DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Mary MacNeil, RN Chairperson Andrea Arkell Public Member Karen Goldenberg Public Member Heather Stevanka, RN Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) DENISE COONEY for ) College of Nurses of Ontario

• and - ) JOAN BROOKS ) DANIEL LIBMAN for Registration No. HB04034 ) Joan Brooks ) CHRISTOPHER WIRTH ) Independent Legal Counsel ) Heard: October 4, 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 October 4, 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 prohibiting 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 Joan Brooks.

The Panel considered the submissions of College Counsel and the Member’s Counsel and decided that there be an order prohibiting 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 Joan Brooks.

The Allegations

The allegations against Joan Brooks (the “Member”) as stated in the Notice of Hearing dated May 28, 2021 are as follows:

IT IS ALLEGED THAT:

1. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that while employed as a Registered Practical Nurse at the University Health Network – Toronto Rehabilitation Institute, in Toronto, Ontario (the “Facility”), you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession as follows:

a. on or about June 9 and 10, 2018, you provided inappropriate and/or inadequate care and treatment to Patient [A], and/or you inadequately documented the care and treatment you provided to Patient [A], including but not limited to:

i. you applied restraints to Patient [A] without assessing the appropriateness of restraints, and/or reasonable alternatives to restraints, and/or need for restraints;

ii. you applied restraints to Patient [A] without obtaining an order for the application of restraints and/or failed to implement a medical directive for the application of restraints;

iii. you failed to document the application of restraints to Patient [A];

iv. you failed to appropriately observe and/or monitor Patient [A] following the application of restraints;

v. you failed to assess and/or inadequately documented the ongoing need for restraints on Patient [A];

vi. you failed to initiate appropriate interventions after finding Patient [A] appeared to be deceased;

vii. after determining Patient [A] was deceased, you transported him to his bed;

viii. after determining Patient [A] was deceased, you failed to notify a manager that he was deceased; and/or

ix. you failed to document information about Patient [A]’s death;

b. on or about June 9 and 10, 2018, you failed to properly document your observations with respect to Patient [B], including you documented that Patient [B] fell asleep in the dining lounge when she had not; and/or

c. in or about June and July 2018, you provided inaccurate information to the Facility in its investigation of the circumstances of Patient [A]’s death.

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(7) of Ontario Regulation 799/93, in that while employed as a Registered Practical Nurse at the Facility, you verbally, physically or emotionally abused a client when on or about June 9 and 10, 2018, you applied restraints to Patient [A] despite there being no clinical indication that restraints were appropriate, and/or without a physician’s order for the application of restraints to Patient [A].

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 paragraph 1(13) of Ontario Regulation 799/93, in that, while employed as a Registered Practical Nurse at the Facility, you failed to keep records as required, and in particular, on or about June 9 and 10, 2018:

a. you failed to document the application of restraints to Patient [A];

b. you failed to document the ongoing need for restraints on Patient [A]; and/or

c. you failed to document information about Patient [A]’s death.

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 paragraph 1(14) of Ontario Regulation 799/93, in that, while employed as a Registered Practical Nurse at the Facility, you falsified a record relating to your practice, and in particular:

a. you documented that Patient [B] fell asleep in the dining lounge when she had not.

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

a. on or about June 9 and 10, 2018, you provided inappropriate and/or inadequate care and treatment to Patient [A], and/or you inadequately documented the care and treatment you provided to Patient [A], including but not limited to:

i. you applied restraints to Patient [A] without assessing the appropriateness of restraints, reasonable alternatives to restraints and/or need for restraints;

ii. you applied restraints to Patient [A] without obtaining an order for the application of restraints and/or failed to implement the medical directive for the application of restraints;

iii. you failed to document the application of restraints to Patient [A];

iv. you failed to appropriately observe and/or monitor Patient [A] following the application of restraints;

v. you failed to assess and/or inadequately documented the ongoing need for restraints on Patient [A];

vi. you failed to initiate appropriate interventions after finding Patient [A] appeared to be deceased;

vii. after determining Patient [A] was deceased, you transported him to his bed;

viii. after determining Patient [A] was deceased, you failed to notify a manager that he was deceased; and/or

ix. you failed to document information about Patient [A]’s death;

b. on or about June 9 and 10, 2018, you failed to properly document your observations with respect to Patient [B], including but not limited to you documented that Patient [B] fell asleep in the dining lounge when she had not; and/or

c. in or about June and July 2018, you provided inaccurate information to the Facility in its investigation of the circumstances of Patient [A]’s death.

Member’s Plea

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

1. Joan Brooks (the “Member”) obtained a certificate in nursing from George Brown College – St. James Campus in 1981.

2. The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on January 1, 1982.

3. The Member has been employed as a part-time RPN at the University Health Network – Toronto Rehabilitation Institute (the “Facility”) in Toronto, Ontario since January 1, 2000. She had worked at the Facility for approximately 18 years at the time of the misconduct set out below. The Member remains employed by the Facility.

4. The Member has no prior discipline history with CNO.

THE FACILITY

5. The Facility is a rehabilitation hospital that aims to help patients overcome or live with disabling injuries, illnesses, or age-related health concerns.

6. The Geriatric Psychiatry Unit (the “Unit”) is a specialized unit of the Facility. The Unit’s goal is to help reduce harmful patient behaviours, thereby improving patients’ quality of life.

7. There are 20 beds on the Unit. Patients on the Unit have a diagnosis of some form of dementia and are usually admitted because of challenging behaviours that make it difficult for them to remain unsupervised. These behaviours include but are not limited to resisting medical support, restlessness, wandering, aggression, screaming and sexual inappropriateness.

Facility Policies

8. The Facility’s expectations and requirements with respect to the application of restraints to patients are described in its Medical Directive for Initiation of Mechanical Restraints (the “Medical Directive”) and Patient Restraints Minimization Policy (the “Restraints Policy”).

9. The Facility’s expectations and requirements with respect to the care provided after a patient is deceased is set out in its Care After Death Policy (the “CAD Policy”).

The Medical Directive

10. In compliance with the Patient Restraints Minimization Act, 2001, S.O. 2001, c. 16, the Facility minimizes the use of restraints on patients.

11. The Medical Directive authorizes all RNs and RPNs at the Facility who have completed its Restraints Minimization Education, and who have reviewed and understood the Medical Directive and the Restraints Policy, to implement the Medical Directive and to apply mechanical restraints to patients who meet the indications set out in the Medical Directive.

12. The Facility defines “mechanical restraint” as a device applied to restrain the movement of the whole or a portion of a patient’s body to control his or her activities. Mechanical restraints must be selected with the patient’s unique circumstances in mind and are only to be applied for the “shortest period of time in accordance with the [Restraints Policy].”

13. The Medical Directive states that, “mechanical restraint use should be evaluated and reordered as indicated in the [Restraints Policy].”

14. The Medical Directive further provides that,

restraints should only be used to prevent a patient from sustaining or inflicting serious bodily harm to himself/herself or others. Mechanical restraints are to be used only after all appropriate alternatives have been tried and failed or in an emergency situation when there is an imminent risk of bodily harm or to others.

The Restraints Policy

15. The Restraints Policy provides that restraints are used only after all appropriate alternatives have been considered and/or exhausted and, if applied, represent the least restrictive restraint necessary for the particular patient.

16. The Restraints Policy includes a detailed procedure for assessing the need for restraining a patient, exploring alternatives to restraints, obtaining informed consent from the patient or their substitute decision-maker, and documentation of the application of restraints.

17. The Restraints Policy provides that restraints are only to be applied after a health care team assessment and analysis of the patient’s behaviour has been completed, a physician’s order specific to a particular patient has been obtained, or the Medical Directive has been implemented.

18. A healthcare provider’s implementation of restraints and reasoning justifying the use of restraints on a particular patient must be documented in the Physical Restraint Monitoring Record. Staff are also required to complete the corresponding Consent to Physician Restraints Form and Restraint Monitoring Tool, in accordance with the Restraints Policy and Medical Directive.

19. A patient’s Physical Restraint Monitoring Record must be completed at every check in accordance with the schedule set out in the Restraints Policy.

The Care After Death Policy

20. The CAD Policy applies to patients through the dying process, from end-of-life care through to when deceased patients leave the Facility.

21. Central to the CAD Policy is the respect shown to the deceased patient’s physical, religious and spiritual wishes, as well as those of the patient’s family and friends, where circumstances permit. For example, the Facility tries to accommodate requests for personal time, prayers or special religious rites around this extremely challenging time for patients and their loved ones.

22. Upon determination that a patient has died, the Facility requires staff nurses to follow the CAD Policy by notifying the attending physician and Unit manager or manager-on-call that a death has occurred before initiating the preparation of the deceased patient’s body and personal belongings for transfer to the morgue.

23. In cases where coroner autopsies are required or requested, the staff nurses are to leave the deceased patient’s body “as is at the time of death.” Staff are also expected to complete a series of forms, such as adding the Medical Certificate of Death to the patient’s health care record.

Facility Training

24. The Member completed the Facility’s annual Restraint Minimization Geriatric Program Professional Development in November 2015 and December 2016.

25. The training, delivered by an advanced practising nurse educator, reviewed policies, expectations and duties with respect to restraint assessment, application, documentation, and evaluation.

26. The presentation set out the Facility’s policy that physical restraints require careful consideration before their application, and require ongoing monitoring and timely interdisciplinary clinical note entries once applied.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

The Unit Night Shift Complement

27. The Member worked alongside three other nursing colleagues on the June 9, 2018 23:00 to June 10, 2018 07:30 night shift on the Unit.

28. The Member’s colleagues were Zahra Mollanedjad, RPN; Elenita Lumibao, RN; and Joanne Pacione, RN.

29. The Member, Ms. Lumibao and Ms. Pacione regularly worked on the Unit. Ms. Lumibao was the Charge Nurse on the night shift. Ms. Mollanedjad usually worked at one of the Facility’s satellite locations. The Unit was not Ms. Mollanedjad‘s “home site”.

30. There were approximately 17 patients in the Unit at the time of the incidents. Each of the four nurses on shift that night was assigned between four and six specific patients.

31. It is Facility practice for all nurses to monitor each other’s patients while their nursing colleagues are on 1 – 1.5-hour breaks or are supporting other patients requiring complex care. Each nurse has primary responsibility for documenting with respect to their individual patient assignments, but nurses are expected to update other patients’ charts during their colleagues’ breaks to ensure ongoing monitoring, and that documentation is an accurate reflection of patients’ health status throughout the night.

Patient [A]

32. Patient [A] was a 79-year-old patient with moderate to advanced dementia. He was admitted to the Unit on April 23, 2018.

33. Patient [A] suffered from seizures. He presented as sporadically unsteady on his feet. He did not use any assistive devices for ambulation. He was occasionally restrained when agitated to mitigate fall risk.

34. The following entries were documented in Patient [A]’s chart by other members of the healthcare team immediately before the night shift began. At 17:00 on June 9, 2018, a colleague documented:

Pt observed in group this PM. Pt calm. Smiling & winking at staff at times tried to stand x2, said “I need to pee.” Nurse informed, walked & toileted, settled well back to group. Pt con’t to observe & was alert throughout.

35. The next entry in Patient [A]’s chart was documented by a colleague at 22:00 on June 9, 2018 as follows:

Received Pt sitting in [illegible] with clip alarm in the dining room. Calm + quiet on approach. Medication crushed + given with Jam. Ate supper 100% with total assist. Extremely verbally and physically aggressive with HS [illegible] hitting yelling, grabbing caregiver’s hand during care. Care done be x3 staff. Settled to bed @ 2030 hrs @ 2140 hrs attempt to get up, refused to settle to bed, very aggressive with transferring to w/c. He [illegible] in w/c with clip alarm place in the dining room. Unable to check VS [vital signs].

36. Ms. Mollanedjad was Patient [A]’s assigned nurse during the June 9-10, 2018 night shift (23:00 - 07:30).

37. At the start of her shift at 23:00, Ms. Mollanedjad documented the following in Patient [A]’s chart:

Received Pt was sitting in w/c with clip alarm in the dining room. Refused going back to bed. Transferred to geri-chair. No further

concern noted. ---------

Patient [B]

38. Patient [B] was a 78-year-old patient with vascular dementia.

39. Patient [B] was occasionally restrained in a Posey pelvic restraint for her own safety because she was at a high risk of falls when agitated or confused.

40. The Member was Patient [B]’s assigned nurse during the June 9-10, 2018 night shift (23:00 - 07:30).

Inappropriate Assessment, Application and Undocumented Restraint of Patient [A]

41. The dining room and surrounding corridors on the Unit are equipped with video surveillance cameras. The following events were captured on camera, without audio.

42. From approximately 22:45 to 23:55, Patient [A] was sitting in a wheelchair in the Unit’s dining room. He appeared calm.

43. At approximately 23:41, Ms. Lumibao brought a Broda chair with a Posey pelvic restraint on the seat into the dining room and subsequently left the room. A Posey pelvic restraint is an approved physical restraint at the Facility and the only type of mechanical restraint used on the Unit.

44. At approximately 23:57, the Member and her nursing colleagues – Ms. Mollanedjad, Ms. Lumibao and Ms. Pacione – entered the dining room wearing gloves in anticipation of physical contact with a patient.

45. All four nurses then transferred Patient [A] to a Broda chair.

46. Neither the Member nor any of her colleagues documented that Patient [A] was transferred from a wheelchair to a Broda chair, or the reason for the transfer.

47. At approximately 23:59, the Member and Ms. Pacione applied a Posey pelvic restraint to Patient [A]. There was no physician’s order requesting that Patient [A] be restrained. Ms. Mollanedjad stood directly in front of Patient [A] and watched the Member apply the restraint. Ms. Lumibao remained in the dining hall and exited around 0:00.

48. Neither the Member nor any of her nursing colleagues followed the Medical Directive and Restraints Policy with respect to the application and documentation of physical restraints to Patient [A]. The Member did not, nor did she ensure that any of her colleagues, document the application of a physical restraint, the rationale for the application of the physical restraint, indicate if an alternative option was considered prior to the application of the physical restraint, or complete the required documentation, including the Physical Restraint Monitoring Record Form, in accordance with the Medical Directive and Restraints Policy. The Member also did not take measures to ensure that her colleague, Ms. Mollanedjad, assigned to Patient [A] completed the appropriate documentation, despite knowing that Ms. Mollanedjad did not regularly work on the Unit.

Failure to Appropriately Observe and/or Monitor Patient [A]

49. The Restraints Policy requires that, once restraints are applied, a patient must be monitored every 15 minutes for the first hour, 30 minutes thereafter for one hour, and subsequently every hour until the restraint is released. The restraints must be released every two hours to provide patient care.

50. By 00:02 – shortly after Patient [A] was restrained in the Broda chair – the Member, Ms. Mollanedjad and Ms. Pacione exited the dining room. Patient [A] remained restrained in the Broda chair.

51. Ms. Mollanedjad returned to the dining room briefly at 00:04 and put pillows behind Patient [A]’s head and under his feet. Patient [A] remained physically restrained. Ms. Mollanedjad exited the dining room. She did not complete any documentation with respect to the interaction.

52. At approximately 00:22, Ms. Lumibao entered the dining room, turned off the lights and exited. She did not approach or assess Patient [A]. He remained restrained in the Broda chair. She did not complete any documentation with respect to the interaction.

53. Patient [A] attempted to stand but was unable to do so due to the restraint. The blanket slipped off his lap.

54. At approximately 00:29, the Member entered the dining room with Patient [B]. She did not turn the lights back on. She approached Patient [A], lifted his gown to confirm the restraint was still in place, picked up a pillow on the floor, and tossed it onto his lap while turning to walk away.

55. The Member left the blanket that had fallen from Patient [A]’s lap on the floor. She did not assess him, adjust or release the restraint in accordance with the Restraints Policy, or provide care. She did not document this interaction or report it to any of her colleagues.

56. From approximately 01:15 until 02:15, Ms. Mollanedjad and Ms. Pacione went on breaks. The Member and Ms. Lumibao were responsible for providing coverage to Patient [A] during Ms. Mollanedjad’s break.

57. From the video footage, from approximately 01:00 until 01:30, Patient [A] can be seen trying to reach for the blanket that had by that time fallen to the floor. He adjusted his gown, lifted his legs, and strained forward with outstretched limbs.

58. From approximately 01:50 until 02:00, Patient [A] continuously struggled against the restraint, with his limbs rigidly stretching outward, kicking, and holding in a tension pose.

59. By approximately 01:58, Patient [A]’s movements appear increasingly rigid.

60. From 02:00 until 02:10, Patient [A] rocked back and forth.

61. The Member entered the dining room at 02:10. She approached Patient [A], picked up a pillow that had fallen on the ground and put it behind Patient [A]’s head. She did not assess the ongoing use of the pelvic restraint, release the restraint, or otherwise assess Patient [A]. The Member did not document this interaction in Patient [A]’s chart.

62. Other than this interaction at 02:10, neither the Member nor Ms. Lumibao entered the dining room to check on Patient [A] during their colleagues’ breaks. They did not monitor and assess the ongoing need for restraint. The Member did not follow the schedule in the Restraints Policy for monitoring and releasing the restraints as required or ensure that she and her colleagues were following the Restraints Policy.

63. Patient [A]’s last physical movement is visible at 02:12.

64. From approximately 02:30 until 05:00, the Member and Ms. Lumibao went on a 2.5-hour break. Ms. Mollanedjad and Ms. Pacione were responsible for providing care to Patient [A] during this time.

65. Between 02:10 and 03:35, no one entered the dining room.

66. At 03:35, Ms. Mollanedjad stood in the doorway of the dining room, glanced at Patient [B] who was sliding the length of her arm back and forth on the table in front of her in a cleaning motion, and walked away nine seconds later. There is no corresponding documentation of this interaction in either Patient [B]’s or Patient [A]’s chart.

67. Ms. Mollanedjad inaccurately documented in Patient [A]’s chart that, at 04:15 on June 10, 2018, his status had not changed since her last entry at 23:00: “no further concern noted.” No one entered the dining room at that time to check on Patient [A].

68. The Member admits that appropriate monitoring of Patient [A], in accordance with the Restraints Policy, required monitoring Patient [A] every 15 minutes for the first hour, every 30 minutes for the second hour and every hour thereafter, including a full removal of the restraint every two hours to provide patient care. The Member acknowledges that she did not personally comply with this requirement in the Restraints Policy, and she did not ensure that her nursing colleagues complied with the Restraints Policy with respect to Patient [A].

Failure to Follow CAD Policy

69. At 05:28, the Member and Ms. Lumibao entered the dining room. The Member walked toward Patient [A], and upon seeing him, pointed at Ms. Lumibao, and then gestured back toward Patient [A].

70. The Member believed that Patient [A] was dead and stated to Ms. Lumibao, “I think he is gone”, “Oh my god, he is dead, not breathing” or words to that effect.

71. The Member did not call a Code Blue, take his vital signs, or ensure that her colleagues do so, as Facility protocol requires when a patient is found unresponsive.

72. Ms. Lumibao exited the dining room at 05:28. The Member remained in the dining room and prepared to remove Patient [B] from the dining room.

73. At 05:29, the Member approached Patient [B], who was partially clothed after moving her gown from her upper body over the course of the evening.

74. The Member prepared to remove Patient [B] from the dining room. The Member paused mid-transfer, returned to Patient [A] and touched his right leg. She did not conduct any other assessment. The Member turned immediately back to Patient [B] and wheeled her backwards, with feet dragging on the floor, out of the dining room.

75. Ms. Lumibao returned to the dining room, along with Ms. Pacione and a vitals machine, at 05:29. Ms. Lumibao picked up the blanket that had remained on the ground beside Patient [A], threw it on his lap from a distance, and walked away.

76. At approximately 05:30, Ms. Pacione unlocked the wheel locks on both sides of Patient [A]’s Broda chair. Ms. Pacione removed Patient [A] from the dining room and transported him to his room.

77. Ms. Mollanedjad entered Patient [A]’s room at 05:33.

78. The Member pushed a linen hamper toward Patient [A]’s room and entered at around the same time.

79. By 05:35, all four nurses were in Patient [A]’s room.

80. Over approximately the next 20 minutes, the four nurses went in and out of Patient [A]’s room with fresh laundry hampers, soiled linen bins and a supply cart. The interactions between the Member and her colleagues during this time were not recorded on video because there was no video camera in Patient [A]’s room.

81. At some point during this 20-minute window, Ms. Pacione and Ms. Lumibao procured one or more fresh blankets to “keep the body warm”. The Member admits that the collective intention was to make it appear that Patient [A] died in bed or more recently than the Member and her colleagues suspected.

82. The Member admits and acknowledges that she did not follow the CAD Policy in relation to Patient [A]. According to the Facility’s CAD Policy, if Patient [A] was alive and declining when he was found by any of the nurses, he should have been immediately assessed, and a Code Blue and 911 called. If Patient [A] was found deceased in the dining room, Patient [A] should not have been transferred to his room and, subsequently, out of the Broda chair and into his bed. The Member ought to have, but failed to notify a manager on finding Patient [A] deceased. The Member acknowledges she did not follow the CAD Policy.

Documentation of Patient [A]’s death

83. Ms. Mollanedjad documented the following entry in Patient [A]’s chart on June 10, 2018. She documented the time at 05:15.

Noted he was sounds sleeping. back to bed had large BM 3 staff ♀ VS. T = 35.4 noted vital sign was absent @ 0520 No respiration pupel fixed & he is in bed @ present of charting. Dr on called by RN to informed @ 0550.

84. This documentation was inaccurate. Patient [A] remained restrained in the Broda chair in the dining room from 23:59 until Ms. Pacione wheeled him out of the dining room at 05:30. He was not in bed at 05:15 as Ms. Mollanedjad’s charting indicates. The Member admits and acknowledges that she failed to document any information about Patient [A]’s death, and/or to ensure that Ms. Mollanedjad’s documentation was accurate.

85. The Facility was ultimately unable to determine the correct time of Patient [A]’s death, due to the conduct of the Member and her colleagues.

Inaccurate Information Provided During Facility Investigation

86. On June 11, 2018, the manager of the Unit (the “Manager”) learned of Patient [A]’s death. She reviewed Patient [A]’s chart and found the Member’s entry about his death unclear. As a result, the Facility investigated Patient [A]’s death.

87. The Manager called the Member on June 13, 2018. The Member admits that she made the following inaccurate statements on that occasion:

• The Member told the Manager that she arrived in the dining room at approximately 23:45 and found Patient [A] already transferred into a Broda chair. The Member explicitly denied being involved in any transfer involving Patient [A]. However, the Member was involved in the transfer of Patient [A], and the application of restraints.

• The Member told her Manager that on finding Patient [A], she and her colleagues “cleaned [Patient [A]] up”, took his vitals, shut the door, and transferred him to bed despite her belief that he was dead when she found him. However, no one took Patient [A]’s vitals and cleaned him up before transferring him to bed.

88. The Facility held three in-person investigation meetings with the Member with respect to Patient [A]’s death. The first meeting took place on June 25, 2018. The Member admits that she made the following inaccurate statements at that meeting:

• The Member told the Facility the Patient [A] was put in restraints before she interacted with him and that she was not involved in the restraint application, even though she and Ms. Pacione were the two nurses who applied the Posey pelvic restraint.

• The Member told the Facility that Ms. Mollanedjad “did not mention anything” about Patient [A] being in restraints and that, had she known, she would have checked on him or ensured Ms. Mollanedjad watched him more vigilantly. As set out above, the Member was one of two nurses who applied the restraint.

• The Member told the Facility that she did not know Patient [A] was restrained in a Broda chair until she and her colleagues transferred him to bed upon being found dead in the dining room.

89. The Facility held a second fact-finding meeting with the Member on July 10, 2018. The Member admits that she made the following inaccurate statements at that meeting:

• The Member once again told the Facility that she was not involved in transferring Patient [A] to a Broda chair. She expressly denied applying the restraints, or knowing that Patient [A] was restrained at any time during her shift. She again stated she only learned he was restrained when she assisted in moving Patient [A]’s body into his bed after finding him deceased in the dining room.

• The Member told the Facility that she never touched Patient [A] while he was in the dining room.

90. The Member acknowledges that her statements to the Facility in June and July 2018, as set out above, were false.

Failure to Observe Patient [B] and Accurately Document Care Provided

91. As set out above, the Member was Patient [B]’s assigned nurse during the night shift on the Unit from 23:00 on June 9, 2018 until 7:30 on June 10, 2018.

92. At 00:29, the Member wheeled Patient [B] into the dining room in a Broda chair.

93. The Member placed Patient [B] in front of a large table and interior window facing outward into the hallway outside the dining room.

94. Patient [B] removed a blanket from her lap, muttered to herself, and started repetitively wipe it across the table in front of her in a cleaning motion while seated in the Broda chair.

95. Patient [B] grew increasingly distressed, removed her gown from her body exposing her breasts, and strained upward from her seated position while continuously talking aloud to herself.

96. The Member entered the dining room at 02:10 and put a pillow that had fallen on the ground back behind Patient [A]’s head. The Member did not observe or provide care to Patient [B].

97. Between 04:30 and 04:32, Patient [B] leaned into her elbow, appearing to sob as she rubbed her head and face with her hand, kicked her legs and tried to stand. She pushed away an extra chair that had been placed close by.

98. At 05:16, Patient [B] wrapped a blanket around her head, covering her face.

99. At 05:20, Ms. Mollanedjad entered the dining room, removed the blanket from Patient [B]’s face, and exited.

100. The Member and Ms. Lumibao entered the dining room at 05:28. By this time, Patient [B] was half-nude, having twisted herself free from her gown because of her strained movements throughout the evening. Other than entering the dining room at 02:10, the Member did not check on Patient [B].

101. The Member documented one entry in Patient [B]’s chart at 06:00 for the duration of her entire shift:

Asleep in bed on first rounds. Pt slept until 0030 AM – kept getting up sitting at bedside. Pt was monitored in D/lounge for long periods, rubbing gown on able until she fell asleep. Transferred to BR [bedroom], voided and settled in bed. Now asleep.

102. This documentation is inaccurate. Patient [B] remained in the Broda chair, in various states of distress, from 00:30 to 05:30.

103. Patient [B] remained in the dining room until the Member removed her around 05:29.

CNO STANDARDS OF PRACTICE

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

Documentation Standard

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

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 as defined by organizational policies; and

d. ensuring that relevant [patient] care information is captured in a permanent record.

Ethics Standard

106. The Ethics practice standard sets out the ethical values relating to nursing care, including, amongst other things, dedication to patient well-being, and maintaining commitments to nursing colleagues through truthful and respectful interactions. One of the most important ethical values in providing nurse care is truthfulness.

107. The standard states that “[t]eam cohesiveness is necessary to promote the best possible outcome for [patients]. In situations in which [patient] safety and well-being are compromised, however, nurses’ primary responsibility is to their [patients]. Nurses, therefore, take action when team members put [patients] at risk or are abusive to [patients] in any way.”

Professional Standards

108. CNO’s Professional Standards provides that each nurse is accountable to the public and responsible for ensuring that their practice and conduct meet legislative requirements and the practice standards of the profession.

109. A nurse demonstrates this standard by actions such as:

a. providing, facilitating, advocating and promoting the best possible care for patients;

b. assessing/describing the patient situation using a theory, framework or evidence-based tool and identifying/recognizing abnormal or unexpected patient responses and acting appropriately;

c. advocating on behalf of patients;

d. seeking assistance appropriately and in a timely manner;

e. providing direction to, collaborating with, and sharing knowledge and expertise;

f. acting as a role model and mentor to less-experienced nurses and students; and

g. taking action in situations in which patient safety and well-being are compromised.

Therapeutic Nurse-Client Relationship Standard

110. CNO’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) provides guidance to nurses on establishing and maintaining appropriate relationships with patients. The TNCR Standard notes that the therapeutic relationship with patients is at the core of the practice of nursing.

111. The TNCR Standard places the responsibility for establishing and maintaining the therapeutic nurse-patient relationship on the nurse. Therapeutic nursing services “contribute to the [patient’s] health and well-being” and the relationship is based on “trust, respect, empathy and professional intimacy, and requires the appropriate use of power inherent in the care provider’s role.”

112. The TNCR Standard specifies that nurses meet the standard for patient-centred care by working with the patient to ensure that all professional behaviours and actions meet the therapeutic needs of the patient.

113. Nurses violate the therapeutic relationship they are expected to develop with their patients when unacceptable conduct occurs. The TNCR Standard defines “abuse” as betraying a patient’s trust or violating the respect or professional intimacy inherent in the relationship when the nurse knew, or ought to have known, the action could cause or could be reasonably expected to cause, physical, emotional or spiritual harm to the patient. Abuse may be verbal, emotional, physical, sexual, financial or take the form of neglect. The intent of the nurse does not justify the neglect.

114. A nurse meets the standard by:

a. gaining an understanding of the patient’s abilities, limitations and needs related to his/her health condition and the patient’s needs for nursing care or services;

b. recognizing that the patient’s well-being is affected by the nurse’s ability to effectively establish and maintain a therapeutic relationship; and

c. engaging the patient in evaluating the nursing care and services that the patient is receiving.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

115. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a), 1(b) and 1(c) of the Notice of Hearing, as described in paragraphs 27-103 above, and that she failed to meet the standard of practice of the profession in her interactions with, documentation relating to, and provision of care for, Patient [A] and Patient [B] on or about June 9 and 10, 2018, and when she provided inaccurate information to the Facility during its investigation in or about June and July 2018 into Patient [A]’s death. In particular, the Member admits that her actions breached the standards of practice articulated in CNO’s Documentation Standard, Ethics Standard, Professional Standards and TNCR Standard.

116. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 2 of the Notice of Hearing, as described in paragraphs 41-48 above, in that she physically and emotionally abused Patient [A] when she applied restraints to Patient [A] despite there being no clinical indication that restraints were appropriate, and/or without a physician’s order for the application of restraints to Patient [A].

117. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3(a), 3(b), 3(c) of the Notice of Hearing, as described in paragraphs 41-90 above, in that she failed to keep records, as required, in relation to the application of restraints and ongoing assessment, observation and monitoring provided to Patient [A] on or about June 9 and 10, 2018, including information about his death.

118. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 4 of the Notice of Hearing, as described in paragraphs 91-103 above, in that she falsified a record relating to her practice when she documented that Patient [B] fell asleep in the dining room on or about June 9 and 10, 2018 when she had not.

119. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 5(a), 5(b) and 5(c) of the Notice of Hearing, as described in paragraphs 27-103 above, and that such conduct brings shame to herself and to the profession, and was disgraceful, dishonourable and unprofessional.

Decision

The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities based upon clear, cogent and convincing evidence.

Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1(a) i, ii, iii, iv, v, vi, vii, viii, ix, 1(b), 1(c), 2, 3(a), 3(b), 3(c), 4(a), 5(a) i, ii, iii, iv, v, vi, vii, viii, ix, 5(b) and 5(c) of the Notice of Hearing. With respect to allegation #2, the Panel finds that the Member physically and emotionally abused the patient. As to allegations #5(a) i, ii, iii, iv, v, vi, vii, viii, ix, 5(b) and 5(c), 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.

Allegations #1(a) i, ii, iii, iv, v, vi, vii, viii, ix, 1(b) and 1(c) in the Notice of Hearing are supported by paragraphs 27 to 115 in the Agreed Statement of Facts. The Member admits that she committed the acts of professional misconduct when she failed to monitor, assess, and document her findings or care provided to Patient [A] and Patient [B]. Patient [A] was known to the University Health Network - Toronto Rehabilitation Institute (the "Facility") as he had been a patient there for the previous two months. Patient [A] was known to suffer from a seizure disorder, he was also considered a fall risk, with a diagnosis of moderate to advanced dementia. Patient [A] occasionally became agitated and required restraints. The Member applied a Posey pelvic restraint to Patient [A] without a physician's order and without documentation supporting the need for restraints. The Member failed to follow the Facility’s Medical Directive for Initiation of Mechanical Restraints (the "Medical Directive"), which states "Mechanical restraints are to be used only after all appropriate alternatives have been tried and failed." The Member failed to follow the Patient Restraints Minimization Policy (the "Restraints Policy") where it states that health care providers can apply restraints only after the health care team assessment and analysis of the patients' behaviour has been completed, a physician’s order specific to the patient has been obtained, or the Medical Directive has been implemented. The Member did not follow any of these policies. The Member did not document, nor did she ensure that any of her colleagues documented the application of physical restraints on Patient [A] or the alternative options that were considered. The Member failed to act as a role model for Zahra Mollanedjad (“Ms. Mollanedjad”), RPN, knowing the Facility was not her home base. The Member failed to ensure that Ms. Mollanedjad was aware of the Facility’s policies and procedures. The Member failed to initiate and document the required checks per policy on the Physical Restraint Monitoring Record Form or that the restraint on Patient [A] had been fully removed every two hours to provide patient care. Patient [A] remained restrained for five and one-half hours. The Member failed to follow the Care After Death Policy (the "CAD Policy") when the Member and Elenita Lumibao (“Ms. Lumibao”), RN found Patient [A] deceased in the dining room restrained in his Broda chair. The Member failed to follow the Facility’s policy when finding a patient deceased. The Member and her colleagues knowingly and willingly moved Patient [A] to his room and put him into bed. The Member helped cover Patient [A] with blankets to "keep the body warm". The Member admits that the collective intention was to make it appear that Patient [A] died in bed or more recently.

The Member also failed to provide care to Patient [B] when she placed Patient [B] in a Broda chair and left her in the dining room for approximately five hours in various states of distress. Patient [B] was observed on video removing her gown, exposing her breasts, and sobbing; Patient [B] was kicking her legs and had placed a blanket over her head, covering her face. The Member breached the Professional Standards when she chose not to provide, facilitate or advocate for Patient [B] when she left her unsupervised and unchecked for five hours. The Member’s only documentation on Patient [B] was at 06:00, where the Member reported that Patient [B] fell asleep in the dining lounge when she had not.

The Member knowingly and willingly gave inaccurate and misleading information during an investigation at the Facility when she denied any involvement in Patient [A]'s transfer to the Broda chair. The Member denied the application of the Posey pelvic restraint, reporting that Patient [A] was put into restraints before she interacted with him. The Member reported that Ms. Mollanedjad did not inform her that Patient [A] was restrained. The Member falsely reported that she had not known that Patient [A] was in restraints until she assisted in moving his body into his bed after finding him deceased in the dining room.

The Member failed to ensure that her documentation provided a complete record of the care provided, including assessing Patient [A], planning interventions, collaborating with her three colleagues, and evaluating the outcomes of her interventions. The Member breached the Ethics Standard when she failed to promote the best possible outcome for Patient [A]. The standard states that nurses take action when team members put patients at risk or are abusive to patients in any way. The Member further breached the Professional Standards when she failed to take action when patient safety and well-being were compromised. Finally, the Member breached the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) when she betrayed Patient [A]’s trust and abused her position of power when she failed to advocate for Patient [A].

The Member placed Patient [B], a 78-year-old woman with a diagnosis of vascular dementia, into the dining lounge at 00:29. Patient [B] remained in the Broda chair for approximately five hours in various stages of distress. The Member did not take any actions when Patient [B] was sobbing, kicking her legs, and attempting to stand. The Member did not provide, facilitate, advocate, or promote the best possible care for Patient [B], which is part of the Professional Standards. The Member breached the Documentation Standard which states “nurses are accountable for ensuring their documentation of patient care is accurate, timely and complete.”

Allegation #2 in the Notice of Hearing is supported by paragraphs 41 to 48 and 113, 116 in the Agreed Statement of Facts. The Member admits that she committed the act of professional misconduct by physically and emotionally abusing Patient [A] when she and three of her colleagues took Patient [A] to the dining lounge, removed him from his wheelchair where he had been sitting quietly and placed him in a Broda chair. The Member applied the Posey pelvic restraint without a physician's order and without indicating the rationale for applying the restraint. There was no indication that Patient [A] required restraints. The TNCR Standard defines abuse as betraying the patient's trust or betraying the patient's trust when the nurse knew or ought to have known the action could cause or could be reasonably expected to cause physical, emotional or spiritual harm to the patient. Abuse can also take the form of neglect. The Member both betrayed the patient's trust and also neglected him. She betrayed his trust that she would provide proper nursing care when she applied restraints that did not have a clinical rationale or a physician's order. She also neglected the patient, failing to properly assess him or his restraints for five and a half hours while taking a two and a half-hour break. During these five and a half hours, the patient was denied help. His blanket had fallen to the floor. He was denied nursing care while he struggled against the restraints, with his limbs rigidly stretching outward, kicking and holding in a tension pose. His movements then appeared increasingly rigid. Shortly after that, the Member approached the patient but did not assess him or his restraints. The patient trusted the Member to care for him when he had been in distress and needed the Member to do her job by adequately assessing his status and restraints. The Member failed to do so and betrayed this trust.

Upon finding the patient at 0528, the Member did not call a Code Blue, did not take vital signs or ensure her colleagues did so: further betrayal of the patient's trust for her to provide adequate nursing care. Even after the patient died, the Member continued to betray the patient's trust, moving his body inappropriately and attempting to deceive others about the events leading up to and around the time of his passing. Her reprehensible, neglectful and disrespectful conduct was a breach of standards and constituted abuse. The Member failed to follow the Medical Directive and the Restraints Policy.

Allegations #3(a), 3(b) and 3(c) in the Notice of Hearing are supported by paragraphs 41 to 90 and 117 in the Agreed Statement of Facts. The Member admits that she committed acts of professional misconduct when she failed to document her observations and assessments for Patient [A] and the need for mechanical restraints. The Member failed to follow multiple policies, the Medical Directive, the Restraints Policy and the CAD Policy. The Member failed to reassess the need for the Posey pelvic restraint on Patient [A]. The Member failed to record her nursing care and aspects of her nursing process, including her independent and collaborative assessment. The Member failed to take action when colleagues failed to document interactions with Patient [A]. The Member failed to document that Patient [A] was moved from his Broda chair and placed into his bed when he was found deceased. The Member failed to inform the attending physician and the unit manager or manager-on-call that Patient [A] had died. The Member knew or should have known that the CAD Policy states that a patient whose death would be a coroner’s case should not be touched or moved. The Member failed to document the details of how Patient [A] was found alone and deceased in his Broda chair. She did not document that he was placed back into his bed and covered with blankets in an attempt to make it appear that he died in bed. The Member failed to ensure she documented care provided to Patient [A]. The Member did not assess, implement, plan, or reassess Patient [A] until 05:28 when he was found deceased. The Member breached the Documentation Standard when she failed to ensure her documentation was clear, accurate, and done in a timely manner. The Member failed to provide nursing care when she did not follow the nursing process, which included assessment, planning, intervention (independent and collaborative) and evaluation of Patient [A].

Allegation #4(a) in the Notice of Hearing is supported by paragraphs 91 to 104 in the Agreed Statement of Facts. The Member admits that she committed acts of professional misconduct when she falsified a record relating to her practice when she documented that Patient [B] fell asleep in the dining room when she had not. The Member committed misconduct when she falsified Patient [B]’s records.

Allegations #5(a) i, ii, iii, iv, v, vi, vii, viii, ix, 5(b) and 5(c), in the Notice of Hearing are supported by paragraphs 27 to 103 and 119 in the Agreed Statement of Facts. The Panel finds that the Member's conduct was clearly relevant to the practice of nursing and was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations. The Member put Patient [A] and Patient [B] at risk of harm when she failed to document her rationale, interactions, care, observations, and outcomes. Nurses are accountable for practising in accordance with the Professional Standards, practice expectations, legislation, and regulations. The Member failed to provide, advocate, and promote the best possible care for her patients when she deliberately and knowingly physically and emotionally abused Patient [A]. The Member failed to provide care, support and comfort to Patient [B] and left her in various stages of distress alone in a dark dining lounge. Lastly, the Member failed to cooperate with the Facility when she repeatedly provided inaccurate information regarding the death of Patient [A]. One of the most important ethical values in providing nursing care is truthfulness.

The Panel also finds that the Member's conduct was dishonourable as it demonstrated an element of dishonesty, deceit, and moral failing when the Member did not document care provided to Patient [B] and Patient [A]. The Member failed to monitor or check on Patient [B], who was left alone for approximately five hours in a dining lounge without lights and in various stages of distress. The Member failed to provide basic nursing care putting her patients at risk. The Member contributed to the cover-up of Patient [A]’s death when she gave misleading information during an investigation. The Member took a 2.5-hour break leaving one RN and one RPN to care for 17 vulnerable patients, knowing the patient population presented with challenging diagnoses, such as dementia and mental illness, therefore, putting patients and nursing staff at risk. The Member knew or ought to have known that her conduct was unacceptable and fell 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 physically and emotionally abused Patient [A] when, without cause, she applied mechanical restraints. The Member lied to investigators on more than one occasion at the Facility when she denied any responsibility or interactions with Patient [A]. The Member knowingly and willingly left Patient [B] alone in a room with the lights out for five hours in various stages of distress yet charted that the patient had been sleeping when she had not. The Member’s actions around Patient [A]’s death was most reprehensible. In his final hours, he was left alone, restrained, and not accurately assessed by those entrusted to do so. When the Member found Patient [A], she did not call a code or take his vital signs. By moving Patient [A] and applying blankets in an attempt to keep the body warm, the Member was trying to cover up what really happened and in doing so she disrespected Patient [A]’s passing. The Member knew or ought to have known her conduct was a violation of the nursing professions standards. The Member’s conduct casts serious doubt on the Member's moral fitness and inherent ability to discharge the higher obligations the public expects professionals to meet. The Member demonstrated a lack of integrity, dishonesty, abuse of power, and disregard for the welfare and safety of the patients in her care. Health professionals will not tolerate this conduct. The Member's conduct has brought shame not only on herself but also on the profession.

Penalty

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

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

Penalty Submissions

Submissions were made by College Counsel.

College Counsel submitted that the Joint Submission on Order also provides in Appendix "A," an Undertaking by the Member for the Member's permanent resignation as a member of the College effective November 1, 2021. The Undertaking includes the Member's commitment not to apply for membership with the College as a Registered Nurse or Registered Practical Nurse at any time in the future.

College Counsel submitted that the Member breached her obligations to Patient [A], the Facility and the legislative requirements that restraints be minimized and only used once everything else has been exhausted. The Member did none of these and applied restraints to a highly vulnerable patient without assessment, need, or a physician’s order.

College Counsel submitted that Patient [A] was found dead in his chair 5½ hours later. He died alone, restrained to his chair, and added, "no one should have to die this way." College Counsel submitted that the Member failed to provide treatment, dignity, and respect to Patient [A].

College Counsel submitted that the Member failed to keep records as required and she falsified and misled the Facility during its investigation denying any interactions or responsibility in Patient [A]'s care. The Member denied assisting her colleagues in putting Patient [A] back in bed and covering him with blankets to make the death appear more recent than it was.

Lastly, College Counsel submitted that the Member failed to provide Patient [B] with care. The Member falsified Patient [B]’s records reporting that the patient fell asleep and was in bed when she was not.

The aggravating factors in this case were:

• The Member breached her obligations to provide care to Patient [A] and Patient [B];

• The Member failed to follow the Patient Restraints Minimization Act, 2001, S.O. 2001, c.16 and the Restraints Policy of the Facility as the use of restraints is to be minimized and used only as a last resort, there is a need for ongoing monitoring, but the Member instead applied restraints to a highly vulnerable patient without assessment and did not document it;

• The Member failed to treat Patient [A] and Patient [B] with respect and dignity;

• The Member falsified documents when she reported care she did not provide;

• The Member moved the body of Patient [A] after his death;

• The Member gave false information during an investigation by the Facility regarding Patient [A]'s death.

The mitigating factors in this case were:

• The Member admitted and pleaded guilty to all of the allegations;

• The Member took responsibility for her actions by entering into an Agreed Statement of Facts and a Joint Submission on Order;

• The Member has no prior discipline history with the College.

The Member's undertaking to permanently resign as a member of the College and to not apply for membership with the College as a Registered Nurse or Registered Practical Nurse at any time in the future, along with the proposed penalty of an oral reprimand, provides general deterrence. It sends a clear message to the profession that not documenting care, giving false statements, and restraining patients without cause or a physician's order are severe breaches and will not be tolerated.

The proposed penalty provides for specific deterrence through the oral reprimand. It sends a clear message to the Member that nurses are held to a higher standard, and the public expects the nurse to provide, facilitate, promote, and advocate for the best possible care and take action in situations where patient safety and well-being are compromised. Nurses have ethical and moral obligations that show they are dedicated to patient well-being; nurses show this through being truthful, respectful in interactions with patients and their loved ones.

Overall, the public is protected because all aspects of the penalty address the most critical issue of public protection, and the penalty sends a powerful message to the public that this behaviour is not acceptable and will not be tolerated by the profession. The Documentation Standard, Ethics Standard, Professional Standards, and the TNCR Standard are the nursing profession's cornerstones and must therefore be upheld and respected. Nurses are responsible for building trust, respecting the patient's journey, and providing safe and ethical care.

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. Lumibao (Discipline Committee, 2021): The Decision and Reasons were not available at the time of submission, only the Discipline Panel’s order was available. This case is similar in that the member was involved in the same matter as the Member in the case before this Panel. The member entered into a Joint Submission on Order, agreed to an undertaking where she resigned her certificate of registration and agreed to never reapply for reinstatement with the College.

CNO v. Mollanedjad (Discipline Committee, 2021): The Decision and Reasons were not available at the time of submission, only the Discipline Panel’s order was available. This case is similar in that the member was involved in the same matter as the Member in the case before this Panel. The member entered into a Joint Submission on Order and the penalty included an oral reprimand, a 4-month suspension of her certificate of registration, a minimum of 2 meetings with a Regulatory Expert, 24-month employer notification, 6 random spot audits of the member's documentation and that the member cannot practise independently for 24 months.

Submissions were made by the Member’s Counsel.

The Member’s Counsel submitted that the Member entered into the Agreed Statement of Facts and the Joint Submission on Order, thereby taking responsibility for her actions. The Member has no prior discipline history with the College and has had an unblemished practice for the past 39 years.

The Member’s Counsel submitted that the Member’s conduct was alarming but uncharacteristic, pointing out that the Member has been employed with the Facility for the past 18 years and will continue to be employed there until November 1, 2021, when she will resign her certificate to practice adding that she will be caring for her 102-year-old mother. The Member’s Counsel submitted that the Member’s conduct, "happened on one night shift." The Member’s counsel states, “the Member presented herself as knowledgeable, and her conduct was serious but only a moment in time." Adding "the Member has provided high-quality care."

The Member’s Counsel submitted that the Joint Submission on Order provides for the most serious order and that per the Undertaking the Member cannot reapply for reinstatement of registration with the College in the future.

The Member’s Counsel submitted that this sends a strong message to the Member, and the public is protected because the Member will no longer be practising.

Lastly, the Member’s Counsel submitted that this is an appropriate order that is a product of negotiations by experienced counsel; moreover, it meets the goals of penalty and is consistent with prior cases. The Member’s Counsel added that the Panel is bound to accept the Joint Submission on Order unless by doing so it would bring the administration of justice into disrepute and the departure would have to be so shocking that the function of the Panel has broken down.

The Member’s Counsel submitted one case to the Panel to demonstrate that the proposed penalty should be accepted: R. v. Anthony-Cook (Supreme Court of Canada, 2016): This case was submitted to demonstrate the principles to be considered when a trial judge is concerned that a Joint Submission on Order was not appropriate nor in the public interest. The Member’s Counsel suggested that the Panel should not depart from the Joint Submission on Order in the case before this Panel unless the proposed penalty brought the administration of justice into disrepute.

Penalty Decision

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

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

Reasons for Penalty Decision

The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The Panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly.

The Panel concluded that the proposed penalty is reasonable and in the public interest.

The Member cooperated with the College and has accepted responsibility by agreeing to the facts and a proposed penalty.

The Panel finds that the penalty satisfies the principles of specific and general deterrence and public protection. Specific deterrence is met through the reprimand. Given the Undertaking, a reprimand without further penalty sanctions is acceptable. General deterrence is met by sending a clear message that this type of conduct will not be tolerated. The ultimate goal is to protect the public, and this is achieved through the Member's Undertaking to permanently resign her certificate of registration with the public portion of the College Registration reflecting this Undertaking. In light of the Member's permanent resignation, the goals of remediation and rehabilitation need not be addressed.

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.