DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Sherry Szucsko-Bedard, RN Chairperson Andrea Arkell Public Member Sylvia Douglas Public Member Carolyn Kargiannakis, RN Member Jane Walker, RN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) GLYNNIS HAWE for ) College of Nurses of Ontario
- and - )
SALOMIE ROBINSON ) JANE LETTON for Registration No. 8836991 ) Salomie Robinson
) CHRISTOPHER WIRTH ) Independent Legal Counsel
) Heard: April 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 April 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 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 Salomie Robinson.
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 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 Salomie Robinson.
The Allegations
College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs 1(b), 2, 3(a) and 4(b) in the Notice of Hearing dated December 11, 2020. The Panel granted this request. The remaining allegations against Salomie Robinson (the “Member”) as amended are as follows:
IT IS ALLEGED THAT:
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that, while employed as a Registered Nurse at Southlake Regional Hospital (the “Facility”), 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) on or about March 9, 2019, you placed your colleague, [ ], in a “chokehold”;
(b) [withdrawn];
(c) you failed to administer and/or failed to document the administration and/or the disposal of medication on one or more of the occasions listed in Appendix “A”;
(d) you provided inadequate care and/or inadequately documented the care you provided to [Patient 1], in that:
(i) you failed to complete an assessment and/or document your assessment, rationale for administration, and effect of a PRN medication on one or more of the occasions listed in Appendix “B”;
(ii) you documented administering Hydromorphone 2mg without a witness signature, as required by the Facility, on one or more of the occasions listed in Appendix “C”;
(iii) you documented administering medications at times that were inconsistent with when you withdrew the medication and/or administered the medication, on one or more of the occasions listed in Appendix “D”;
(e) on or about November 16, 2018, you failed to complete a re-assessment and/or document your re-assessment of [Patient 2] at any time prior to 19:00; and/or
(f) on or about December 9, 2018, you failed to complete a re-assessment and/or document your re-assessment of [Patient 3] at any time prior to 19:00;
[withdrawn];
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(13) of Ontario Regulation 799/93, in that, while employed as a Registered Nurse at the Facility, you failed to keep records as required with respect to the following incidents:
(a) [withdrawn];
(b) you failed to document the administration and/or disposal of medication on one or more of the occasions listed in Appendix “A”;
(c) you inadequately documented the care you provided to [Patient 1], in that:
(i) you failed to document your assessment, rationale for administration, and effect of a PRN medication on one or more of the occasions listed in Appendix “B”;
(ii) you documented administering Hydromorphone 2mg without a witness signature, as required by the Facility, on one or more of the occasions listed in Appendix “C”;
(iii) you documented administering medications at times that were inconsistent with when you withdrew the medication and/or administered the medication, on one or more of the occasions listed in Appendix “D”;
(d) on or about November 16, 2018, you failed to document your re-assessment of [Patient 2] at any time prior to 19:00; and/or
(e) on or about December 9, 2018, you failed to document your re-assessment of [Patient 3] at any time prior to 19:00; and/or
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that, while employed as a Registered Nurse 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 with respect to the following incidents:
(a) on or about March 9, 2019, you placed your colleague, [ ], in a “chokehold”;
(b) [withdrawn];
(c) you failed to administer and/or failed to document the administration and/or disposal of medication on one or more of the occasions listed in Appendix “A”;
(d) you provided inadequate care and/or inadequately documented the care you provided to [Patient 1], in that:
(i) you failed to complete an assessment and/or document your assessment, rationale for administration, and effect of a PRN medication on one or more of the occasions listed in Appendix “B”;
(ii) you documented administering Hydromorphone 2mg without a witness signature, as required by the Facility, on one or more of the occasions listed in Appendix “C”;
(iii) you documented administering medications at times that were inconsistent with when you withdrew the medication and/or administered the medication, on one or more of the occasions listed in Appendix “D”;
(e) on or about November 16, 2018, you failed to complete a re-assessment and/or document your re-assessment of [Patient 2] at any time prior to 19:00; and/or
(f) on or about December 9, 2018, you failed to complete a re-assessment and/or document your re-assessment of [Patient 3] at any time prior to 19:00.
APPENDIX A
Date
Time
Patient
Medication
November 4, 2018
17:16
[Patient 1]
Hydromorphone 1mg
November 7, 2018
10:00
[Patient 4]
Diazepam 2.5mg
November 8, 2018
10:00
[Patient 4]
Diazepam 1mg
November 13, 2018
17:00
[Patient 1]
Insulin Lispro
November 13, 2018
14:00
[Patient 1]
Acetaminophen 650mg
November 13, 2018
17:00
[Patient 1]
Gliclazide 30mg
November 15, 2018
15:59
[Patient 1]
Hydromorphone 1mg injectable
APPENDIX B
Date
Time
Medication
November 3, 2018
15:45
Hydromorphone 2mg
November 4, 2018
08:26
Hydromorphone 2mg
November 4, 2018
12:54
Hydromorphone 2mg
November 4, 2018
18:53
Hydromorphone 2mg
November 13, 2018
11:30
Hydromorphone 2mg
November 14, 2018
11:45
Hydromorphone 1mg
November 15, 2018
09:30
Hydromorphone 1mg
November 17, 2018
13:00
Hydromorphone 2mg
APPENDIX C
Date
Time
November 4, 2018
14:00
November 13, 2018
14:00
November 13, 2018
18:00
November 15, 2018
10:00
November 15, 2018
14:00
November 15, 2018
18:00
November 17, 2018
13:00
November 17, 2018
14:00
November 17, 2018
18:00
APPENDIX D
Date
Time
Medication
November 4, 2018
14:00
Hydromorphone 2mg
November 13, 2018
10:00
Hydromorphone 4mg
November 17, 2018
10:00
Hydromorphone 2mg
November 17, 2018
14:00
Hydromorphone 2mg
November 17, 2018
18:00
Hydromorphone 2mg
Member’s Plea
The Member admitted the allegations set out in paragraphs 1(a), 1(c), 1(d)(i), (ii), (iii), 1(e), 1(f), 3(b), 3(c)(i), (ii), (iii), 3(d), 3(e), 4(a), 4(c), 4(d)(i), (ii), (iii), 4(e) and 4(f) 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 as amended and without its Appendix “A” reads, unedited, as follows:
THE MEMBER
Salomie Robinson (the “Member”) graduated with a diploma in nursing from Trinidad and Tobago in 1988.
The Member first registered with the College of Nurses of Ontario (the “CNO”) as a Registered Nurse (“RN”) on June 8, 1988. She is currently entitled to practice nursing without restrictions in Ontario.
The Member was employed as a full-time RN at Southlake Regional Hospital in Newmarket, Ontario (the “Facility”) from February 6, 2018 to April 18, 2019, when her employment was terminated in relation to the incidents which are the subject of the discipline proceeding.
The Member is currently employed as a full-time RN at SRT MedStaff, where she provides home-care services. The Member has been working at MedStaff since January 1, 2000.
FACILITY POLICIES
The Facility used AcuDose, an automated dispensing machine, to track medication withdrawals and wastage. AcuDose records the quantity and dosage, the identity of the nurse withdrawing medication, the date and time of the withdrawal, and the patient for whom the medication was withdrawn. AcuDose also records the same information when a nurse wastes medication.
The Facility’s Narcotic, Controlled Drug and Targeted (“NCT”) Substance Administration policy requires that drugs are not to be removed from the AcuDose until immediately prior to administering to a patient. All NCT drugs must be signed out by the nurse who will administer the substance. Any remaining balance after administration must be wasted with a witness, who must countersign all wastage. The nurse administering the controlled substance is responsible for documenting the administration of the drug.
The Facility’s Independent Double Check of Medication policy requires that two healthcare providers conduct checks of medication dispensation and administration. Both healthcare providers are required to sign and initial the patient’s medication administration record (“MAR”) after administration, and to record if any of the medication is to be wasted.
The Facility’s Medication Administration and Medication Hand-Off policy requires that all nurses verify that they are administering the right medication, at the right time, and that nurses document all assessments, medication administrations, and post-administration effectiveness of medication.
INCIDENTS OF PROFESSIONAL MISCONDUCT
The Member Placed Her Arms Around a Colleague’s Neck
At approximately 16:30 on March 9, 2019, the Member and five nursing colleagues were gathered at the Facility’s nursing station.
One of the nurses present, [ ] (“[the Colleague]”), said to the group, “the most senior nurse buys everyone coffee” or words to that effect, implicitly referring to the Member, who was the most senior amongst the group.
Following [the Colleague]’s comment, the Member approached [the Colleague] from behind, put her arms around her neck and put her in a “chokehold”.
When the Member eventually let go, [the Colleague]’s face was red. If [the Colleague] were to testify, she would state that the incident left red marks on her neck.
The Facility disciplined the Member and she subsequently resigned.
If the Member were to testify, she would state that this incident was intended in a joking manner and that she did not mean to physically harm [the Colleague]. Further, she did not observe [the Colleague]’s face go red or marks on [the Colleague]’s neck. Nonetheless, she recognizes that the nature of this physical interaction was inappropriate in a professional setting and she should not have engaged in this behaviour.
The Member Failed to Document the Administration and/or Wastage of Medication
Patient [4]
On November 7, 2018 at 09:23, the Member withdrew 5 mg diazepam for Patient [4]. At 10:00, the Member administered 2.5 mg diazepam to Patient [4]. The Member did not document administering or wasting the remaining 2.5 mg diazepam.
On November 8, 2018 at 08:17, the Member withdrew 5 mg diazepam for Patient [4]. At 10:00, the Member administered 2.5 mg diazepam to Patient [4]. The Member documented wasting a total of 1.5 mg diazepam, in 0.5 mg increments, at three separate times: 16:31, 16:32 and 16:33. The Member did not document wasting or administering the remaining 1 mg diazepam.
Patient [1]
On November 4, 2018 at 17:16, the Member withdrew hydromorphone 1 mg for Patient [1]. The Member did not document administering or wasting the hydromorphone in or around that time in Patient [1]’s MAR.
The Member failed to document the administration of three medications to Patient [1] on November 13, 2018:
a. Patient [1] was ordered to receive Insulin Lispro by scale, subject to his blood glucose levels, at daily scheduled intervals: 08:00, 12:00, 17:00, and 22:00. The Member did not document [Patient 1]’s blood sugar and/or her administration of Insulin Lispro at 17:00;
b. Patient [1] was ordered Acetaminophen 650 mg at 06:00, 14:00, and 22:00. The Member did not document administering Acetaminophen at 14:00; and
c. Patient [1] was ordered Gliclazide 30 mg at 17:00. The Member did not document administering Gliclazide at 17:00.
- On November 15, 2018 at 15:59, the Member withdrew 2 mg hydromorphone in injectable form. However, the Member only documented administering 1 mg injectable hydromorphone once during her shift, at 09:30. The Member did not document the administration or wastage of the excess 1 mg hydromorphone at any point during her shift.
The Member Inadequately Documented Care Provided to Patient [1]
Patient [1] was admitted to the Facility on September 28, 2018. The Member was assigned to the care of Patient [1] from December 20, 2018 until his discharge on January 15, 2019.
The Member did not document her assessment of Patient [1] and did not document her rationale for the administration of and/or the effect of as-needed (“PRN”) medications, on several occasions.
On November 3, 2018 at 15:45, the Member administered 2 mg PRN hydromorphone without also documenting her assessment, rationale for administration or effect of the PRN medication.
On November 15, 2018 at 09:30, the Member administered 1 mg PRN hydromorphone without documenting her assessment, rationale for administration or effect of the PRN medication.
Furthermore, on the following dates, the Member administered 2 mg PRN hydromorphone without documenting Patient [1]’s pain score prior to or after she administered the PRN medication:
a) November 4, 2018 at 08:26, 12:54, and 18:53;
b) November 13, 2018 at 11:30; and
c) November 17, 2018 at 13:00.
On November 14, 2018 at 11:45, the Member administered 1 mg PRN hydromorphone without documenting Patient [1]’s pain score prior to or after she had administered the medication.
The Member also documented administering 2 mg hydromorphone to Patient [1] without a witness signature, as required by the Facility’s independent double-check policy, on the following occasions:
a) November 4, 2018 at 14:00;
b) November 13, 2018 at 14:00;
c) November 13, 2018 at 18:00;
d) November 15, 2018 at 10:00;
e) November 15, 2018 at 14:00;
f) November 15, 2018 at 18:00;
g) November 17, 2018 at 13:00;
h) November 17, 2018 at 14:00; and
i) November 17, 2018 at 18:00.
- The Member documented administering medications to Patient [1] at times that were inconsistent with when she withdrew the medications and/or administered them:
a) on November 4, 2018 at 14:00, the Member documented administering 1 mg hydromorphone but there is no corresponding record of the hydromorphone having been withdrawn in or around that time;
b) on November 13, 2018 at 10:00, the Member documented that she administered 4 mg hydromorphone, but there is no record of the Member dispensing the medication until 15:20; and
c) on November 17, 2018, the Member withdrew a total of 6mg/ml hydromorphone in 2 mg/ml increments, at 10:48, 13:10, and 17:20. The Member documented administering a total of 8mg/ml hydrmorphone in 2 mg/ml increments at 10:00, 13:00, 14:00, and 18:00, and wasting 1 mg/ml of hydromorphone at 13:11, with no other corresponding withdrawals or disposals.
The Member Failed to Re-assess and/or Failed to Document Re-assessments
Patient [2]
- On November 16, 2018 at 09:00, the Member administered one PRN tablet of acetaminophen 325 mg/oxycodone 5mg to Patient [2]. After the administration, the Member documented that [Patient 2] was agitated, grimacing, and that “pt goal not met” as a result of her intervention. The Member did not document further re-assessments or interventions regarding the patient’s pain for the remainder of her shift, which concluded at 19:00.
Patient [3]
On December 9, 2018 at 13:20, the Member documented that Patient [3] had a pain score of 8 out of 10 and, as a result, the Member had administrated one tablet of PRN acetaminophen 300 mg/caffeine/codeine 30 mg (Tylenol 3) to Patient [3]. The Member did not document assessing or re-assessing [Patient 3]’s pain or physical condition following the administration of the PRN medication at any time during the remainder of her shift, which ended at 19:00.
The Facility investigated the Member’s documentation and medication errors in paragraphs 16 to 29 and concluded that the Member had failed to follow Facility policies. The Member was suspended for five days.
CNO STANDARDS OF PRACTICE
- CNO publishes nursing standards to set out the expectations of practice for its members. CNO’s standards inform nurses of their accountabilities and apply to all nurses, regardless of their position, job description or practice setting.
Documentation Standard
The Documentation Standard states that a nurse meets the standard by “ensuring that 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.”
Maintaining accurate and timely records is not only necessary for developing care plans based on complete health histories, it is also a practice that reflects nurses’ commitment to providing effective and ethical care by showing accountability for professional practice and the care the patient receives.
The Documentation Standard indicates that nurses also meet the standard by demonstrating the following:
(a) documenting in a timely manner and completing documentation during, or as soon as possible after, the care or event;
(b) documenting when information for a specific time frame cannot be recalled; and
(c) clearly identifying the individual performing the assessment and/or intervention when documenting.
Medication Standard
CNO’s Medication Standard requires nurses to “prepare and administer medication(s) to [patients] in a safe, effective and ethical manner.”
Nurses meet the Medication Standard by “promot[ing] and/or implement[ing] strategies to minimize the risk of misuse and drug diversion”, which include independent double-check signature policies for the administration and disposal of all controlled substances.
The Medication Standard requires nurses to ensure their medication practices are “evidence-informed”. This requires nurses administering PRN medications to assess and document the reason for, the administration of, and the effects of, PRN medications in a patient’s MAR.
Professional Standards
CNO’s Professional Standards provides that “[e]ach nurse establishes and maintains respectful, collaborative, therapeutic and professional relationships.”
One of the guiding principles of this standard is that all nurses are accountable for their own decisions and actions, and for maintaining professionalism and competence throughout their careers.
A nurse meets the standard by:
(a) role-modelling positive collegial relationships, as well as professional values, beliefs and attributes;
(b) taking responsibility for errors when they occur and taking appropriate action to maintain patient safety;
(c) using a wide range of communication and interpersonal skills to effectively establish and maintain collegial relationships; and
(d) ensuring practice is consistent with CNO’s standards of practice and guidelines as well as legislation.
The Member admits and acknowledges that her conduct towards her colleague, [ ], breached the CNO’s Professional Standards.
The Member admits and acknowledges that her failure to maintain appropriate documentation with respect to Patients [1], [4], [2], and [3] breached the CNO’s Professional Standards, Documentation Standard, and Medication Standard.
MEMBER’S PRIOR HISTORY WITH CNO
Caution Received by the Member
- On May 18, 2007, the Member received a letter of caution from CNO’s Executive Committee (as it then was) and was required to meet with the Director of Investigations and Hearings. The caution arose as a result of a report to CNO of incidents that occurred during the Member’s employment in a long-term care setting between September 2003 and April 2005. The report indicated that the Member refused to count and report narcotics, slept during shifts, removed a patient’s call bell, permitted inappropriate practices of nursing and non-regulated health professional colleagues, exhibited rude and uncooperative behaviour toward her superior, was disruptive during a staff development session and arrived late to shifts. A copy of the Executive Committee’s decision is attached at Appendix “A”.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1 (a), (c), (d)(i), (d)(ii), (d)(iii), (e), and (f) of the Notice of Hearing, in that she contravened the standards of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 9-42 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3 (b), (c)(i), (c)(ii), (c)(iii), (d), and (e), in that she failed to keep records as required, as described in paragraphs 15-30 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 4 (a), (c), (d)(i), (d)(ii), (d)(iii), (e), and (f), of the Notice of Hearing, as described in paragraphs 9-42 above, and that such conduct is disgraceful, dishonourable and unprofessional.
The CNO requests leave from the Discipline Committee to withdraw the allegations in paragraphs 1(b), 2, 3(a) and 4(b) of the Notice of Hearing.
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(c), 1(d)(i), (ii), (iii), 1(e), 1(f), 3(b), 3(c)(i), (ii), (iii), 3(d), 3(e), 4(a), 4(c), 4(d)(i), (ii), (iii), 4(e) and 4(f) of the Notice of Hearing. As to allegations #4(a), 4(c), 4(d)(i), (ii), (iii), 4(e) and 4(f), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be disgraceful, 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 9-14, 38-41 and 44 in the Agreed Statement of Facts. The Member failed to meet the College’s Professional Standards when she placed her colleague in a “chokehold.” It is expected that nurses are accountable for their decisions and are to maintain professionalism throughout their careers. The Member admitted that she breached the College’s Professional Standards when she engaged in this behaviour.
Allegation #1(c) in the Notice of Hearing is supported by paragraphs 15-19, 30, 35-37, 42 and 44 in the Agreed Statement of Facts. The Member breached the College’s Medication Standard when she failed to document wastage when she administered diazepam and hydromorphone to Patient [4] and when she did not document medications administered to Patient [1]. The Medication Standard requires the nurse to administer medications in a safe and ethical manner and by not maintaining accurate documentation when administering medication, the Member did not meet this standard.
Allegations #1(d)(i), (ii) and (iii) in the Notice of Hearing are supported by paragraphs 20-27, 30, 32-37, 42 and 44 in the Agreed Statement of Facts. While caring for Patient [1], the Member administered narcotics without documenting Patient [1]’s pain score, or the rationale for giving the medication on numerous occasions. The Member admitted to administering narcotics without obtaining a witness signature as required by the Facility at which she was working, as well as administering narcotics at different times than she documented. The Member practiced unsafe medication administration on several occasions. As a result, the Member breached the College’s Professional Standards, Documentation Standard and Medication Standard.
Allegations #1(e) and 1(f) in the Notice of Hearing are supported by paragraphs 28-37, 42 and 44 in the Agreed Statement of Facts. While caring for Patients [2] and [3] it was found that the Member administered pain medication to both, but did not document any reassessment of their pain or their condition. The College’s Documentation Standard is clear that a nurse meets the standard by ensuring that documentation is a complete record that includes assessment, planning, intervention and evaluation. The Member also failed to meet the Medication Standard which indicates that when administering PRN medication, the nurse is required to document the reason for giving it and the effects of the medication. The Member’s performance fell below expected College standards in her care for both patients.
Allegations #3(b), 3(c)(i), (ii), (iii), 3(d) and 3(e) in the Notice of Hearing are supported by paragraphs 15-30, 31-37, 42 and 45 in the Agreed Statement of Facts. The Member committed an act of professional misconduct when she failed to keep records when she:
Did not document medication wastage;
Did not document medication administration;
Did not document care provided to patients;
Documented medication times that were inconsistent with when the medications were drawn up and administered; and
Did not document patient assessments or reassessments.
With respect to Allegations #4(a), 4(c), 4(d)(i), (ii), (iii), 4(e) and 4(f), the Panel finds that the Member’s conduct would reasonably be regarded by members of the profession to be dishonourable, disgraceful and unprofessional. This is supported by paragraphs 9-42 and 46 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct was unprofessional as she failed to meet the standards expected of the profession by demonstrating a serious and persistent disregard for her professional obligations. The Panel also finds that the Member’s conduct was dishonourable in that she demonstrated an element of moral failing and knew or ought to have known that her conduct fell well below the standards of a professional.
Finally, the Panel finds that the Member’s conduct was disgraceful as it shames the Member and by extension the profession. The Member’s actions were intentional when she put a “chokehold” on a colleague and did not assess patients on several occasions. This casts serious doubt on the Member’s moral fitness and inherent ability to discharge the higher obligations the public expects professionals to meet.
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:
Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for 4 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.
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 of this Order becomes final. If the Expert determines that a greater number of session 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 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 7 days before the first meeting, the Member provides the Expert with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;
iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):
Code of Conduct,
Documentation,
Professional Standards, and
Medication;
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:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards his/her report to the Director, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into her behaviour;
vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;
b) For a period of 18 months from the date this Order becomes final, or from the commencement or resumption of the Member’s employment in any nursing position, the Member will notify her employers of the decision. To comply, the Member is required to:
i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;
ii. Provide her employer(s) with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;
iii. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to the Director, that will confirm the following:
that they received a copy of the required documents,
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
that they agree to perform 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 3 months from the date the Member begins or resumes employment with the employer,
b. the second audit shall take place within 6 months from the date the Member begins or resumes employment with the employer, and
c. the third audit shall take place within 9 months from the date the Member begins or resumes employment with the employer;
d. the fourth and final audit shall take place within 12 months from the date the Member begins or resumes employment with the employer; and
iv. The audits shall, on each occasion, involve the following:
reviewing a random selection of at least 10 of the Member’s charts to ensure they meet both CNO and employer standards, and
discussing (by telephone or in person), with at least 3 of the Member’s patients, the care provided to them by the Member in order to cross reference the patients’ comments against the patients’ charts to ensure the Member is:
a. accurately documenting patients’ assessments and/or re-assessments and that her documentation practice aligns with both the Documentation Standard and the patients’ respective care plans, and
b. meeting medication administration requirements in patients’ respective care plans and that her medication administration practices align with the Medication Standard.
- 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 aggravating factors in this case were:
The Member’s conduct was serious;
The Member’s behaviour caused a risk of harm to a colleague;
The Member’s behaviour/practice caused a risk of harm to patients;
The breaches of the standards were repeated over a length of time;
The Member has a previous history with the College where she received a caution. The previous investigation involved similar breaches in medication documentation and administration practices as well as being difficult with colleagues.
The mitigating factors in this case were:
The Member cooperated with the College;
The Member was forthright;
The Member was willing to acknowledge and accept responsibility for her conduct by agreeing to the Agreed Statement of Facts and the Joint Submission on Order.
The proposed penalty provides for general deterrence through:
- The 4 month suspension.
The proposed penalty provides for specific deterrence through:
The 4 month suspension; and
The oral reprimand.
The proposed penalty provides for remediation and rehabilitation through:
The 2 meetings with the Regulatory Expert;
The terms, conditions and limitations on the Member’s certificate of registration.
Overall, the public is protected because this process will assist the Member in gaining additional insight and knowledge into her practice. The 18 month employer notification, and 12 month spot chart audits will ensure the Member is monitored for a significant amount of time after she returns from the suspension.
College Counsel submitted cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee.
CNO v. Whyte (Discipline Committee, 2020): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member failed to assess and document her assessment when caring for a patient. This case involved one patient and only a few incidents compared to the case being heard. The penalty given included an oral reprimand, a 3 month suspension, 2 meetings with a Regulatory Expert and 24 months of employer notification.
CNO v. Campeau (Discipline Committee, 2020): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member failed to assess and identify changes to a patient’s condition and failed to transfer the patient to hospital. The penalty given included an oral reprimand, a 3 month suspension, 2 meetings with a Regulatory Expert and 12 months of employer notification.
CNO v. Keddie (Discipline Committee, 2020): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member touched a colleague on the buttocks as a friendly gesture. The penalty given included an oral reprimand, a 1 month suspension, 2 meetings with a Regulatory Expert and 12 months of employer notification.
College Counsel submitted that the penalty documented in the Joint Submission on Order fits within the penalties for previous similar cases.
The Member’s Counsel submitted that she echoed the submissions of College Counsel and that the penalty being proposed is consistent with other College cases.
Penalty Decision
The Panel accepts the Joint Submission on Order and accordingly orders.
The Member is required to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
The Executive Director is directed to suspend the Member’s certificate of registration for 4 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.
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 of this Order becomes final. If the Expert determines that a greater number of session 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 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 7 days before the first meeting, the Member provides the Expert with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;
iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):
Code of Conduct,
Documentation,
Professional Standards, and
Medication;
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:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards his/her report to the Director, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into her behaviour;
vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;
b) For a period of 18 months from the date this Order becomes final, or from the commencement or resumption of the Member’s employment in any nursing position, the Member will notify her employers of the decision. To comply, the Member is required to:
i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;
ii. Provide her employer(s) with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;
iii. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to the Director, that will confirm the following:
that they received a copy of the required documents,
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
that they agree to perform 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 3 months from the date the Member begins or resumes employment with the employer,
b. the second audit shall take place within 6 months from the date the Member begins or resumes employment with the employer, and
c. the third audit shall take place within 9 months from the date the Member begins or resumes employment with the employer;
d. the fourth and final audit shall take place within 12 months from the date the Member begins or resumes employment with the employer; and
iv. The audits shall, on each occasion, involve the following:
reviewing a random selection of at least 10 of the Member’s charts to ensure they meet both CNO and employer standards, and
discussing (by telephone or in person), with at least 3 of the Member’s patients, the care provided to them by the Member in order to cross reference the patients’ comments against the patients’ charts to ensure the Member is:
a. accurately documenting patients’ assessments and/or re-assessments and that her documentation practice aligns with both the Documentation Standard and the patients’ respective care plans, and
b. meeting medication administration requirements in patients’ respective care plans and that her medication administration practices align with the Medication Standard.
- 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 specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The Panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly.
The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility. The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection. Specific deterrence is met through the oral reprimand and the 4 month suspension of the Member’s certificate of registration. General deterrence is met by the 4 month suspension which sends a strong message to the members that there are serious consequences for such conduct. Remediation and rehabilitation are met through the 2 meetings with a Regulatory Expert, completion of the review of the standards and completion of Reflective Questionnaire. The public is protected through the 18 month employer notification and 12 month spot audits where the Member will be monitored closely.
The penalty is in line with what has been ordered in previous cases.
I, Sherry Szucsko-Bedard, 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.