College of Nurses of Ontario v. Krin, 2021 ONCNO 152492

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Mary MacNeil, RN Chairperson Margarita Cleghorne, RPN Member Karen Goldenberg Public Member Carly Hourigan Public Member Terry Holland, RPN Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO JEAN-CLAUDE KILLEY for College of Nurses of Ontario

• and -

CINDY KRIN Registration No. 16155973 KIM PATENAUDE for Cindy Krin

CHRISTOPHER WIRTH Independent Legal Counsel

Heard: May 26, 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 26, 2021, via videoconference. Cindy Krin (the “Member”) appeared with the assistance of a French interpreter.

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 the Member.

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

The Allegations

The allegations against the Member as stated in the Notice of Hearing dated March 31, 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 practicing as a Registered Nurse (“RN”) at Montfort Hospital in Ottawa, Ontario (the “Facility”), you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, and in particular, on or about August 5-6, 2018:

(a) you failed to complete periodic assessments of one of your assigned patients, [ ], with appropriate frequency;

(b) you documented inaccurate and/or false entries in [the Patient’s] health record, documenting events at or about 0450 and/or 0610 on August 6, 2018 that did not occur and/or did not occur at those times;

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(13) of Ontario Regulation 799/93, in that, while practicing as an RN at the Facility, you failed to keep records as required, and in particular:

(a) you documented inaccurate and/or false entries in [the Patient’s] health record, documenting events at or about 0450 and/or 0610 on August 8, 2018 that did not occur and/or did not occur at those times;

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(14) of Ontario Regulation 799/93, in that, while practicing as an RN at the Facility, you falsified a record relating to your practice, and in particular:

(a) you documented inaccurate and/or false entries in [the Patient’s] health record, documenting events at or about 0450 and/or 0610 on August 6, 2018 that did not occur and/or did not occur at those times;

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(37) of Ontario Regulation 799/93, in that, while practicing as an RN at the Facility, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional, and in particular on or about August 5-6, 2018:

(a) you failed to complete periodic assessments of one of your assigned patients, [ ], with appropriate frequency;

(b) you documented inaccurate and/or false entries in [the Patient’s] health record, documenting events at or about 0450 and/or 0610 on August 6, 2018 that did not occur and/or did not occur at those times.

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a), 1(b), 2(a), 3(a), 4(a) and 4(b) 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:

LA MEMBRE

1. Cindy Krin (la « membre ») a obtenu un diplôme en soins infirmiers du Collège Montmorency en décembre 2010.

2. La membre s'est inscrite à l'Ordre des infirmières et infirmiers de l'Ontario (« 0110 ») à titre d'infirmière autorisée (« IA ») le 13 septembre 2016. La membre est également une membre en règle de l'organisme de réglementation des soins infirmiers du Québec, l'Ordre des infirmières et infirmiers du Québec, depuis décembre 2010.

3. La membre a été embauchée en tant qu'infirmière autorisée au service des urgences de l'Hôpital Monfort (« l'établissement ») à Ottawa, en Ontario, le 18 septembre 2017. Elle a été licenciée le 16 août 2018 pour l'incident de faute professionnelle décrit ci-dessous.

4. La membre est actuellement employée en tant qu'infirmière autorisée à temps plein chez Extendicare Medex à Ottawa (Ontario) et en tant qu'infirmière autorisée occasionnelle à l'Urgence médicale Code Bleu à Montréal (Québec).

5. La membre n'a pas d'antécédents disciplinaires avec 10110 ou l'Ordre des infirmières et infirmiers du Québec.

LA POLITIQUE PERTINENTE DE L'ÉTABLISSEMENT ET LES ATTENTES DU SERVICE DES URGENCES

6. La politique de l'établissement « Dossier médical électronique - Tenue à jour par les professionnels de la santé » (la « Politique ») exige que le personnel infirmier tienne une documentation « exacte, véridique et honnête ». De plus, la Politique souligne que la documentation doit être « opportune et documentée pendant, ou dans un délai raisonnable après, l'intervention ». Pour le service des urgences, en particulier, le personnel infirmier s'appuie principalement sur des dossiers papier, par opposition à la documentation électronique.

7. Si les infirmières et infirmiers doivent modifier les informations saisies au dossier, ils sont autorisés à changer les informations dans le dossier du patient dans les 120 heures suivant l'intervention ou l'évaluation non documentée ou incomplète.

8. L'établissement attend des infirmières et infirmiers qu'ils fassent des rondes toutes les heures pour documenter les soins aux patients. Si les patients sont éveillés, les infirmières et infirmiers sont censés entrer dans les salles d'examen et poser une série de questions standard pour vérifier la lucidité, les changements de symptômes, etc. Si les patients sont endormis, les infirmières et infirmiers doivent tout de même entrer dans les salles d'examen et effectuer un contrôle visuel des patients pour s'assurer de leur sécurité et de leur état de santé général.

LE PATIENT

9. (le « patient ») était un homme de 41 ans qui s'est rendu, de sa propre initiative, au service des urgences de l'établissement vers 16 h 37 le 5 août 2018.

10. Le patient a été vu par une médecin du service des urgences vers 22 h 45. Peu de temps après, à 23 h 04, le patient a reçu 1 mg de Risperdal, un medicament antipsychotique.

11. La membre travaillait dans l'équipe de nuit du service des urgences les 5 et 6 août 2018, de 19 h 30 à 07 h 30.

12. La membre approchait de la fin de son quart de nuit lorsqu'elle a découvert le patient pendu dans la salle d'examen à 07 h 14, le 6 août 2018. Malgré le fait que la membre ait déclenché un code bleu, le patient a été déclaré mort à 07 h 15 par suicide.

LES INCIDENTS PERTINENTS POUR LES ALLÉGATIONS DE FAUTE PROFESSIONNELLE

13. Après son admission au service des urgences, le patient a dit à la médecin qu'il voulait obtenir une ordonnance pour contrôler les « voix » et les « hallucinations ». Le patient a indiqué qu'il avait des pensées suicidaires au moins une fois par mois et qu'il s'inquiétait de sa stabilité. Le patient a également dit à la médecin qu'il craignait que sa psychose ne revienne parce qu'il entendait des voix lui disant de se tuer.

14. La médecin lui a demandé s'il était actuellement suicidaire ou s'il avait l'intention de se suicider. Le patient a répondu qu'il n'avait pas d'idées suicidaires ou d'hallucinations à ce moment précis.

15. Le patient a demandé à la médecin s'il pouvait être évalué par un psychiatre parce qu'il voulait de l'aide pour contrôler les voix et qu'il était prêt à attendre le matin (6 août 2018) pour être évalué, si nécessaire, afin de recevoir une ordonnance.

16. La médecin a déterminé que le patient devait être évalué par un psychiatre, elle a donc ordonné une consultation psychiatrique. Aucun observateur ou « gardien » n'a été demandé.

17. Le patient n'a pas identifié de facteurs de stress ou de déclencheurs immédiats à la médecin lors de l'évaluation initiale qui auraient nécessité une admission en vertu d'un Formulaire 1. Le patient a pu faire l'objet d'une évaluation psychiatrique tôt le 6 août 2018 et le patient n'a pas laissé entendre que ce délai posait problème ou qu'il courait un risque imminent d'automutilation.

18. Le patient a quitté sa chambre environ sept fois entre 23 h 07 et 03 h 59 les 5 et 6 août 2018, respectivement. Le patient a quitté le service des urgences pour fumer l'extérieur, aller aux toilettes et arpenter les couloirs. Chaque fois qu'il retournait dans sa chambre, il fermait la porte, fermait les stores et éteignait les lumières.

19. La membre a dit à un collègue qu'il lui semblait approprié de laisser le patient garder sa porte fermée parce qu'un patient dans la salle d'examen voisine était agité, bruyant et dérangeant. Par conséquent, la membre et son collègue ont determine que, pour éviter que le patient s'énerve, celui-ci devait être autorisé à fermer sa porte.

20. À 00 h 15, la membre a ouvert la porte du patient et a procédé à une verification visuelle. Bien que la membre n'ait pas consigné sa vérification dans le dossier du patient, la vidéosurveillance de l'établissement montre qu'elle s'est approchée de la chambre du patient et a procédé a une évaluation rapide de ce dernier.

21. À 02 h 00, la membre a consigné dans le dossier du patient qu'il était « sorti prendre l'air ».

22. La membre a pris une pause de 03 h 30 à 04 h 30. À son retour au service des urgences, son collègue l'a informée verbalement de l'état du patient. Il l'a informée qu'il n'avait pas vérifié l'état du patient pendant la pause de la membre parce que trois nouveaux patients étaient arrivés, monopolisant son temps pendant la pause de la membre.

23. Le patient a quitté sa chambre pour aller fumer une cigarette à l'extérieur. Le patient est retourné dans sa chambre à 03 h 59.

24. Selon la vidéo de surveillance de l'établissement, le patient n'a plus quitté sa chambre après 03 h 59 le 6 août 2018.

25. De 03 h 59 à 07 h 14, personne n'est entré dans la chambre du patient ou n'a interagi avec lui depuis les couloirs pour effectuer une évaluation ou une vérification de routine de son état.

26. Cependant, la membre a documenté qu'a 04 h 50, elle a vu le patient faire le tour du couloir de manière calme et posée alors qu'elle était au poste de soins infirmiers.

27. La membre a également documenté qu'à 06 h 10, le patient a refusé un verre d'eau et a demandé à la membre à quelle heure le psychiatre devait venir l'examiner ce jour-là.

28. Si la membre devait témoigner, elle déclarerait qu'elle a perdu la notion du temps parce que le service des urgences était particulièrement chargé la nuit du 5 au 6 août 2018, mais qu'elle était consciente des attentes de l'établissement en matière de vérifications régulières des patients et de documentation en temps opportun et, en particulier, de l'attente consistant à effectuer et de documenter des verifications toutes les heures des patients qui pourraient être à risque d'automutilation.

29. La membre reconnaîtrait aussi pleinement et admettrait qu'elle n'a pas évalué le patient de façon appropriée à 04 h 59 et 06 h 10, malgré ce qu'elle a documenté dans le dossier médical du patient. La membre reconnaît en outre que, comme le confirme la vidéosurveillance du service des urgences des 5 et 6 août 2018, le patient n'a pas quitté sa chambre après 03 h 59 et qu'aucun membre du personnel infirmier ne s'est approché ou n'est entré dans sa salle d'examen aux heures que la membre a consignées dans le dossier du patient.

30. La première fois que la membre est entrée dans la chambre du patient après son contrôle à 00 h 15, c'était autour de 07 h 14, moment où elle a trouvé le patient suspendu à un luminaire. Malgré le déclenchement d'un code bleu, le décès du patient a été prononcé à 07 h 15.

31. Si la membre devait témoigner, elle soulignerait qu'elle était en état de choc après avoir découvert le patient lorsqu'elle a rempli le dossier susmentionné. Elle a suivi une thérapie dans un cabinet privé et a assisté à des séances de counseling à la suite de l'incident. Néanmoins, la membre reconnaît que les données qu'elle a saisies dans le dossier médical du patient à 04 h 50 et à 06 h 10 sont inexactes et qu'elle a omis de remplir et de documenter avec précision les évaluations périodiques du patient, comme l'exigent les normes d'exercice de l'établissement et de l'OIIO.

NORMES D'EXERCICE DE L'OIIO

32. L'OIIO publie des normes de soins infirmiers afin de définir les attentes relatives à l'exercice de la profession infirmière. Les normes de l’OIIO informent les infirmières et infirmiers de leurs obligations redditionnelles et s'appliquent à toutes les infirmières et tous les infirmiers, quels que soient leur rôle, leur description de poste et leur domaine d'exercice.

Normes professionnelles

33. Les Normes professionnelles de l'OIIO stipulent que chaque infirmière est responsable envers le public et qu'elle doit veiller à ce que son exercice et sa conduite respectent les exigences législatives et les normes d'exercice de la profession. L'infirmière démontre cette norme de différentes façons, notamment :

a. en s'assurant d'exercer conformément aux normes d'exercice et aux directives professionnelles de l’OIIO, ainsi qu'a la législation;

b. en prenant des mesures dans des situations où la sécurité et le bien-être du client sont compromis; et

c. en évaluant/décrivant les résultats d'interventions spécifiques et en modifiant le plan/l'approche.

34. La membre admet que le fait de ne pas avoir surveillé et évalué le patient de manière appropriée constitue une infraction aux Normes professionnelles.

La norme « La tenue de dossiers »

35. La norme « La tenue de dossiers » de l’OIIO stipule que les infirmières sont tenues de s'assurer que leur documentation sur les soins aux clients est « exacte, opportune et complète ». La norme précise qu'une infirmière satisfait à la norme, notamment :

a. en s'assurant que la documentation constitue un dossier complet des soins infirmiers fournis et reflète tous les aspects du processus de soins infirmiers, notamment l'évaluation, la planification, l'intervention (réalisée de manière autonome ou collaborative) et l'évaluation;

b. en consignant les informations en temps opportun et en remplissant la documentation pendant, ou dès que possible après, le soin ou l'intervention;

c. en indiquant quand une information a été saisie en retard;

d. en documentant les données objectives et subjectives; et

e. en s'assurant que les informations pertinentes relatives aux soins du client sont consignées dans un dossier permanent.

36. La membre admet que le fait de ne pas avoir tenu une documentation appropriée en ce qui concerne l'évaluation et la surveillance du patient a constitué une infraction à la norme « La tenue de dossiers ».

La relation thérapeutique

37. L'un des thèmes centraux de la norme « La relation thérapeutique » de l’OIIO est le maintien et la promotion de soins infirmiers sécuritaires. La santé et le bien-être du patient sont au coeur de tous les soins thérapeutiques, quel que soit le milieu d'exercice. En vertu du déséquilibre des pouvoirs dans une relation thérapeutique, on fait confiance aux infirmières pour fournir des soins adaptés, et axés sur le patient, qui protègent la santé physique, émotionnelle, mentale et spirituelle du patient, tant que ce dernier se trouve dans les limites de la relation professionnelle.

38. La membre admet que le fait de ne pas avoir surveillé et évalué le patient de façon appropriée pour assurer sa sécurité a constitué une infraction à la norme « La relation thérapeutique ».

AVEUX DE FAUTE PROFESSIONNELLE

39. La membre admet avoir commis les fautes professionnelles alléguées aux paragraphes 1 à 4 de l'Avis d'audience et décrits aux paragraphes 6 à 31 ci-dessus.

40. En particulier, la membre admet avoir commis les fautes professionnelles alléguées aux paragraphes 1(a) et 4(a) de l'Avis d'audience et décrits aux paragraphes 6 à 31 ci-dessus, en omettant d'effectuer des évaluations périodiques de son patient assigné, [ ], à une fréquence appropriée.

41. La membre admet qu'elle a commis les fautes professionnelles alléguées aux paragraphes 1(b), 2(a), 3(a) et 4(b) de l'Avis d'audience et décrits aux paragraphes 6 à 31 ci-dessus, en consignant des informations inexactes dans le dossier medical du [le patient] lorsqu'elle a documenté des événements vers 04 h 50 et 06 h 10, le 6 août 2018, qui n'ont pas eu lieu et/ou ne se sont pas produits à ces moments-là.

42. La membre admet que les fautes professionnelles alléguées aux paragraphes 1 à 4 de l'Avis d'audience, et décrites aux paragraphes 6 à 31 ci-dessus, seraient raisonnablement considérées comme déshonorantes et contraire aux devoirs de la profession par les membres de la profession.

[Translation]

THE MEMBER

1. Cindy Krin (the “Member”) obtained a diploma in nursing from College Montmorency in December 2010.

2. The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on September 13, 2016. The Member has also been a member in good standing with the regulatory nursing body in Québec, Ordre des infirmières et infirmiers du Québec, since December 2010.

3. The Member was hired as an Emergency Department RN at Monfort Hospital (the “Facility”) in Ottawa, Ontario on September 18, 2017. She was terminated on August 16, 2018 for the incident of professional misconduct described below.

4. The Member is currently employed as a full-time RN at Extendicare Medex in Ottawa, Ontario and a casual RN at Urgence Medicale Code Bleu in Montreal, Québec.

5. The Member has no prior disciplinary history with either CNO or the Ordre des infirmières et infirmiers du Québec.

RELEVANT FACILITY POLICY AND EMERGENCY DEPARTMENT EXPECTATIONS

6. The Facility’s Electronic Health Record – Maintenance by Health Professionals policy (the “Policy”) requires that nursing staff maintain “accurate, true and honest” documentation. Moreover, the Policy emphasizes that documentation must be “timely and documented during, or within a reasonable amount of time after, the care event”. For the Emergency Department, specifically, nurses rely mostly on paper-based charting as opposed to electronic documentation.

7. If nurses need to amend chart entries, they are permitted to change information in the patient record within 120 hours after the undocumented or incomplete procedure or assessment.

8. The Facility’s expectation is that nurses will perform hourly rounds to document patient care. If patients are awake, nurses are expected to enter examination rooms and ask a standard series of questions to ascertain lucidness, symptom changes, etc. If patients are asleep, nurses are still expected to enter examination rooms and do a visual check of patients to ensure safety and overall health.

THE PATIENT

9. (the “Patient”) was a 41-year-old male who admitted himself voluntarily to the Facility’s Emergency Department at approximately 1637 on August 5, 2018.

10. The Patient was seen by an Emergency Department physician at approximately 2245. Shortly thereafter, at 2304, the Patient was administered 1 mg of Risperdal, an antipsychotic medication.

11. The Member was working the night shift in the Emergency Department on August 5-6, 2018 from 1930 until 0730.

12. The Member was nearing the end of her night shift when she discovered the Patient hanged in the examination room at 0714 on August 6, 2018. Despite the Member calling a Code Blue, the Patient was declared dead at 0715 from suicide.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

13. Following his admission to the Emergency Department, the Patient told the physician that he wanted to get a prescription to control “voices” and “hallucinations”. The Patient indicated that he was having suicidal thoughts at least once a month that were causing him to worry about his stability. The Patient also told the physician that he feared his psychosis was returning because he was hearing voices telling him to kill himself.

14. The physician asked him if he was presently suicidal or had plans to kill himself. The Patient replied that he was not having suicidal ideation or hallucinations at the present time.

15. The Patient asked the physician if he could be assessed by a psychiatrist because he wanted help to control the voices and was willing to wait until the morning (August 6, 2018) to be assessed, if necessary, to receive a prescription.

16. The physician determined that the Patient should be assessed by a psychiatrist, so she ordered a psychiatric consult. No observer or “sitter” was requested.

17. The Patient did not identify any immediate stressors or triggers to the physician during the admission assessment that would have required an admission under a Form 1. The earliest the Patient could undergo a psychiatric assessment was in the morning on August 6, 2018 and the Patient did not suggest that this was an issue with this timeline or that he was at imminent risk of self-harm.

18. The Patient left his room approximately seven times between 2307 and 0359 on August 5 and 6, 2018, respectively. The Patient left the Emergency Department to smoke outside, use the washroom and pace the hallways. Each time he re-entered the room, he closed the door, shut the blinds and turned off the lights.

19. The Member told a colleague that she felt it was appropriate to let the Patient keep his door closed because a patient in the examination room next door was agitated, noisy and causing a disturbance. Therefore, the Member and her colleague determined that, in order to prevent escalating the nerves of the Patient, he should be permitted to close his door.

20. At 0015, the Member opened the Patient’s door and conducted a visual check. Although the Member did not document her check in the Patient’s chart, the Facility’s video surveillance captures the Member approaching the Patient’s room and completing a rapid assessment of the Patient.

21. At 0200, the Member recorded in the Patient’s chart that he “went out to get some air”.

22. The Member went on a shift break from 0330 to 0430. Upon her return to the Emergency Department, her colleague verbally updated her on the Patient’s status. He informed her that he had not checked on the Patient during the Member’s break because three new patients arrived, monopolizing his time during the Member’s break.

23. The Patient left his room to go outside for a cigarette. The Patient returned to his room at 0359.

24. According to Facility surveillance video, the Patient did not leave his room after 0359 on August 6, 2018.

25. From 0359 until 0714, no one entered the Patient’s room or interacted with him from the hallways to conduct an assessment or routine status check.

26. However, the Member documented that at 0450, she observed the Patient circling the corridor in a calm and collected manner while she was at the nursing station.

27. The Member further documented that at 0610, the Patient refused a glass of water and asked the Member what time the psychiatrist was coming to evaluate him that day.

28. If the Member were to testify, she would state that she lost track of time because the Emergency Department was particularly demanding the night of August 5-6, 2018, but that she was aware of the Facility’s expectations of regular patient checks and timely documentation and, in particular, of the expectation to conduct and document hourly checks of patients who could be at risk of self-harm.

29. The Member would also fully acknowledge and admit that she did not appropriately assess the Patient at 0459 and 0610, despite what she documented in the Patient’s health record. The Member further acknowledges that, as supported by Emergency Department video surveillance from August 5-6, 2018, the Patient did not leave his room after 0359 and no nurse approached or entered his examination room at the times the Member documented in the Patient’s chart.

30. The first time the Member entered the Patient’s room after her 0015 check was at or around 0714, at which time she found the Patient hanging from a light fixture. Despite calling a Code Blue, the Patient was pronounced dead at 0715.

31. If the Member were to testify, she would emphasize that she was in shock following her discovery of the Patient when she completed the above referenced charting. She sought private therapy and counselling in the aftermath of the incident. Nevertheless, the Member accepts that her entries in the Patient’s health record at 0450 and 0610 are inaccurate, and that she failed to complete and accurately document periodic assessments of the Patient, as required by the Facility and CNO’s standards of practice.

CNO STANDARDS OF PRACTICE

32. CNO publishes nursing standards to set out the expectations for the practice of nursing. CNO’s standards inform nurses of their accountabilities and apply to all nurses regardless of their role, job description and area of practice.

Professional Standards

33. 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:

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

b. taking action in situations in which client safety and well-being are compromised; and

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

34. The Member admits that her failure to appropriately monitor and assess the Patient breached the Professional Standards.

Documentation Standard

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

a. 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;

b. documenting in a timely manner and completing documentation during, or as soon as possible after, the care or event;

c. indicating when an entry is late;

d. documenting both objective and subjective data; and

e. ensuring that relevant client care information is captured in a permanent record.

36. The Member admits that her failure to maintain appropriate documentation with respect to assessing and monitoring the Patient was a breach of the Documentation standard.

Therapeutic Nurse-Client Relationship

37. A central theme of CNO’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) is the maintenance and promotion of safe nursing care. At the core of all therapeutic care, regardless of practice setting, is the patient’s health and well-being. Nurses are trusted, by virtue of the power imbalance in the nurse-patient role, to provide responsive patient-centred care that protects the physical, emotional, mental and spiritual health of the patient while they are in the boundaries of the professional relationship.

38. The Member admits that her failure to appropriately monitor and assess the Patient to ensure his safety breached the TNCR Standard.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

39. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1-4 of the Notice of Hearing and as described in paragraphs 6-31 above.

40. In particular, the Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a) and 4(a) of the Notice of Hearing and as described in paragraphs 6-31 above in that she failed to complete periodic assessments of her assigned patient, [ ], with appropriate frequency.

41. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(b), 2(a), 3(a), and 4(b) of the Notice of Hearing and as described in paragraphs 6-31 above in that she documented inaccurate entries in [the Patient’s] health record when she documented events at or about 0450 and 0610 on August 6, 2018 that did not occur and/or did not occur at those times.

42. The Member admits that the acts of professional misconduct as alleged in paragraphs 1-4 of the Notice of Hearing and as described in paragraphs 6-31 above would reasonably be regarded by members as dishonourable and unprofessional.

Submissions

College Counsel submitted that the Agreed Statement of Facts supports the allegations and asked the Panel to make findings of professional misconduct against the Member.

The Member’s Counsel had nothing further to add.

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), 1(b), 2(a), 3(a), 4(a) and 4(b) of the Notice of Hearing. As to allegations 4(a) and 4(b), 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.

Allegations #1(a) and 1(b) in the Notice of Hearing are supported by paragraphs 6 to 41 in the Agreed Statement of Facts. The Panel finds that the Member failed to meet the standards of practice of the profession. Failure to monitor and appropriately assess a patient is a breach of the Professional Standards and the TNCR Standard. A nurse is required to take action when a patient’s safety and well being is compromised. [The Patient] was admitted to the emergency department with recent suicidal thoughts. [The Patient] requested a prescription to control the voices and hallucinations and voices that were telling him to kill himself. The doctor did not order frequent checks on the client, but the Member should have used her professional knowledge and clinical judgement and instituted those checks herself. The Member also breached the Documentation Standard when she documented inaccurate entries in [the Patient’s] health record.

Allegation #2(a) in the Notice of Hearing is supported by paragraphs 6 to 32, 35, 39 and 41 in the Agreed Statement of Facts. The Panel finds that the Member failed to keep records as required by failing to complete periodic assessments of her assigned patient, [ ], with appropriate frequency. The Member documented inaccurate and false events at or about 0450 to 0610 on August 6, 2021 that did not occur and/or did not occur at these times. The Documentation Standard requires a nurse to be accountable for accurate, timely and complete documentation by documenting in a timely manner.

Allegation #3(a) in the Notice of Hearing is supported by paragraphs 6 to 32, 35, 39 and 41 in the Agreed Statement of Facts. The Panel finds that the Member falsified records. The Member documented events at or about 0450 to 0610 on August 6, 2021 that did not occur and/or did not occur at these times. The Documentation Standard requires a nurse to be accountable for accurate documentation by ensuring that documentation is completed after the event. Also the documentation is subjective and objective.

Allegations #4(a) and 4(b) in the Notice of Hearing are supported by paragraphs 6 to 31 and 39 to 42 in the Agreed Statement of Facts.

With respect to allegations #4(a) and 4(b), the Panel finds that the Member’s conduct in regards to [the Patient] where the Member failed to complete periodic assessments with an appropriate frequency and documented inaccurate entries in the health record was unprofessional. The Member’s conduct demonstrated a serious and persistent disregard for her professional obligations.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of dishonesty and deceit when the Member documented events at or about 0450 to 0610 on August 6, 2021 that did not occur and/or did not occur at these times. The Member knew or ought to have known that her conduct was unacceptable and fell 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. Exiger que la membre se présente devant le Comité pour être réprimandée dans les trois mois suivant la date à laquelle la présente ordonnance devient définitive.

2. Ordonner à la directrice générale de suspendre le certificat d'inscription de la membre pendant 3 mois. Cette suspension prendra effet à la date à laquelle la présente ordonnance deviendra définitive et se poursuivra sans interruption tant que la membre demeurera inscrite dans une catégorie de membre actif.

3. Ordonner à la directrice générale d'imposer les conditions et restrictions suivantes au certificat d'inscription de la membre :

a) La membre participera à deux réunions avec une experte en réglementation (« l'experte »), à ses frais et dans les six mois suivant la date à laquelle la présente ordonnance deviendra définitive. Pour se conformer, la member doit s'assurer que:

i. L'experte possède de vastes connaissances en matière de réglementation des soins infirmiers et a été approuvée par la directrice de la conduite professionnelle (la « directrice ») avant les réunions;

ii. Au moins sept jours avant la première réunion, la membre fournit à l'experte une copie :

1. de l'ordonnance du sous-comité;

2. de l'Avis d'audience;

3. de l'Exposé conjoint des faits;

4. du présent Exposé conjoint sur l'ordonnance; et

5. si disponible, une copie de la décision et des motifs du sous-comité.

iii. Avant la première réunion, la membre examine les publications suivantes de l’OIIO et remplit les questionnaires de réflexion, les modules d'apprentissage en ligne, les outils aidant à la prise de décisions et les formulaires en ligne de participation (le cas échéant) qui y sont associés :

1. Code de conduite;

2. La tenue de dossiers;

3. Normes professionnelles; et

4. La relation thérapeutique.

iv. Au moins sept jours avant la première réunion, la membre fournira à l'experte une copie des Questionnaires de réflexion dument remplis, et des formulaires en ligne de participation.

v. Les sujets abordés lors des séances avec l'experte comprendront :

1. les actes ou omissions pour lesquels la membre a été reconnue coupable de faute professionnelle;

2. les conséquences potentielles de la faute professionnelle pour les patients, les collègues, la profession et la membre elle-même;

3. les stratégies pour éviter que la faute professionnelle ne se reproduise;

4. les publications, questionnaires et modules énoncés ci-dessus; et

5. l'élaboration d'un plan d'apprentissage en collaboration avec l'experte.

vi. Dans les 30 jours suivant la fin de la dernière séance, la membre veillera à ce que l'experte transmette son rapport à la directrice, dans lequel l'experte confirmera :

1. les dates auxquelles la membre a participé aux séances;

2. que l'experte a reçu les documents requis de la part de la membre;

3. que l'experte a examiné les documents et les sujets requis avec la membre; et

4. l'évaluation de l'experte visant à déterminer si la membre a réfléchi à son comportement.

vii. Si la membre ne se conforme pas à une ou plusieurs des exigences ci-dessus, l'experte peut annuler toute séance prévue, même si cela a pour conséquence que la membre enfreigne une condition ou une restriction imposée à son certificat d'inscription.

b) Pendant une période de 14 mois à compter de la date à laquelle l'ordonnance devient définitive, la membre doit informer ses employeurs de la décision. Pour se conformer, la membre est tenue de :

i. Veiller à ce que la directrice soit informée du nom, de l'adresse et du numéro de téléphone de tout employeur dans les 14 jours suivant le début ou la reprise d'un emploi à un poste d'infirmière;

ii. Fournir à son ou ses employeurs une copie :

1. de l'ordonnance du sous-comité;

2. de l'Avis d'audience;

3. de l'Exposé conjoint des faits;

4. du présent Exposé conjoint sur l'ordonnance; et

5. une copie de la décision et des motifs du sous-comité, si disponible.

iii. N'exercer la profession infirmière que pour un employeur qui accepte de transmettre, et qui transmet effectivement, un rapport à la directrice dans les 14 jours suivant le début ou la reprise de l'emploi de la membre à tout poste d'infirmière, confirmant :

1. qu'il a reçu une copie des documents requis;

2. qu'il accepte de tenir la directrice informée dans l'éventualité où il recevrait des informations indiquant que la membre a enfreint les normes d'exercice de la profession; et

3. qu'il accepte de réaliser 3 vérifications ponctuelles aléatoires de la documentation de la membre aux intervalles suivants et de fournir un rapport à la directrice concernant l'exercice de la membre après chaque vérification :

a. la première vérification doit avoir lieu dans les 4 mois suivant la date à laquelle la membre commence ou reprend son emploi chez l'employeur;

b. la deuxième vérification doit avoir lieu dans les 8 mois suivant la date à laquelle la membre commence ou reprend son emploi chez l'employeur; et

c. la troisième vérification doit avoir lieu dans les 12 mois suivant la date à laquelle la membre commence ou reprend son emploi chez l'employeur.

iv. Les vérifications doivent, à chaque fois, comporter les éléments suivants :

1. l'examen d'au moins trois dossiers de la membre choisis de manière aléatoire, pour s'assurer qu'ils respectent les normes de 1'0110 et de l'employeur en matière de tenue des dossiers et de plan de soins; et

2. discuter (par téléphone ou en personne), avec au moins trois patients de la membre, des soins fournis par la membre et de la qualité des interactions de la membre avec les patients, afin de s'assurer que la membre a fourni les soins nécessaires ou requis aux patients et que la documentation de la membre reflète fidèlement les soins fournis.

3. Tous les documents remis par la membre à l’OIIO, à l'experte ou à l'employeur ou aux employeurs seront remis par une méthode vérifiable, dont la membre conservera la preuve.

[Translation]

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 3 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in 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 2 meetings with a Regulatory Expert (the “Expert”), at her own expense and within 6 months from the date this Order becomes final. To comply, the Member is required to ensure that:

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

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

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. Code of Conduct,

2. Documentation,

3. Professional Standards, and

4. Therapeutic Nurse-Client Relationship;

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

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

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;

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

b) For a period of 14 months from the date the Order becomes final, 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;

iii. Only practice nursing for an employer who agrees to, and does, forward a report to the Director within 14 days of the commencement or resumption of the Member’s employment in any nursing position, confirming:

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

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, and

3. that they agree to perform 3 random spot audits of the Member’s documentation at the following intervals and provide a report to the Director regarding the Member’s practice after each audit:

a. the first audit shall take place within 4 months from the date the Member begins or resumes employment with the employer,

b. the second audit shall take place within 8 months from the date the Member begins or resumes employment with the employer, and

c. the third audit shall take place within 12 months from the date the Member begins or resumes employment with the employer.

iv. The audits shall, on each occasion, involve the following:

1. reviewing a random selection of at least 3 of the Member’s charts to ensure they meet both CNO and employer documentation and care plan standards, and

2. discussing (by telephone or in person), with at least 3 of the Member’s patients, the care provided by the Member and the quality of the Member’s interactions with the patients to ensure that the Member provided necessary and/or required care to the patients and that the Member’s documentation accurately reflects the care provided.

3. 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.

The proposed penalty provides for general and specific deterrence through:

• An oral reprimand;
• A 3 month suspension.

The proposed penalty provides for remediation and rehabilitation through:

• 2 meetings with a Regulatory Expert;
• 14 months of employer notification.

Overall, the public is protected because:

• The employer is required to conduct 3 random spot audits of the Member’s documentation;
• The required audit of 3 of the Member’s charts ensures that CNO and employer documentation standards are being followed, the necessary care is provided and the documentation accurately reflects the care provided.
• The spot audits ensure rehabilitation and also assist with practice improvement.

The proposed penalty maintains public confidence in the College’s ability to regulate members of the profession and will maintain public confidence in the College’s disciplinary mechanism.

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. Nkwelle (Discipline Committee, 2018). In this case there were similarities as the member also worked the night shift in an emergency department with a high risk client who committed suicide during the shift. The conduct was similar in that the member failed to complete Q15 checks on a client and inaccurately documented these checks which ended in tragedy. The penalty received was an oral reprimand, a 3 month suspension, 2 meetings with a Nursing Expert and 12 months of employer notification.

CNO v. Ohiegbomwan (Discipline Committee, 2020). In this case the member failed to ensure that patients received appropriate treatment and failed to assess or monitor patients’ conditions. The penalty received was an oral reprimand, a 3 month suspension, 2 meetings with a Regulatory Expert, a nursing course, 18 months of employer notification and 3 random spot audits of 5 residents’ charts.

CNO v. Francis (Discipline Committee, 2018). The member failed to follow-up appropriately with a client after the client discussed suicide and made available movies to clients on the units which were therapeutically inappropriate. In this case there was a tragic ending. The penalty received was an oral reprimand, a 3 month suspension, 2 meetings with a Nursing Expert and 12 months of employer notification.

The Member’s Counsel agreed with College Counsel’s submission and indicated it was appropriate to proceed on a Joint Submission on Order which speaks to deterrence, protection of the public, maintenance of public confidence and rehabilitation.

The Member’s Counsel submitted that the mitigating factors include:

• It was a busy night on that shift and the Member lost the notion of time;
• The Member admitted to paragraphs 28-31 of the Agreed Statement of Facts;
• The Member was in shock due to the incident and sought therapy and counselling at her own expense since the incident;
• The Member admitted to the allegations and therefore avoided an unnecessary prolonged hearing.

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 3 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in 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 2 meetings with a Regulatory Expert (the “Expert”), at her own expense and within 6 months from the date of this Order becomes final. To comply, the Member is required to ensure that:

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

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

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. Code of Conduct,

2. Documentation,

3. Professional Standards, and

4. Therapeutic Nurse-Client Relationship;

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

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

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;

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

b) For a period of 14 months from the date the Order becomes final, 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;

iii. Only practice nursing for an employer who agrees to, and does, forward a report to the Director within 14 days of the commencement or resumption of the Member’s employment in any nursing position, confirming:

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

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, and

3. that they agree to perform 3 random spot audits of the Member’s documentation at the following intervals and provide a report to the Director regarding the Member’s practice after each audit:

a. the first audit shall take place within 4 months from the date the Member begins or resumes employment with the employer,

b. the second audit shall take place within 8 months from the date the Member begins or resumes employment with the employer, and

c. the third audit shall take place within 12 months from the date the Member begins or resumes employment with the employer.

iv. The audits shall, on each occasion, involve the following:

1. reviewing a random selection of at least 3 of the Member’s charts to ensure they meet both CNO and employer documentation and care plan standards, and

2. discussing (by telephone or in person), with at least 3 of the Member’s patients, the care provided by the Member and the quality of the Member’s interactions with the patients to ensure that the Member provided necessary and/or required care to the patients and that the Member’s documentation accurately reflects the care provided.

3. 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 oral reprimand and 3 month suspension serve as both a general and specific deterrent. The 2 meetings with a Regulatory Expert and 14 months of employer notification serve to protect the public and ensure rehabilitation. The 3 random spot audits not only protect the public but also assist with practice improvement.

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

I, Mary MacNeil, 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.