DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Mary MacNeil, RN Chairperson Sylvia Douglas Public Member Ingrid Wiltshire-Stoby, NP Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO DENISE COONEY for College of Nurses of Ontario
- and -
MARIA IMELDA LAGRIMAS-MENDIOLA Registration No. 0400135 PHILIP ABBINK for Maria Imelda Lagrimas-Mendiola CHRISTOPHER WIRTH Independent Legal Counsel
Heard: June 28, 2022
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 June 28, 2022, via videoconference.
The Allegations
The allegations against Maria Imelda Lagrimas-Mendiola (the “Member”) as stated in the Notice of Hearing dated April 22, 2022 are as follows:
IT IS ALLEGED THAT:
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that while working as a Registered Nurse at Toronto Western Hospital in Toronto, Ontario (the “Facility”), you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, and in particular, in or around 2016, you submitted false claims under the Facility’s employee group benefit plan (the “Benefit Plan”).
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(8) of Ontario Regulation 799/93, in that while working as a Registered Nurse at the Facility, you misappropriated property from a client or workplace, and in particular, in or around 2016, you submitted false claims under the Benefit Plan.
You committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(14) of Ontario Regulation 799/93, in that while working as a Registered Nurse at the Facility, you falsified a record relating to your practice, and in particular, in or around 2016, you submitted false claims under the Benefit Plan.
You 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(15) of Ontario Regulation 799/93, in that while working as a Registered Nurse at the Facility, you signed or issued, in your professional capacity, a document that you knew or ought to have known contained a false or misleading statement, and in particular, in or around 2016, you submitted false claims under the Benefit Plan.
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 working 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, and in particular, in or around 2016, you submitted false claims under the Benefit Plan.
Member’s Plea
The Member admitted the allegations set out in paragraphs 1, 2, 3, 4 and 5 in the Notice of Hearing. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.
Agreed Statement of Facts
College Counsel and the Member’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited, as follows:
MEMBER
Maria Imelda Lagrimas-Mendiola (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on December 31, 2003.
The Member has been employed as an RN at Toronto Western Hospital (the “Facility”), located in Toronto, Ontario, since 2004. At the time of the incidents described below, she was employed as an operating room nurse at the Facility.
BENEFIT PLAN
The Facility’s employee benefit plan (the “Benefit Plan”) is a group insurance policy which provides coverage for extended health care, dental, and other insurance benefits. The Facility is the Plan Sponsor for the Benefit Plan and funds the cost of claims paid out under the plan. SunLife Insurance (“SunLife”) administers the Benefit Plan on behalf of the Facility. Employees contribute to the cost of the Benefit Plan as set out in their employment agreement and/or collective agreement, and based on their election for individual or family coverage.
In order to submit a claim online, plan members must confirm that the information submitted is accurate and true, and agree, if requested, to provide original receipts and/or supporting documents.
The Benefit Plan provides that the Member and her dependents were entitled to orthopaedic shoes up to a maximum of $250 per calendar year. Similarly, the Member and her dependents were eligible for orthotics up to a value of $225 per calendar year. A prescription from a physician or podiatrist was required for both services. The Member and her dependents were also entitled to reasonable and customary services of a podiatrist, up to a value of $200 per calendar year.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
In June 2016, the Member submitted false claims for shoe modifications under the Benefit Plan and received approximately $750 in relation to those false claims.
SunLife began an investigation into fraudulent benefit claims and the Facility identified the Member as a potential participant in such activity. The investigation revealed a number of irregularities with benefit claims submitted by the Member that indicated fraudulent activity.
At a meeting on August 24, 2018, the Member admitted to the Facility that she had submitted fraudulent claims. Following the meeting, in an e-mail written by the Member to the Facility, the Member accepted responsibility and apologized for her misconduct.
The Member made restitution of $2,225.00 on August 28, 2018. For the purposes of this proceeding, she acknowledges $750 in improper claims.
BENEFIT FRAUD CASES
- To date, a total of 52 benefit fraud cases involving substantially similar schemes as the one identified in this case, involving either cash or products not covered by the benefit plan, have been referred to the Discipline Committee. The dollar amounts of the claims involved range from under $500 to over $45,000.
CNO STANDARDS
Professional Standards
CNO’s Professional Standards provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by CNO. It includes seven broad standard statements pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership and relationships.
CNO’s Professional Standards provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring their practice and conduct meets the legislative requirements and the standard of the profession. Nurses are responsible for their actions and the consequences of those actions as well as for conducting themselves in ways that promote respect for the profession. Nurses demonstrate this standard by actions such as ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation.
CNO’s Professional Standards provides, in relation to the leadership standard, that leadership requires self-knowledge (understanding one’s beliefs and values and being aware of how one’s behaviour affects others), respect, trust, integrity, shared vision, learning, participation, good communication techniques and the ability to be a change facilitator. The leadership expectation is not limited to nurses in formal leadership positions and all nurses, regardless of their position, have opportunities for leadership. Nurses demonstrate this standard by actions such as role-modelling professional values, beliefs and attributes.
Ethics
CNO’s Ethics Standard describes ethical values that are important to the nursing profession in Ontario including patient well-being, patient choice, privacy and confidentiality, respect for life, maintaining commitments, truthfulness and fairness.
CNO’s Ethics Standard provides, in relation to maintaining commitments, that nurses have a commitment to the nursing profession and being a member of the profession brings with it the respect and trust of the public. To continue to deserve this respect, nurses have a duty to uphold the standards of the profession, conduct themselves in a manner that reflects well on the profession, and to participate in and promote the growth of the profession.
CNO’s Ethics Standard also provides, in relation to truthfulness, that truthfulness means speaking and acting without intending to deceive.
The Member admits and acknowledges that she contravened CNO’s Professional Standards and Ethics Standard when she submitted false claims under the Benefit Plan.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1 of the Notice of Hearing in that she contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 6 to 9 and 11 to 17 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 2 of the Notice of Hearing in that she misappropriated property from a workplace, as described in paragraphs 6 to 9 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3 of the Notice of Hearing in that she falsified a record relating to her practice, as described in paragraphs 6 to 9 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 4 of the Notice of Hearing in that she signed or issued, in her professional capacity, a document that she knew or ought to have known contained a false or misleading statement, as described in paragraphs 6 to 9 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 5 of the Notice of Hearing, and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 6 to 9 and 11 to 17 above.
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, 2, 3, 4 and 5 of the Notice of Hearing. As to allegation #5, the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be unprofessional and dishonourable.
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 in the Notice of Hearing is supported by paragraphs 6 to 9 and 11 to 18 in the Agreed Statement of Facts. The Member submitted false claims under Toronto Western Hospital’s (the “Facility”) employee group benefit plan (the “Benefit Plan”) in June 2016 and received approximately $750.00 in relation to those false claims. The Member admitted that she submitted false claims for shoe modification. The College’s Ethics Standard, in relation to truthfulness, provides that “Truthfulness means speaking or acting without intending to deceive.” The Member deceived the Facility by submitting false claims to the Benefit Plan. The College’s Ethics Standard also provides, in relation to maintaining commitments, that nurses have a commitment to the nursing profession and being a member of the profession brings with it the respect and trust of the public. To continue to deserve this respect, nurses have a duty to uphold the standards of the profession, conduct themselves in a manner that reflects well on the profession, and to participate in and promote the growth of the profession which the Member by her conduct, failed to do. In relation to accountability, the College’s Professional Standards provides that “Each nurse is accountable to the public and responsible for ensuring that her/his practice and conduct meets legislative requirements and the standards of the profession.” The Member demonstrated that she was not accountable to the public when she submitted false claims through the Benefit Plan. Accordingly, the Member breached the College’s Ethics Standard and the Professional Standards.
Allegation #2 in the Notice of Hearing is supported by paragraphs 6 to 9 and 19 in the Agreed Statement of Facts. The Member submitted false claims for shoe modifications under the Benefit Plan in June 2016 and received approximately $750.00 in relation to those false claims. She had access to the Benefit Plan as a result of her professional role with the Facility An investigation by SunLife Insurance revealed a number of irregularities with benefit claims submitted by the Member that indicated fraudulent activity. Receiving money with respect to false benefit claims constitutes misappropriation of property.
Allegations #3 and #4 in the Notice of Hearing are supported by paragraphs 3, 4, 6 to 9, 20 and 21 in the Agreed Statement of Facts. The Member had access to the Facility’s Benefit Plan as a result of her employment and practice as a RN at the Facility. Therefore, when the Member completed benefit claim forms with false information, she was completing a record related to her practice. Similarly, when the Member signed and submitted the fraudulent benefit claim forms, she did so in her professional capacity as a RN employee of the Facility. Accordingly, the facts support the allegations that the Member falsified a record related to her practice and signed, in her professional capacity, a document which contained a false or misleading statement.
With respect to allegation #5 in the Notice of Hearing which is supported by paragraphs 6 to 9 and 11 to 17 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. Patients and the public trust that nurses will demonstrate appropriate and ethical conduct. By falsifying benefit claims for her financial gain, the Member breached this trust on multiple occasions and 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 making fraudulent claims to the Facility’s Benefit Plan and receiving approximately $750.00 for those false claims for shoe modifications. 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:
Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for 2 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) The Member will attend 2 meetings with a Regulatory Expert (the “Expert”), at her own expense and within 6 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 CNO in advance of the meetings;
ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;
iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules and decision tools (where applicable):
Code of Conduct,
Professional Standards, and
Ethics;
iv. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires;
v. The subject of the sessions with the Expert will include:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards their report to CNO, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into her behaviour;
vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;
b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify her employer(s) of the decision. To comply, the Member is required to:
i. Ensure that CNO is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;
ii. Provide her employer(s) with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;
iii. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to CNO, in which it will confirm:
that they received a copy of the required documents, and
that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession.
All documents delivered by the Member to CNO, the Expert or her employer(s) will be delivered by verifiable method, the proof of which the Member will retain.
Penalty Submissions
Submissions were made by College Counsel.
The aggravating factors in this case were:
The Member submitted false claims to her employer’s benefit plan resulting in a financial loss to the Facility of approximately $750.00; and
The Member’s acts were deceitful and compromised the integrity that the public expects of nurses.
The mitigating factors in this case were:
The Member accepted full responsibility for her conduct by admitting to all the allegations of professional misconduct and by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College;
The Member saved the College time and resources;
The Member made restitution in the sum of $2,225.00, even though she only acknowledged $750.00 of false claims for the purposes of this proceeding; and
The Member has no prior discipline history with the College.
The proposed penalty provides for general deterrence through the 2-month suspension of the Member’s certificate of registration and communicates a message to other members of the profession that similar conduct will attract a significant penalty sanction. General deterrence is an important element in this case given the significant number of pending similar cases before the Discipline Committee.
The proposed penalty provides for specific deterrence through the oral reprimand and the 2-month suspension of the Member’s certificate of registration as it demonstrates to the Member the seriousness of her conduct and that this misconduct will not be tolerated.
The proposed penalty provides for remediation and rehabilitation through the 2 meetings with a Regulatory Expert. The Member will also review the College’s publications and complete reflective questionnaires, online learning modules, decision tools and online participation forms, including the development of a learning plan in collaboration with the Expert. These requirements will help to deepen the Member’s understanding of her misconduct and will help to ensure that this conduct is not repeated in her future practice.
Overall, the public is protected because this process will assist the Member in gaining additional insight and knowledge into her practice. This will inform her future practice. The public is also protected through the 12 months of employer notification requirement whereby the Member is required to notify her employers of the Panel’s decision. This penalty sends a message to the public about the profession’s ability to self-regulate and to ensure this conduct is not repeated by the Member in her future practice.
College Counsel submitted the following cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee:
CNO v. Verde-Balayo (Discipline Committee, 2021): In this case, the hearing proceeded by way of a partial Agreed Statement of Facts and a Partial Joint Submission on Order. Similarities to the case before this Panel includes the member making fraudulent claims under her employee group benefit plan. The member submitted false claims under the Benefit Plan and was paid $7,982.50. No restitution was made. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration, 2 meetings with a Regulatory Expert and 12 months of employer notification.
CNO v. Velasquez (Discipline Committee, 2021): In this case, the hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. Similarities to the case before this Panel includes the member making fraudulent claims under her employee group benefit plan. The member submitted false claims under the Benefit Plan and was paid $11,080.00. Restitution was made. The penalty included an oral reprimand, a 3-month suspension of the member’s certificate of registration, 2 meetings with a Regulatory Expert and 12 months of employer notification.
Submissions were made by the Member’s Counsel.
The Member’s Counsel submitted that on the whole he agreed with the submissions of College Counsel. The Member’s Counsel submitted that the Member was deeply remorseful and accepted the Joint Submission on Order.
The oral reprimand meets the goals of specific deterrence, general deterrence and rehabilitation and remediation and will provide an opportunity for the Member to hear from fellow members of the profession and public members about the seriousness of her conduct. It is a meaningful opportunity for the Member to receive insight about the expectations of the College and members of the public.
The mitigating factors in this case were:
The Member accepted full responsibility and apologized immediately to the Facility for her conduct;
The Member admitted to all allegations of professional misconduct and entered into an Agreed Statement of Facts and a Joint Submission on Order with the College;
The Member saved the College time and resources;
The Member made restitution in the sum of $2,225.00, even though the amount of her false claims was only $750.00;
The Member has no prior discipline history with the College.
Penalty Decision
The Panel accepts the Joint Submission on Order and accordingly orders:
The Member is required to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
The Executive Director is directed to suspend the Member’s certificate of registration for 2 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.
The Executive Director is directed to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) The Member will attend 2 meetings with a Regulatory Expert (the “Expert”), at her own expense and within 6 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 CNO in advance of the meetings;
ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;
iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules and decision tools (where applicable):
Code of Conduct,
Professional Standards, and
Ethics;
iv. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires;
v. The subject of the sessions with the Expert will include:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards their report to CNO, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into her behaviour;
vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;
b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify her employer(s) of the decision. To comply, the Member is required to:
i. Ensure that CNO is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;
ii. Provide her employer(s) with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;
iii. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to CNO, in which it will confirm:
that they received a copy of the required documents, and
that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession.
All documents delivered by the Member to CNO, the Expert or her employer(s) will be delivered by verifiable method, the proof of which the Member will retain.
Reasons for Penalty Decision
The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The Panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly.
The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility.
The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection. Specific deterrence is achieved through the oral reprimand and a 2-month suspension of the Member’s certificate of registration, which will send a clear message to the Member that fraud directed towards employer sponsored benefits will not be tolerated. General deterrence is addressed by the 2-month suspension of the Member’s certificate of registration, which will send a clear message to the profession that employee benefit fraud will not be tolerated.
Rehabilitation and remediation will be achieved through the 2 meetings with a Regulatory Expert and associated learning modules. The public will be protected through the 12 months of employer notification, which will make the employer aware of the misconduct so that the employer can appropriately monitor the Member on her return to practice.
The penalty is also in line with what has been ordered in previous cases in similar circumstances.
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.