College of Nurses of Ontario v. Mollanedjad, 2021 CanLII 154456

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Tanya Dion, RN Chairperson

Tim Crowder Public Member Carly Gilchrist, RPN Member Carly Hourigan Public Member

Andrea Norgate, RN Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) DENISE COONEY for

) College of Nurses of Ontario

• and - )

ZAHRA MOLLANEDJAD ) DENNIS OVSYANNIKOV for Registration No. JE100044 ) Zahra Mollanedjad

) CHRISTOPHER WIRTH

) Independent Legal Counsel

) Heard: August 25, 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 August 25, 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 Zahra Mollanedjad.

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

The Allegations

The allegations against Zahra Mollanedjad (“the “Member”) as stated in the Notice of Hearing dated May 3, 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 [the Patient], and/or you inadequately documented the care and treatment you provided to [the Patient], including but not limited to:

i. you failed to take appropriate action with respect to your nursing colleagues’ application of restraints to [the Patient];

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

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

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

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

vi. after determining [the Patient] was deceased, you failed to notify a manager that he was deceased;

vii. after determining [the Patient] was deceased, you failed to appropriately document information about [the Patient]’s death; and/or

b. in or about June and July 2018, you provided inaccurate information to the Facility in its investigation of [the Patient]’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(4) of Ontario Regulation 799/93, in that during your employment as a Registered Practical Nurse at the Facility, you failed to inform the Facility of your inability to accept responsibility in areas where special training is required, or where you were not competent to function without supervision when on or about June 9 and 10, 2018, you failed to inform the Facility of your inability to accept responsibility with respect to the application of restraints to patients.

3. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(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 failed to take appropriate action with respect to your nursing colleagues’ application of restraints to [the Patient].

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(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 [the Patient];

b. you failed to appropriately document your observation and monitoring of [the Patient] following the application of restraints;

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

d. you failed to appropriately document information about [the Patient]’s death.

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 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, in or about June 9 and 10, 2018:

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

b. you failed to appropriately document information about [the Patient]’s death.

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

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

i. you failed to take appropriate action with respect to your nursing colleagues’ application of restraints to [the Patient];

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

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

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

v. you failed to initiate appropriate interventions after finding [the Patient] appeared to be deceased; and/or

vi. after determining [the Patient] was deceased, you failed to notify a manager that he was deceased;

vii. after determining [the Patient] was deceased, you failed to appropriately document information about [the Patient]’s death; and/or

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

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a)(i),(ii), (iii), (iv), (v), (vi), (vii), 1(b); 2; 3; 4(a), (b), (c), (d); 5(a), (b); 6(a)(i),(ii), (iii), (iv), (v), (vi), (vii), and 6(b) in the Notice of Hearing. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.

Agreed Statement of Facts

College Counsel and the Member’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which as amended reads, unedited, as follows:

THE MEMBER

1. Zahra Mollanedjad (the “Member”) obtained a diploma in nursing from Seneca College on May 6, 2005.

2. The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on October 28, 2005.

3. The Member was employed at the University Health Network – Toronto Rehabilitation Institute (the “Facility”) in Toronto, Ontario beginning on April 1, 2006. Her employment was terminated with cause on July 26, 2018 in relation to the incidents described below.

4. The Member is currently employed as a part-time RPN by The Davis Centre, providing long-term care in Bolton, Ontario.

THE FACILITY

5. The Facility is a rehabilitation hospital with multiple clinical sites.

6. During the course of her employment, the Member usually worked at the Facility’s E.W. Bickle Centre site, specializing in complex continuing care, geriatric rehabilitation, and dialysis. The E.W. Bickle Centre site was the Member’s “home unit”, where she worked most frequently.

7. The Member also occasionally worked at other sites within the Facility. The Member worked at the Facility’s site at 550 University Avenue, in the Geriatric Psychiatry Inpatient Unit (“the Unit”) on June 9-10, 2018.

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”).

10. The Medical Directive, Restraints Policy, and CAD Policy applied to staff at all Facility sites, including the Member’s home unit, and the Unit.

The Medical Directive

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

12. 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.

13. The Medical Directive provides that restraints should only be used in limited circumstances:

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

14. The Restraints Policy provides that restraints are used only after all appropriate alternatives have been considered and/or exhausted. Restraints are used only for the purpose of preventing serious bodily harm by a patient to himself or to others.

15. 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.

16. 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.

17. A healthcare provider’s implementation of restraints and reasoning justifying the use of restraints must be documented on the Facility’s Physical Restraint Monitoring Record.

18. 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.

19. A patient’s Physical Restraint Monitoring Record must be completed with each check.

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. 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.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

The Unit Night Shift Staff Complement

23. The Member worked alongside three other nursing colleagues on the June 9, 2018 23:00 to June 10, 2018 07:00 night shift on the Unit. The colleagues were Elenita Lumibao, RPN, who was the charge nurse; Joan Brooks, RN; and Joanne Pacione, RN.

24. During night shifts on the Unit, each nurse is assigned specific patients. However, all nurses monitor each other’s patients while their nursing colleagues are on break or are supporting other patients requiring complex care. Each nurse has primary responsibility for documenting with respect to their individual patient assignments.

[The Patient]

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

26. [The Patient] was a 79-year-old patient with moderate to advanced dementia. He 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.

27. The following entries were entered in [the Patient]’s chart by other members of the healthcare team immediately before the Member was assigned to provide him care. 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.

28. The next entry in [the Patient]’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.

29. At the start of her shift, the Member documented the following in [the Patient]’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. ---------

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

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

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

32. At approximately 23:40, one of the Member’s nursing colleagues, Ms. Lumibao, brought a Broda chair with a restraint on the seat into the dining room. Ms. Lumibao left the room.

33. Shortly before 00:00, the Member and her three nursing colleagues – Ms. Pacione, Ms. Brooks and Ms. Lumibao – entered the dining room with gloves on.

34. All four nurses, including the Member, then transferred [the Patient] from the geri-chair in which he had been sitting to a Broda chair.

35. The Member did not document that [the Patient] was transferred from a geri-chair to a Broda chair. She did not document the reason for [the Patient] being transferred to the Broda chair. None of her nursing colleagues documented [the Patient]’s transfer to the Broda chair, or the reason for doing so.

36. At approximately 00:00, Ms. Brooks and Ms. Pacione applied a Posey pelvic restraint to [the Patient]. A Posey Pelvic restraint is an approved physical restraint at the Facility.

37. The Member stood close by and observed Ms. Brooks and Ms. Pacione’s application of the physical restraint to [the Patient]. She acknowledges that she witnessed her nursing colleagues applying a physical restraint to [the Patient].

38. The Member did not document the rationale for the application of the physical restraint in [the Patient]’s chart and did not indicate if an alternative option was considered prior to the application of the physical restraint. None of her nursing colleagues documented this information either. The Member acknowledges that she did not assess the appropriateness of the application of a physical restraint, or ensure that her colleagues did so.

39. The Member did not complete a Physical Restraint Monitoring Record Form in relation to the application of the physical restraint to [the Patient], as required by the Restraints Policy. None of her nursing colleagues completed this form either. The Member acknowledges that she did not ensure that any of her nursing colleagues completed the form.

40. Shortly after [the Patient] was restrained in the Broda chair, all four nurses, including the Member, exited the dining room. [The Patient] remained restrained in the Broda chair in the dining hall.

41. The Member returned briefly to the dining room at approximately 00:04 and put pillows behind [the Patient]’s head and under his feet. [The Patient] remained physically restrained. The Member did not conduct a physical assessment, such as a vitals check, or reassess the need for the restraint to remain in place. The Member exited the dining room.

42. At approximately 00:29, Ms. Brooks entered the dining room, approached [the Patient], and adjusted the pillow behind his head. [The Patient] remained physically restrained. Ms. Brooks did not document her interaction with [the Patient] in his chart.

43. The last time the Member checked on [the Patient] was at approximately 00:04. The last time any of the nurses checked on [the Patient] was when Ms. Brooks observed [the Patient] at approximately 00:29.

44. The Member admits that the Restraints Policy required scheduled monitoring 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 [the Patient] at times when she was on break.

45. From approximately 01:15-02:15, the Member went on her break.

46. [The Patient] struggled against the restraints, with his limbs rigidly stretching outward, kicking, and holding in a tension pose, from approximately 01:50 to 02:00. [The Patient] leaned back and forth, rocking in place, from 02:00 until 02:10.

47. At 02:10, Ms. Brooks entered the dining room and approached [the Patient]. She picked up a pillow that had fallen on the ground and repositioned it behind [the Patient]’s head. She did not assess the ongoing use of the pelvic restraint, or otherwise assess [the Patient]. Ms. Brooks did not document this interaction in [the Patient]’s chart.

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

49. [The Patient]’s last physical movement is visible at 02:12.

50. The Member was the only staff to enter the dining room again after 02:10. She entered the hall at 03:35, 03:56 and 05:20. On those occasions, the Member did not approach [the Patient], assess the restraints, release the restraints, provide him any care, or otherwise assess [the Patient]. Instead, the Member glanced at [the Patient] from across the dining room.

51. The Member did not document anything in [the Patient]’s chart at the times she entered the dining room at 03:35, 03:56 and 05:20. The Member documented in [the Patient]’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.”

52. The Member documented in [the Patient]’s chart the following entry at 05:15 on June 10, 2018:

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.

53. The Member admits and acknowledges that she falsified a record relating to her practice when she failed to document the application of restraints to [the Patient].

54. The Member admits and acknowledges that she did not follow both the Medical Directive and Restraints Policy with respect to the application of restraints to [the Patient]. If she were to testify, she would say that she did not receive adequate training on the Unit, and in particular with respect to the application of restraints, in order to intervene with her colleagues’ application of restraints and comply with the Medical Directive and the Restraints Policy. However, at no time prior to or during her shift on the Unit, did the Member inform the Facility or any of her colleagues that she was unable to accept responsibility for patients with respect to the use of restraints because she lacked appropriate training.

55. If the Member were to testify, she would state that she deferred to her colleagues’ judgment on the application of restraints because she did not usually work on the Unit. Nevertheless, the Member acknowledges that she owed a duty to her patient to advocate for [the Patient] and ensure his safety. The Member did not inform a Unit manager or coordinator that she felt uncomfortable with her nursing colleagues’ application of restraints to [the Patient]. The Member acknowledges that she should have also documented any disagreement with her colleagues’ approach and raised her concerns with management if she felt [the Patient]’s wellbeing was compromised by the pelvic restraint.

Failure to follow CAD Policy

56. The video footage indicated that at 05:15 [the Patient] remained restrained in the Broda chair in the dining room. He was not in bed at 05:15 as the Member’s charting indicates.

57. At 05:18, the video footage shows that the Member was standing at a nursing station desk, and that she was not in the dining room or close to [the Patient].

58. At 05:20, the Member can be seen entering the dining room and attending to another patient in the dining room. The Member did not check on [the Patient] at that time. In particular, she did not take [the Patient]’s vitals at 05:20 as she documented.

59. Ms. Lumibao entered the dining room at 05:28, followed by Ms. Brooks. Ms. Brooks walked towards [the Patient], and upon seeing him, pointed to Ms. Lumibao, and then to [the Patient]. Ms. Lumibao left the room. Ms. Brooks remained in front of [the Patient].

60. Shortly after, Ms. Pacione and Ms. Lumibao entered the dining room. Eventually Ms. Pacione removed [the Patient] from the dining room and transported him to his room.

61. The Member entered [the Patient]’s room at 05:33. By 05:35, all four nurses were in [the Patient]’s room.

62. Over approximately the next twenty minutes, the four nurses went in and out of [the Patient]’s room. The interactions between the Member and her colleagues during this time were not recorded because there was no video camera in [the Patient]’s room.

63. Inconsistent with the CAD Policy, none of the nurses notified the on-call manager that [the Patient] had died.

64. According to the Facility’s CAD Policy, if [the Patient] 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 [the Patient] was found deceased in the dining room, [the Patient] should not have been transferred to his room and, subsequently, out of the Broda chair and into his bed.

65. The Member admits and acknowledges that she did not follow the Facility’s Medical Directive, Restraints Policy and CAD Policy in relation to her assessment, monitoring, documentation, and care of [the Patient]. She admits that she did not, but ought to have immediately notified the on-call manager of [the Patient]’s death. The Member admits and acknowledges that she falsified a record relating to her practice in her documentation with respect to [the Patient]’s death.

Inaccurate Information Provided During Facility Investigation

66. On June 11, 2018, the manager of the Unit learned of [the Patient]’s death. She reviewed [the Patient]’s health record and found the Member’s entry about his death unclear. As a result, the Facility conducted an internal investigation into [the Patient]’s death.

67. The Facility held its first investigation meeting with the Member into [the Patient]’s death on June 11, 2018.

68. During the meeting, the Member stated that [the Patient] was smiling and alert at the beginning of the shift, and that he was in his own wheelchair, sitting upright, and did not want to go to bed because he was not sleepy. She said that Ms. Lumibao and Ms. Pacione told her that he should be transferred to a Broda chair because it “is more safe”. The Member told the Facility that “the pelvic restraint was applied by 2 nurses” while she went to get pillows to make [the Patient] more comfortable and that she was not present for the restraint application.

69. The Member acknowledges that her statements to the Facility on June 11, 2018, were inaccurate. In particular, the Member admits that she observed her colleagues applying the physical restraint to [the Patient].

70. The Facility held a second fact-finding meeting with the Member on June 25, 2018 and a third structured conversation with her on July 12, 2018. The Member admits that she made the following inaccurate statements at those meetings:

• The Member told the Facility that she observed [the Patient] at around 02:00 and 02:30. However, the Member was on break until approximately 02:15. The Member did not enter the dining room at all. The Member did not document any such observation in [the Patient]’s chart.

• The Member told the Facility that she observed [the Patient] breathing, with his eyes open, at 04:00. However, the Member acknowledges that she did not approach [the Patient] at that time and/or assess him.

CNO STANDARDS OF PRACTICE

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

Documentation Standard

72. 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.

Professional Standards

73. 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.

74. 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; and

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

Therapeutic Nurse-Client Relationship Standard

75. 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.

76. 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.”

77. 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. 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

78. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a) and 1(b) of the Notice of Hearing, as described in paragraphs 30-70 above, and that she failed to meet the standard of practice of the profession in her interactions with, and provision of care for, [the Patient] on or about June 9 and 10, 2018 and when she provided inaccurate information to the Facility during its investigation into [the Patient]’s death. In particular, the Member admits that her actions breached the standards of practice articulated in CNO’s Documentation Standard, Professional Standards and TNCR Standard.

79. 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 30-55 above, in that she failed to inform the Facility of her inability to accept responsibility in areas where special training was required in relation to the application of patient restraints.

80. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3 of the Notice of Hearing, as described in paragraphs 30-70 above, in that she physically and emotionally abused [the Patient] on or about June 9 and 10, 2018 when she failed to take appropriate action with respect to her nursing colleagues’ application of restraints.

81. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 4(a), 4(b), 4(c) and 4(d) of the Notice of Hearing, as described in paragraphs 30-70 above, in that she failed to keep records, as required in relation to her care provided to [the Patient] on or about June 9 and 10, 2018.

82. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 5(a) and 5(b) of the Notice of Hearing, as described in paragraphs 30-70 above, in that she falsified a record relating to her practice in relation to her care provided to [the Patient] on or about June 9 and 10, 2018.

83. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 6(a) and 6(b) of the Notice of Hearing, as described in paragraphs 30-70 above, and that such conduct brings shame to herself and to the profession, and was unprofessional and dishonourable.

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), 1(b); 2; 3; 4(a),(b),(c),(d); 5(a),(b); 6(a)(i),(ii),(iii),(iv),(v),(vi),(vii) and 6(b) of the Notice of Hearing. With respect to allegation #3, the Panel finds that the Member physically and emotionally abused the patient. As to allegations #6(a)(i),(ii),(iii),(iv),(v),(vi),(vii) and 6(b), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonourable and unprofessional.

Reasons for Decision

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

Allegation #1(a)(i) in the Notice of Hearing is supported by paragraphs 30-78 in the Agreed Statement of Facts. At approximately 00:00, Ms. Brooks and Ms. Pacione applied a Posey pelvic restraint to [the Patient]. The Member stood close by and observed Ms. Brooks and Ms. Pacione’s application of the physical restraint to [the Patient]. She acknowledges that she witnessed her nursing colleagues applying the physical restraint to [the Patient]. If the Member were to testify, she would state that she deferred to her colleagues’ judgement on the application of the restraint because she did not usually work on the unit. By allowing her colleagues to apply these restraints, the Member breached the TNCR Standard. As indicated in the standard a nurse must “contribute to the health and well being of a patient”. If the Member had any concerns or questions about the use of a restraint she ought to have brought up her concerns. 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[ ].

Allegation #1(a)(ii) in the Notice of Hearing is supported by paragraphs 30-78 in the Agreed Statement of Facts. The Member did not document the rationale for the application of the physical restraint in [the Patient]’s chart and did not indicate if an alternative option was considered prior to the application of the physical restraint. By not documenting her rationale, the Member breached the Documentation Standard. The 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 this standard by ensuring documentation is a complete record of nursing care provided and reflects all aspects of the nursing process, including assessment, planning and intervention.

Allegation #1(a)(iii) in the Notice of Hearing is supported by paragraphs 30-78 in the Agreed Statement of Facts. The Member admits that the Restraints Policy required scheduled monitoring 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. By not following her hospital restraint policy, the Member failed to meet the Professional Standards. This standard ensures that each nurse is accountable to the public and responsible for ensuring that their practice and conduct meet legislative requirements.

Allegation #1(a)(iv) in the Notice of Hearing is supported by paragraphs 30-78 in the Agreed Statement of Facts. After restraining [the Patient] the Member briefly returned to the dining room at approximately 00:04 and put pillows behind [the Patient]’s head and under his feet. [The Patient] remained physically restrained. The Member did not conduct a physical assessment or reassess the need for the restraint to remain in place. By not assessing her patient the Member failed to meet the CNO’s Professional Standards. A nurse meets this standard by providing, facilitating, advocating and promoting the best possible outcome for the patient. The Member should have assessed her patient, recognizing the importance of releasing him from a restraint as early as possible.

Allegation #1(a)(v) in the Notice of Hearing is supported by paragraphs 30-78 in the Agreed Statement of Facts. The Member admits and acknowledges that she did not follow the Facility’s Medical Directive and CAD Policy. According to the Facility’s CAD Policy, if [the Patient] 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 [the Patient] was found deceased in the dining room, [the Patient] should not have been transferred to his room and, subsequently, out of the Broda chair and into his bed. The Member failed to meet the CNO’s Professional Standards as she failed ”to take action in any situation in which a patient’s safety and well being are compromised”.

Allegation #1(a)(vi) in the Notice of Hearing is supported by paragraphs 30-78 in the Agreed Statement of Facts. Inconsistent with the CAD Policy, none of the nurses notified the on-call manager that [the Patient] had died. The Member had the professional responsibility to follow hospital policy. By not doing so the Member put the patient’s overall wellbeing at risk. The Member breached the CNO’s Professional Standards by “failing to assess/describe the patient situation, identifying/ recognizing abnormal or unexpected patient responses”.

Allegation #1(a)(vii) in the Notice of Hearing is supported by paragraphs 30-78 in the Agreed Statement of Facts. The Member admits, and the Panel finds, that she falsified a record relating to her practice in her documentation with respect to [the Patient]’s death. The Member breached the Documentation Standard. This standard clarifies that a nurse meets the standard by ensuring documentation is a complete record of nursing care provided, documentation is completed in a timely manner and ensures that relevant patient care information is captured.

Allegation #1(b) in the Notice of Hearing is supported by paragraphs 30-78 in the Agreed Statement of Facts. During the meeting, the Member stated that [the Patient] was smiling and alert at the beginning of the shift, and that he was in his own wheelchair, sitting upright, and did not want to go to bed because he was not sleepy. She said that Ms. Lumibao and Ms. Pacione told her that he should be transferred to a Broda chair because it “is more safe”. The Member told the Facility that “the pelvic restraint was applied by 2 nurses” while she went to get pillows to make [the Patient] more comfortable and that she was not present for the restraint application. The Member acknowledges that her statements to the Facility on June 11, 2018, were inaccurate. In particular, the Member admits that she observed her colleagues applying the physical restraint to [the Patient]. The Facility held a second fact-finding meeting with the Member on June 25, 2018 and a third structured conversation with her on July 12, 2018. The Member admits that she made the following inaccurate statements at those meetings:

The Member told the Facility that she observed [the Patient] at around 02:00 and 02:30. However, the Member was on break until approximately 02:15. The Member did not enter the dining room at all. The Member did not document any such observation in [the Patient]’s chart.

The Member told the Facility that she observed [the Patient] breathing, with his eyes open, at 04:00. However, the Member acknowledges that she did not approach [the Patient] at that time and/or assess him.

The Member’s initial comments to her facility were not truthful. The Member did not initially report an honest portrayal of the overall situation. A nurse must always put the patient first. The Member failed to meet the Professional Standards as she failed to take action when patient safety and well being were compromised.

Allegation #2 in the Notice of Hearing is supported by paragraphs 30-55 and 79 in the Agreed Statement of Facts. If she were to testify, the Member would say that she did not receive adequate training on the Unit, and in particular with respect to the application of restraints, in order to intervene with her colleagues’ application of restraints and comply with the Medical Directive and the Restraints Policy. However, at no time prior to or during her shift on the Unit, did the Member inform the Facility or any of her colleagues that she was unable to accept responsibility for patients with respect to the use of restraints because she lacked appropriate training.

Allegation #3 in the Notice of Hearing is supported by paragraphs 30-70 and 80 in the Agreed Statement of Facts. The Member acknowledges that she physically and emotionally abused the patient by failing to take appropriate action to the application of the physical restraints. The Member continually allowed the patient to be restrained while he was settled and sleeping. By failing to assess the patient at the appropriate intervals the Member failed to assess the patient’s well-being. It can be emotionally troubling for an individual to be physically restrained against his will. It is a nurse's responsibility to ensure a patient’s physical and emotional wellbeing are assessed on a regular basis. It is not dignified to leave a patient in restraints without proper rationale or clinical indication.

Allegation #4(a) in the Notice of Hearing is supported by paragraphs 30-70 and 81 in the Agreed Statement of Facts. The Member did not document the rationale for the application of the physical restraint in [the Patient]’s chart and did not indicate if an alternative option was considered prior to the application of the physical restraint.

Allegation #4(b) in the Notice of Hearing is supported by paragraphs 30-70 and 81 in the Agreed Statement of Facts. The Member admits that the Restraints Policy required scheduled monitoring 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. The Member did not document anything in [the Patient]’s chart at the times she entered the dining room at 03:35, 03:56 and 05:20. The Member documented in [the Patient]’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.”

Allegation #4(c) in the Notice of Hearing is supported by paragraphs 30-70 and 81 in the Agreed Statement of Facts. After restraining [the Patient] the Member briefly returned to the dining room at approximately 00:04 and put pillows behind [the Patient]’s head and under his feet. [The Patient] remained physically restrained. The Member did not conduct a physical assessment or reassess the need for the restraint to remain in place.

Allegation #4(d) in the Notice of Hearing is supported by paragraphs 30-70 and 81 in the Agreed Statement of Facts. The Member admits, and the Panel finds, that she falsified a record relating to her practice in her documentation with respect to [the Patient]’s death.

Allegation #5(a) in the Notice of Hearing is supported by paragraphs 30-70 and 82 in the Agreed Statement of Facts. The Member did not document the rationale for the application of the physical restraint in [the Patient]’s chart and did not indicate if an alternative option was considered prior to the application of the physical restraint.

Allegation #5(b) in the Notice of Hearing is supported by paragraphs 30-70 and 82 in the Agreed Statement of Facts. The Member admits, and the Panel finds, that she falsified a record relating to her practice in her documentation with respect to [the Patient]’s death.

With respect to allegation #6, the Panel finds that the Member’s conduct in disregarding her professional obligations when she failed to intervene when her colleagues applied a restraint, by failing to document the application of a restraint, by failing to monitor the ongoing application of the restraint, by finding [the Patient] deceased and moving him to his room and by falsifying documentation was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of dishonesty and deceit through failing to uphold her professional obligations by failing to intervene, to monitor the application of a restraint and by moving a deceased body with out any medical intervention. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional.

Penalty

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

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

2. Directing the Executive Director to suspend the Member’s certificate of registration for 4 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.

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

a) The Member will attend 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 sessions are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date that this Order becomes final. To comply, the Member is required to ensure that:

i. The Expert has expertise in nursing regulation and has been approved by the Director 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:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):

1. Code of Conduct,

2. Documentation,

3. Therapeutic Nurse-Client Relationship Standard, and

4. Professional Standards;

iv. Before the first meeting, the Member reviews and completes the CNO’s self-directed learning package, One is One Too Many, at her own expense, including the self-directed Nurses’ Workbook;

v. 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 and Nurses’ Workbook;

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

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

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

3. strategies for preventing the misconduct from recurring,

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

5. the development of a learning plan in collaboration with the Expert;

vii. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards his/her report to the Director, in which the Expert will confirm:

1. the dates the Member attended the sessions,

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

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

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

viii. 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 24 months from the date the Member returns to the practice of nursing, the Member will notify her employers of the decision. To comply, the Member is required to:

i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;

ii. Provide her employer(s) with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

iii. 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 Direction confirming the following:

1. the employer received a copy of the required documents,

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

3. the employer agrees to perform 6 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,

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

e. the fifth audit shall take place within 15 months from the date the Member begins or resumes employment with the employer,

f. the sixth and final audit shall take place within 18 months from the date the Member begins or resumes employment with the employer;

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

1. reviewing a random selection of the Member’s charts to ensure they meet both CNO and employer standards,

2. discussing (by telephone or in person), with at least 3 of the Member’s patients, the care provided by the Member to ensure that the Member provided the necessary and/or required care to the patients and that she is utilizing appropriate documentation techniques consistent with the Documentation Standard, legislation and employer standards; and

c) The Member shall not practice independently in the community for a period of 24 months from the date the Member returns to the practice.

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

Penalty Submissions

Submissions were made by College Counsel.

The aggravating factors in this case were:

• Several findings of breaches of standards;

• Findings of abuse;

• Findings of falsification of records;

• Case involves an elderly and vulnerable patient while in the Member’s care;

• The Member stood by and watched as her colleagues applied a restraint to the patient without conducting an appropriate assessment or without any apparent need for the application of the restraint;

• Restraints are intended as a last resort in very limited circumstances and the circumstances were not present in this case;

• The Member did not document the application of the restraint and she along with her nursing colleagues left the patient physically restrained and essentially unattended for five hours;

• He died alone in the dining room, physically restrained;

• The Member’s documentation did not accurately reflect what occurred in this case;

• On finding the patient deceased the Member and her colleagues transferred the patient to his room;

• The Member did not properly document her interventions;

• The Member demonstrated total disrespect to the patient;

• The Member lied to her facility during the investigation process;

• The Member’s conduct was serious which raises the question of the Member’s ability to discharge the higher obligations that the public rightly expects of nurses.

The mitigating factors in this case were:

• The Member took early responsibility for her actions by pleading guilty and entering into a resolution by agreeing to the Agreed Statement of Facts and the Joint Submission on Order;

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

The proposed penalty appropriately meets the goals of penalty. The overarching goal of any penalty is to protect the public, while enhancing public confidence in the College’s ability to regulate its nurses. This goal is achieved through a penalty that addresses specific deterrence, general deterrence, rehabilitation and remediation.

The proposed penalty provides for general and specific deterrence through the oral reprimand and the suspension of the Member’s certificate of registration. The oral reprimand will assist the Member in understanding how her actions are perceived by both her nursing colleagues of the profession as well as the public, thereby protecting the public. The suspension sends a strong signal to this Member and other members of the profession that this kind of behaviour is unacceptable and this will ensure that the conduct will not be repeated and the public is thereby protected.

The proposed penalty provides for remediation and rehabilitation through the Regulatory Expert meetings and review of the College’s standards. This will prepare the Member to return to practice to meet the standards expected of nurses.

Overall, the public is protected because of the employee notification, the “spot” audits of the Member’s documentation and the restriction of independent practice. There will be employer oversight once she returns to practice, in particular to ensure that her documentation is accurate.

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. Farah (Discipline Committee, 2020). In this case, the member admitted to failing to assess, reassess and document a patient’s need for a restraint and the application of the restraint. The patient was a 92 year old female with Parkinson’s and Dementia. The panel ordered a penalty which included an oral reprimand, a 2 month suspension, a minimum of two meetings with a Regulatory Expert and a 12 month employer notification period.

CNO v. Blum (Discipline Committee, 2019). In this case, the member failed to deescalate a developmentally delayed patient that was displaying self harming behaviour, assess the ongoing need for a chemical restraint and document her restraint in the patient’s chart. Once restrained the member did not follow up and assess the patient. There were also other allegations of abuse which included “swatting of the hand” of a dementia patient and making verbal abusive comments towards the patient. The panel ordered a penalty which included an oral reprimand, a 3 month suspension, two meetings with a Regulatory Expert and 12 months of employer notification.

CNO v. Popo (Discipline Committee, 2020). In this case, the member failed to appropriately monitor an 87 year old surgical patient, falsely documenting that she completed checks on a patient when she had not and failed to take appropriate actions after finding the patient without vital signs. The panel ordered a penalty which included an oral reprimand, a 3 month suspension, a minimum of two meetings with a Regulatory Expert and 18 months of employer notification.

CNO v. Van De Walle (Discipline Committee, 2017). In this case, the member denied the allegations against her. The member was accused of falsely reporting to her employer that she had not seen a colleague strike a patient and the panel found that the member had not been truthful about what she had seen and did in fact observe her colleague strike a patient while placing the patient in a head lock. The penalty ordered included an oral reprimand, a 2 month suspension, two meetings with a Nursing Expert and 12 months of employer notification.

Submissions were made by the Member’s Counsel. It was the Member’s position that the Panel should accept the Joint Submission on Order. The penalty contained therein is well tailored to the misconduct demonstrated. The penalty contained monitoring requirements including the meetings with a Regulatory Expert as well as the “spot” audits and the penalty is in line with previous cases. The mitigating circumstances included the Member’s long career without any complaints about her to the College. This was the first complaint about the Member to the College. It was the Member’s first finding of misconduct. The Member recognizes her errors and accepts responsibility for her misconduct. The Member fully cooperated with the investigation and the entire process of the hearing. By entering into the Agreed Statement of Facts and the Joint Submission on Order the Member also saved the College the expense of a lengthy hearing.

Penalty Decision

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

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

2. The Executive Director is directed to suspend the Member’s certificate of registration for 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.

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

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

i. The Expert has expertise in nursing regulation and has been approved by the Director 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:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):

1. Code of Conduct,

2. Documentation,

3. Therapeutic Nurse-Client Relationship Standard, and

4. Professional Standards;

iv. Before the first meeting, the Member reviews and completes the CNO’s self-directed learning package, One is One Too Many, at her own expense, including the self-directed Nurses’ Workbook;

v. 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 and Nurses’ Workbook;

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

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

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

3. strategies for preventing the misconduct from recurring,

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

5. the development of a learning plan in collaboration with the Expert;

vii. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards his/her report to the Director, in which the Expert will confirm:

1. the dates the Member attended the sessions,

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

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

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

viii. 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 24 months from the date the Member returns to the practice of nursing, the Member will notify her employers of the decision. To comply, the Member is required to:

i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;

ii. Provide her employer(s) with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

iii. 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 Direction confirming the following:

1. the employer received a copy of the required documents,

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

3. the employer agrees to perform 6 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,

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

e. the fifth audit shall take place within 15 months from the date the Member begins or resumes employment with the employer,

f. the sixth and final audit shall take place within 18 months from the date the Member begins or resumes employment with the employer;

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

1. reviewing a random selection of the Member’s charts to ensure they meet both CNO and employer standards,

2. discussing (by telephone or in person), with at least 3 of the Member’s patients, the care provided by the Member to ensure that the Member provided the necessary and/or required care to the patients and that she is utilizing appropriate documentation techniques consistent with the Documentation Standard, legislation and employer standards; and

c) The Member shall not practice independently in the community for a period of 24 months from the date the Member returns to the practice.

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

Reasons for Penalty Decision

The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses 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 has ordered an oral reprimand, suspension of four months, terms, conditions and limitations on her certificate of registration and two meetings with a Nursing Expert. The Panel concluded that the proposed penalty is reasonable and in the public interest. Public safety is paramount. 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. The oral reprimand sends a strong message to the Member and the profession that this type of behaviour will not be tolerated. In order to provide strong, client centred care nurses must follow and adhere to policies, procedures and CNO standards of practice. Terms, conditions, and limitations on the Member’s certificate of registration sets expectations and boundaries on the Member’s practice. By seeking guidance of a Nursing Expert, it provides a remediation and rehabilitation component to the Penalty. Overall, the public is protected because of the employee notification, the “spot” audits of the Member’s documentation and the restriction of independent practice. There will be employer oversight once she returns to practice.

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

I, Tanya Dion, RN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.