practice. There were recurring themes of practice concerns with the Member such as proper G-tube care, medication administration and improper programming of IV pumps.

CVAD and IV Techniques

48. During the PPRP, [the Senior Charge Nurse] noted numerous instances in which the Member failed to apply proper sterile techniques when dealing with Central Venous Access Devices (“CVAD”) and Claves (needle free-connector). These devices are very common on the Unit. As a result, [ ] provided the Member with education.

49. A PICC line, which is a type of CVAD, provides a direct line to the heart via the aorta. As a result, it is a high risk of infection if not dealt with properly. The Member also failed to check the condition of PICC line sites or dressings and patency of lines before accessing. When she did check the line, it was done poorly and she programmed the pump incorrectly.

Diabetic Patients

50. With respect to diabetic patients, concerns were noted with the timing of their meals and medication administration. Insulin administration has to be timed with meal/tube feeding. If insulin is given and a feed has not been started, the patient may develop hypoglycemia. Before a feed, the nurse must know the patient’s blood sugar level as it affects the dose of insulin to administer.

51. In one instance, the Member started a patient’s feed 30 minutes late at 08:30 instead of 08:00 and then attempted to turn the feed off at 10:00 when it should have been turned off two hours later at 10:30. The Member’s response when confronted about this was that the patient did not need the last 60cc. According to [ ], the amount of carbohydrate in the patient’s feed has to match the amount of insulin administered. If the feed is turned off early, it affects the insulin dose. [The Senior Charge Nurse] had to intervene in the patient’s care.

52. The Member also failed to disinfect the end of the insulin pen prior to attaching the needle. During the PPRP meeting, the Member stated that she did not think this was necessary.

53. In addition, there was another incident in which the Member was unable to properly calculate the insulin dosage and required assistance from [the Senior Charge Nurse].

Medication Management

54. During the first day of the PPRP, [the Senior Charge Nurse] noted that the Member failed to verify the eight patient rights or three checks before administering medication. On several occasions, [the Senior Charge Nurse] witnessed the Member leave medication poured but unattended while she left the room to obtain water.

55. On one occasion, the Member forgot to give a medication, but signed that she had administered it. On another occasion, the Member did not provide a chlorhexidine wash prior to administration of a topical cream. When reminded to do this by [the Senior Charge Nurse], the Member stated that the order for the wash was finished. In fact, the wash had been re-ordered and it was the last day for the wash to be given based on the first order. The Member failed to check the MAR.

56. The Member pulled out an IV medication from the fridge and was about to administer it immediately before being stopped by [the Senior Charge Nurse]. IV medications must be brought to room temperature before administration or else they can cause discomfort to the patient.

57. On August 4, 2015, a patient received a new order for a multivitamin with minerals. The Member went to retrieve this from the ADU. She first selected the sustained release (“SR”) version instead of the regular controlled release vitamin. [The Senior Charge Nurse] pointed this out to the Member. She then returned the medication and went to retrieve a new one, but again selected the “SR” version. She could not explain the difference between the versions.

Sterile Techniques

58. Apart from poor sterile techniques with the CVAD, [the Senior Charge Nurse] witnessed other more general issues with sterilization. For example:

• The Member put on sterile gloves and then opened packages thus negating the sterile gloves;

• In dealing with wounds, the Member contaminated wounds despite being reminded three times regarding going from dry outlying intact skin areas to inside of wound; and

• Prior to flushing a Foley catheter, the Member poured the sterile water into a Styrofoam cup which was not sterile.

G-tubes

59. The Member made numerous errors with respect to proper G-tube techniques throughout the PPRP, including flushing the incorrect amount of water during medication administration and feeding. These errors continued after receiving education.

60. On an occasion when a G-tube got plugged, the Member failed to follow the proper protocol for problem solving and was unsuccessful. She then obtained assistance from the most junior RPN on the Unit who was able to resolve the problem.

Miscellaneous

61. There were some miscellaneous errors noted by [the Senior Charge Nurse] during the PPRP. For example, on July 23, 2015, the Member administered Flovent to a patient, but failed to provide a required oral rinse. When questioned about this during the daily meeting, the Member stated that she was not aware such a rinse was necessary. It was explained to her that neglecting to conduct the rinse could result in thrush.

62. On one occasion, a patient required a fleet enema, but the Member did not know what that was and required assistance from other staff.

63. On July 29, 2015, the Member needed to complete a simple dressing change, but was required to do MRSA/VRE swabs to test for bacterial infection first. The Hospital policy requires these swabs to be taken from “every opening”. Apart from taking the swabs from the appropriate places, the Member also took a vaginal swab. When asked by [the Senior Charge Nurse] why she did that, the Member stated that she had to take swabs from every opening. Following that reasoning, [the Senior Charge Nurse] then asked why did not take a swab from the patient’s mouth or ear. The Member was unable to answer this question.

64. The Member required a significant amount of assistance from other staff and often used patients’ call bells to obtain help. This was problematic as other staff would leave what they were doing under the false impression that the patient or Member was in urgent distress.

August 2015 - Patient [E]

65. Patient [E] was a quadriplegic. He has a tracheal tube which accumulates thick mucous because he does not have a cough reflex due to his medical condition.

66. On August 4, 2015, the Member conducted a vacuum dressing for Patient [E]. Patient [E]’s order required a weekly note/assessment on the wound. While the Member measured the wound and drew a picture of it, she did not include any other information, such as the condition/colour of the wound bed, presence of necrotic tissue, exudate colour and amount, tunneling and condition of wound margins. Without this information, the next nurse to conduct a dressing change and assessment would not have the necessary information for comparison to determine whether the wound was healing. The Member did not have any response when asked about this during the PPRP meeting.

67. On August 5, 2015, the Member was assigned to Patient [E] again. At approximately 09:00 hours, Patient [E] went into respiratory distress. This happened relatively often and caused Patient [E] significant anxiety. Staff often had to stay with him until he settled down. On this day, after providing some relief to Patient [E], the Member paged the respiratory therapist (“RT”) for assistance. When the RT arrived, the Member left to care for another patient. When the RT left, the patient was still in distress, but the Member did not return to his room.

68. [The Senior Charge Nurse] felt it was not safe to leave Patient [E] alone as his breathing was compromised. [The Senior Charge Nurse] performed a suctioning and stacking procedure to activate deep breathing to help him calm down as he could not feel his own abdomen muscles due to his medical condition. He also could not activate his call bell in the state he was in. As Patient [E] was a quadriplegic, he had a blowing call bell, in which he would blow air into a tube to activate the bell. Due to the fact Patient [E] was in respiratory distress, he would not have had sufficient air to activate the bell.

69. [The Senior Charge Nurse] asked the Member to return to Patient [E]’s room and stay with him until he settled. The Member responded that he was “fine” and was “always like this” or words to that effect. As a result, [the Senior Charge Nurse] had to stay with Patient [E] for approximately two hours until he settled down. The RT had to return to assess and assist Patient [E] several times that morning. The Member did not enter any notes in Patient [E]’s progress notes during the respiratory distress incident.

70. If the Member were to testify, she would state that on this day she was sent home by the Manager which precipitated a conversation regarding the documentation of Patient [E]. She would further testify, that she did not document because [the Senior Charge Nurse] said she would do so because she was the nurse that had provided care to Patient [E]. The Member acknowledges that she should have completed timely documentation on Patient [E]’s chart prior to her meeting with the Manager.

71. During their daily meeting on August 5, 2015, when [the Senior Charge Nurse] raised this incident, the Member was defensive. She insisted that she had assessed Patient [E] and it was not necessary for her to stay with him. The Member felt that after the RT left, Patient [E] was fine, did not require her presence and she could go on and carry out her other duties. In light of the severity of the incident and the Member’s response, [the Unit Manager] decided to end the PPRP out of concern for patient safety. The Member’s employment at the Hospital was terminated.

CNO STANDARDS

72. CNO’s Professional Standards provides that each nurse is accountable to the public and responsible for ensuring her or his practice and conduct meets the legislative requirements and the standard of the profession. Nurses are responsible for their actions and the consequences of those actions. A nurse demonstrates accountability by actions such as:

• Providing, facilitating, advocating and promoting the best possible care for [patients];

• Assessing/describing the [patient] situation using a theory, framework or evidence-based tool and identifying/recognizing abnormal or unexpected client responses and taking action appropriately;

• Ensuring practice is consistent with CNO’s standards of practice and guidelines as well as legislation;

• Seeking assistance appropriately and in a timely manner;

• Taking action in situations in which [patient] safety and well-being are compromised;

• Evaluating/describing the outcomes of specific interventions and modifying the plan/approach; and

• Taking responsibility for errors when they occur and taking appropriate action to maintain [patient] safety.

73. In addition, CNO’s Professional Standards provides that each nurse continually improves the application of professional knowledge and demonstrates knowledge application by actions such as identifying and addressing practice-related issues.

74. CNO’s Medication standard provides that administering, recommending and/or prescribing medication requires knowledge, technical skills and judgment. With respect to competence, nurses need the competence to assess the appropriateness of medication for a patient, manage adverse reactions, understand issues related to consent and make ethical decisions about medications.

75. The Medication standard also provides that safe medication practice includes reporting all errors and near misses using formal practice-setting communication mechanisms.

76. The Medication standard further provides that a nurse meets the standard by:

• Assessing her or his own knowledge, skill and judgment to competently carry out medication administration, use medication equipment and intervene during an adverse reaction;

• Preparing and administering the medication according to an evidence-based rationale, including:

o Scheduling dosing times for a medication, taking into consideration the effect of food intake or medication absorption, contraindications, required interventions before, during and after administration, and [patient] choice and preference;

o Applying principles of infection prevention and control when administering medication; and

o Verifying the 8 rights of medication administration; and

• Documenting, during and/or after medication administration, in the [patient’s] record according to documentation standards.

77. CNO’s Documentation standard provides that nurses are accountable for ensuring their documentation of patient care is accurate, timely and complete. The standard further clarifies that a nurse meets the standard by:

• Ensuring documentation is a complete record of nursing care provided and reflects all aspects of the nursing process, including assessment, planning, intervention (independent and collaborative) and evaluation;

• Documenting in a timely manner and completing documentation during, or as soon as possible after, the care or event; and

• Ensuring that relevant [patient] care information is captured in a permanent record.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

78. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a), 1(b), 1(d), 1(e), 1(f), 1(g) and 1(h) of the Notice of Hearing in that she contravened a standard of practice of the profession, as described in paragraphs 16 to 77 above.

79. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2(a) and 2(b) of the Notice of Hearing in that she failed to keep records as required, as described in paragraphs 34 to 41, 66 to 70 and 77 above.

80. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3(a), 3(b), 3(d), 3(e), 3(f), 3(g) and 3(h) of the Notice of Hearing, and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 16 to 77 above.

OTHER

81. With the leave of the Panel of the Discipline Committee, CNO withdraws the remaining allegations in the Notice of Hearing, which are as follows:

• 1(c)

• 3(c)

• 4(a) to 4(i)

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)(i)(ii)(iii)(iv), (d), (e), (f)(i)(ii), (g)(i)(ii)(iii), (h)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(ix), 2(a), (b), 3(a), (b)(i)(ii)(iii)(iv), (d), (e), (f)(i)(ii), (g)(i)(ii)(iii), (h)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii) and (ix) of the Notice of Hearing. As to allegations #3(a), (b)(i)(ii)(iii)(iv), (d), (e), (f)(i)(ii), (g)(i)(ii)(iii), (h)(i)(ii)(iii)(iv)(v)(vi)(vii)(viii) and (ix), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonourable and unprofessional.

Reasons for Decision

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

Allegation #1(a) in the Notice of Hearing is supported by paragraphs 16 to 22, 72, 77 and 78 in the Agreed Statement of Facts. The Member failed to complete the requisite training for glucose meter testing as required by the Hospital, thus causing her glucometer barcode to expire, impacting other nurses and preventing proper logging of the tests.

Allegations #1(b)(i)(ii)(iii) and (iv) in the Notice of Hearing are supported by paragraphs 23 to 27, 72 to 76 and 78 in the Agreed Statement of Facts. The Member repeatedly failed to administer prescribed doses of Levemir as ordered.

Allegation #1(d) in the Notice of Hearing is supported by paragraphs 29 to 33, 72 to 76 and 78 in the Agreed Statement of Facts. The Member administered an incorrect dose of Loxapine.

Allegation #1(e) in the Notice of Hearing is supported by paragraphs 34 to 41, 73 to 76 and 78 in the Agreed Statement of Facts. The Member withdrew an additional dose when she ought not to have done so. However, the evidence is unclear if she actively attempted to give the patient the medication. The Member then failed to dispose of the medication properly and document the incident.

Allegations #1(f)(i) and (ii) in the Notice of Hearing are supported by paragraphs 42 to 49, 73 to 76 and 78 in the Agreed Statement of Facts. The Member crushed all of the patient’s medication and gave them together at the same time via G-tube and did not use the correct amount of water to cleanse the G-tube post administration.

Allegations #1(g)(i)(ii) and (iii) in the Notice of Hearing are supported by paragraphs 65 to 77 and 78 in the Agreed Statement of Facts. The Member failed to document the condition of the patient’s wound, left a patient in acute respiratory distress with the respiratory therapist, refused to return to the patient's room when requested and failed to document the patient’s incident in the progress notes.

Allegation #1(h)(i) in the Notice of Hearing is supported by paragraphs 48, 49, 52, 58 and 78 in the Agreed Statement of Facts. The Member failed to perform aseptic technique for CVAD dressing changes, wound dressings and disinfection of needleless connector (clave) and insulin pens.

Allegation #1(h)(ii) in the Notice of Hearing is supported by paragraphs 49, 73 to 76 and 78 in the Agreed Statement of Facts. The Member failed to assess the PICC line for patency, assess dressing integrity and incorrectly programmed the pump.

Allegation #1(h)(iii) in the Notice of Hearing is supported by paragraphs 50, 51, 73 to 76 and 78 in the Agreed Statement of Facts. The Member failed to demonstrate understanding of the need for administering insulin in time with meals and could not properly calculate insulin dosage.

Allegation #1(h)(iv) in the Notice of Hearing is supported by paragraphs 54 to 57, 73 to 76 and 78 in the Agreed Statement of Facts. The Member failed to verify the eight patient rights or three checks before medication administration, left medication unattended, forgot to give a medication but signed that she had administered it, failed to check the medication administration record (MAR) for medication order prior to administration, and failed to demonstrate knowledge of the medications she was administering.

Allegation #1(h)(v) in the Notice of Hearing is supported by paragraphs 47, 59, 60, 73 and 78 in the Agreed Statement of Facts. The Member demonstrated incompetence in G-tube care and management, specifically with respect to flushing, troubleshooting and medication administration.

Allegation #1(h)(vi) in the Notice of Hearing is supported by paragraphs 61, 73 to 76 and 78 in the Agreed Statement of Facts. The Member failed to demonstrate proper aerosol medication administration.

Allegation #1(h)(vii) in the Notice of Hearing is supported by paragraphs 62, 73 to 76 and 78 in the Agreed Statement of Facts. The Member demonstrated lack of knowledge of what an enema was and how to administer one.

Allegation #1(h)(viii) in the Notice of Hearing is supported by paragraphs 63, 73 to 76 and 78 in the Agreed Statement of Facts. The Member did not properly complete the MRSA/VRE swabs from a wound.

Allegation #1(h)(ix) in the Notice of Hearing is supported by paragraphs 66, 73, 77 and 78 in the Agreed Statement of Facts. The Member failed to complete documentation on wound status.

Allegations #2(a) and (b) in the Notice of Hearing are supported by paragraphs 34 to 41, 66 to 70, 77 and 79 in the Agreed Statement of Facts. The Member failed to keep records for medication administration and wastage, documentation of care and documentation of patient status.

Allegation #3(a) in the Notice of Hearing is supported by paragraphs 16 to 22, 72, 73 and 80 in the Agreed Statement of Facts. The Member failed to maintain an active glucometer barcode as per organizational policy.

Allegations #3(b)(i)(ii)(iii) and (iv) in the Notice of Hearing are supported by paragraphs 23 to 27, 72, 76 and 80 in the Agreed Statement of Facts. The Member repeatedly administered doses of Levemir that were different from what was prescribed.

Allegation #3(d) in the Notice of Hearing is supported by paragraphs 29 to 33, 72 to 76 and 80 in the Agreed Statement of Facts. The Member failed to clarify a medication order that was confusing resulting in her administering the wrong dose of Loxapine.

Allegation #3(e) in the Notice of Hearing is supported by paragraphs 34 to 41, 73 to 76 and 80 in the Agreed Statement of Facts. The Member removed a second dose of medication from the ADU that was ordered daily and failed to properly waste or re-enter the medication into the system.

Allegations #3(f)(i) and (ii) in the Notice of Hearing are supported by paragraphs 42 to 46, 73 to 77 and 80 in the Agreed Statement of Facts. The Member failed to administer medication properly through a G-tube: specifically, she crushed all medication together and gave them at the same time, and she failed to flush the G-tube adequately post medication administration.

Allegations #3(g)(i)(ii) and (iii) in the Notice of Hearing are supported by paragraphs 65 to 77 and 80 in the Agreed Statement of Facts. The Member’s documentation for treatment performed was incomplete, she failed to document a patient’s respiratory distress incident and she failed to attend to her patient in respiratory distress when requested by the observing nurse.

Allegation #3(h)(i) in the Notice of Hearing is supported by paragraphs 48, 49, 52, 58, 73 to 77 and 80 in the Agreed Statement of Facts. The Member failed to apply principles of asepsis for central venous access devices, foley catheter flushes and wound dressing changes.

Allegation #3(h)(ii) in the Notice of Hearing is supported by paragraphs 49, 73 and 80 in the Agreed Statement of Facts. The Member failed to check for catheter patency before accessing.

Allegation #3(h)(iii) in the Notice of Hearing is supported by paragraphs 50, 51, 73 to 76 and 80 in the Agreed Statement of Facts. The Member failed to administer medication for diabetic patients in time with meals or feeds.

Allegation #3(h)(iv) in the Notice of Hearing is supported by paragraphs 47, 59, 60, 73 to 76 and 80 in the Agreed Statement of Facts. The Member failed to demonstrate safe medication administration on several occasions as demonstrated by not verifying eight patient rights or three checks prior to administration, left medication unattended, failed to review or confirm medication records prior to administration, and misinterpreting medication orders.

Allegation #3(h)(v) in the Notice of Hearing is supported by paragraphs 47, 59, 60, 73 to 76 and 80 in the Agreed Statement of Facts. The Member failed to administer medication and feeds properly via G-tube.

Allegation #3(h)(vi) in the Notice of Hearing is supported by paragraphs 61, 73 to 76 and 80 in the Agreed Statement of Facts. The Member was unaware of the need for an oral rinse post Flovent administration demonstrating a lack of knowledge for a specific medication administration. The patient was not provided an oral rinse post inhalation.

Allegation #3(h)(vii) in the Notice of Hearing is supported by paragraphs 62, 73 to 76 and 80 in the Agreed Statement of Facts. The Member required assistance in administering a fleet enema due to lack of knowledge.

Allegation #3(h)(viii) in the Notice of Hearing is supported by paragraphs 63, 73 and 80 in the Agreed Statement of Facts. The Member failed to properly obtain MRSA/VRE swabs from a wound.

Allegations #3(h)(ix) in the Notice of Hearing is supported by paragraphs 66, 73, 77 and 80 in the Agreed Statement of Facts. The Member failed to complete a wound assessment and dressing as ordered and failed to document the assessment completely.

The Member’s conduct in all of Allegation #3, was clearly relevant to the practice of nursing. The Panel finds that the Member’s conduct was unprofessional as she showed persistent disregard for her professional obligations for safe medication practice, aseptic technique, device assessment and management, patient assessment and management of respiratory distress, and documentation standards. The Member’s conduct was also dishonourable as she 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’s Counsel advised the Panel that a Joint Submission on Order had been agreed upon. The Joint Submission on Order requests that this Panel make an order as follows:

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

2. Directing the Executive Director to suspend the Member’s certificate of registration for 4 months. This 4-month suspension shall take effect from July 19, 2021 and shall continue to run without interruption as long as the Member remains in a practicing class.

3. Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at her own expense and within 6 months from the date that this Order becomes final. If the Expert determines that a greater number of sessions are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date 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 in advance of the meetings;

ii. At least 7 days before the first meeting, the Member provides the Expert with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. 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):

1. Professional Standards,

2. Medication,

3. Documentation, and

4. Code of Conduct;

iv. At least 7 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:

1. the acts or omissions for which the Member was found to have committed professional misconduct,

2. the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,

3. strategies for preventing the misconduct from recurring,

4. the publications, questionnaires and modules set out above, and

5. 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:

1. the dates the Member attended the sessions,

2. that the Expert received the required documents from the Member,

3. that the Expert reviewed the required documents and subjects with the Member, and

4. the Expert’s assessment of the Member’s insight into her behaviour; and

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

b) Within 12 months from the date that this Order becomes final, or a longer time period as approved by the Director, the Member shall successfully complete at her own expense nursing courses (with clinical or laboratory or other practical components) that have received prior approval from the Director regarding: Medication Administration and Health Assessment. The Member must pass the courses. If the courses are graded, the Member must receive a minimum passing grade of 65%. The Member must provide the Director with proof of enrolment, successful completion of the courses and the specific grades received (if applicable).

c) For a period of 12 months from the date this Order becomes final during which the Member is engaged continuously in the practice of nursing (i.e. not including the period during which the Member’s certificate of registration is suspended), 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:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. a copy of the Panel’s Decision and Reasons, once available; and

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:

1. that they received a copy of the required documents, and

2. 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.

d) For a period of at least 8 months and no longer than 12 months from the date this Order becomes final during which the Member is engaged continuously in the practice of nursing (i.e. not including the period during which the Member’s certificate of registration is suspended), the Member must meet with a Registered Nurse who is employed at the same employer as the Member and who is pre-approved by the Director (“Mentor”) to discuss her efforts to ensure that her care, medication administration and documentation are meeting the standards of practice of the profession. The Member must meet with the Mentor at such frequency as determined by the Mentor, but at least monthly. In order for the Mentor to be pre-approved by the Director, the Member must:

i. Provide the proposed mentor with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. a copy of the Panel’s Decision and Reasons, once available;

ii. Provide the Director with a copy of the proposed mentor’s résumé and a report confirming the following:

1. that the proposed mentor has received a copy of the documents identified in 3(d)(i), and

2. that the proposed mentor agrees to notify the Director and the Member’s employer immediately upon receipt of any information that the Member has breached the standards of practice of the profession.

e) After the 8-month period identified in 3(d) above, the Mentor will determine whether additional meetings with the Member are required and will arrange those meetings as necessary during the 12-month period.

f) The Mentor will advise the Director in writing when the meetings have ended.

g) The Member shall not practice independently in the community for a period of 12 months from the date this Order becomes final during which the Member is engaged continuously in the practice of nursing (i.e. not including the period during which the Member’s certificate of registration is suspended).

4. All documents delivered by the Member to the CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.

Penalty Submissions

Submissions were made by College Counsel.

College Counsel submitted that the penalty set out in the Joint Submission on Order is based on an agreement negotiated by experienced Counsel. The provisions are in-line with the objectives of general deterrence aimed at the profession-at-large and specific deterrence for the Member. The penalty provides for remediation and rehabilitation of the Member. Protection of the public is maintained through the suspension of the Member’s certificate of registration, restrictions placed on the Member’s practice as well as the employer notification. All terms of the penalty help to maintain public confidence in the College.

The aggravating factors in this case are:

• The Member showed a significant number of standard breaches and errors, including two failures to document, over an extended period of time for a number of patients;

• The Member’s medication errors exposed patients to potential harm and in some cases, patients were adversely affected;

• [Patient E] was exposed to potential harm as the Member left the patient unattended;

• The Member’s repeated professional misconduct showed a blatant disregard for her professional obligations.

The mitigating factors in this case are:

• The Member has cooperated with the investigation resulting in an uncontested hearing;

• The Member has shown remorse for her actions by attending the hearing and has taken responsibility for her past behaviours by agreeing to the Agreed Statement of Facts and the Joint Submission on Order;

• There have not been any concerns with the Member’s work performance with her current employer since starting in 2016;

• This is the Member’s first disciplinary issue with the College since graduating in 2004;

• The Member has gained insight and implemented changes to her practice following her tenure at PRHC.

The proposed penalty provides for general deterrence through the four-month suspension. This sends a clear message to the profession-at-large that engaging in similar conduct will result in serious disciplinary sanctions.

The proposed penalty provides for specific deterrence through the four-month suspension and the oral reprimand which will assist the Member in gaining a clearer understanding of how her actions are perceived by both the public and the profession.

The proposed penalty provides for remediation and rehabilitation through the meetings with a Regulatory Expert, review of the College’s publications, completion of courses, and mentoring. These components will support the Member in continuing the learning and insights she has gained as well as giving her an understanding of the importance of adherence to professional standards in her daily practice.

The terms, conditions and limitations on the Member’s certificate of registration including not being able to practice independently in the community for a 12-month period, sends a message to the profession and the public that this behaviour will not be tolerated. The comprehensive remediation and rehabilitation program at the Member’s own cost ensures the public that this Member is committed to rehabilitation.

Overall, the public is protected because the Joint Submission on Order’s comprehensive remediation and rehabilitation program, the terms, conditions and limitations including the employer notification and the restrictions will ensure the Member’s practice is monitored for a significant time when she returns to nursing after her suspension.

College Counsel submitted cases to the Panel to demonstrate that the proposed penalty falls within the range of similar cases from this Discipline Committee.

CNO v. Popo (Discipline Committee, 2020). The hearing proceeded with an Agreed Statement of Facts and Joint Submission on Order. Similarities include that the member failed to assess the patient following notification from a nursing colleague, failure to initiate appropriate interventions after finding a patient without vital signs and documenting false or misleading statements. The penalty included an oral reprimand, a three-month suspension, two meetings with a Regulatory Expert and an 18-month employer notification.

CNO v. Whyte (Discipline Committee, 2020). The hearing proceeded with an Agreed Statement of Facts and Joint Submission on Order. Similarities include that the member failed to assess and respond. In this case, there was a single patient incident. The penalty included an oral reprimand, a three-month suspension, two meetings with a Regulatory Expert, courses and a 24-month employer notification.

CNO v. Rubini-Catalano (Discipline Committee, 2020). This hearing also proceeded by way of an Agreed Statement of Facts and Joint Submission on Order. The similarities in this case included a series of medication errors and incomplete or false documentation, Insulin was administered contrary to the medical order, incorrect drip rates for medication delivery, and a finding of failure to keep records. There was a subcategory of issues not applicable to the present case. Due to these other issues, the member received a seven-month suspension versus the four-month suspension sought for the current Member before the Panel. In addition, there was an oral reprimand, two meetings with a Regulatory Expert, a 24-month employer notification, a mentoring provision and no independent practice in the community for 24-months.

The Member’s Counsel submitted that the Member accepts responsibility in these matters and apologized for any inconvenience. She has taken responsibility for her mistakes, has learned from them gaining significant insight that she has applied to her current practice. The proposed penalty protects the public and addresses all the goals of penalty.

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.

2. The Executive Director is directed to suspend the Member’s certificate of registration for 4 months. This 4-month suspension shall take effect from July 19, 2021 and shall continue to run without interruption as long as the Member remains in a practicing class.

3. The Executive Director is directed to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at her own expense and within 6 months from the date that this Order becomes final. If the Expert determines that a greater number of sessions are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date 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 in advance of the meetings;

ii. At least 7 days before the first meeting, the Member provides the Expert with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. 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):

1. Professional Standards,

2. Medication,

3. Documentation, and

4. Code of Conduct;

iv. At least 7 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:

1. the acts or omissions for which the Member was found to have committed professional misconduct,

2. the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,

3. strategies for preventing the misconduct from recurring,

4. the publications, questionnaires and modules set out above, and

5. 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:

1. the dates the Member attended the sessions,

2. that the Expert received the required documents from the Member,

3. that the Expert reviewed the required documents and subjects with the Member, and

4. the Expert’s assessment of the Member’s insight into her behaviour; and

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

b) Within 12 months from the date that this Order becomes final, or a longer time period as approved by the Director, the Member shall successfully complete at her own expense nursing courses (with clinical or laboratory or other practical components) that have received prior approval from the Director regarding: Medication Administration and Health Assessment. The Member must pass the courses. If the courses are graded, the Member must receive a minimum passing grade of 65%. The Member must provide the Director with proof of enrolment, successful completion of the courses and the specific grades received (if applicable).

c) For a period of 12 months from the date this Order becomes final during which the Member is engaged continuously in the practice of nursing (i.e. not including the period during which the Member’s certificate of registration is suspended), 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:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. a copy of the Panel’s Decision and Reasons, once available; and

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:

1. that they received a copy of the required documents, and

2. 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.

d) For a period of at least 8 months and no longer than 12 months from the date this Order becomes final during which the Member is engaged continuously in the practice of nursing (i.e. not including the period during which the Member’s certificate of registration is suspended), the Member must meet with a Registered Nurse who is employed at the same employer as the Member and who is pre-approved by the Director (“Mentor”) to discuss her efforts to ensure that her care, medication administration and documentation are meeting the standards of practice of the profession. The Member must meet with the Mentor at such frequency as determined by the Mentor, but at least monthly. In order for the Mentor to be pre-approved by the Director, the Member must:

i. Provide the proposed mentor with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. a copy of the Panel’s Decision and Reasons, once available;

ii. Provide the Director with a copy of the proposed mentor’s résumé and a report confirming the following:

1. that the proposed mentor has received a copy of the documents identified in 3(d)(i), and

2. that the proposed mentor agrees to notify the Director and the Member’s employer immediately upon receipt of any information that the Member has breached the standards of practice of the profession.

e) After the 8-month period identified in 3(d) above, the Mentor will determine whether additional meetings with the Member are required and will arrange those meetings as necessary during the 12-month period.

f) The Mentor will advise the Director in writing when the meetings have ended.

g) The Member shall not practice independently in the community for a period of 12 months from the date this Order becomes final during which the Member is engaged continuously in the practice of nursing (i.e. not including the period during which the Member’s certificate of registration is suspended).

4. All documents delivered by the Member to the CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.

Reasons for Penalty Decision

The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses protection of the public, 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 provides public protection.

The Panel accepts that specific deterrence is satisfied through the oral reprimand and the four-month suspension.

The Panel accepts that general deterrence is satisfied by the four-month suspension and 12-month employer notification which sends a strong message to the profession at large that this conduct will not be tolerated by the College.

The Panel further accepts that the Member’s remediation and rehabilitation is satisfied through the two meetings with a Regulatory Expert, completion of nursing courses, review of standards, completion of reflective questionnaires and a period of mentorship of at least 8 months but no longer than 12 months.

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

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.