College of Nurses of Ontario v. Paul Robert Couldridge, 2022 ONCNO 135258

Discipline Committee of the College of Nurses of Ontario

Panel: David Edwards, RPN Chairperson Sylvia Douglas Public Member Shaneika Grey, RPN Member Emilija Stojsavljevic, RPN Member

Between:

College of Nurses of Ontario (Sarah Corman for College of Nurses of Ontario)

• and -

Paul Robert Couldridge Registration No. IC04494 (No Representation for Paul Robert Couldridge)

Christopher Wirth Independent Legal Counsel

Heard: July 25, 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 July 25, 2022, 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 at the Discipline hearing of Paul Robert Couldridge.

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

The Allegations

College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs 1(a)(v) and 6(a)(v) in the Notice of Hearing dated July 19, 2022. The Panel granted this request. The remaining allegations against Paul Robert Couldridge (the “Member”) are as follows:

IT IS ALLEGED THAT:

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

a) your employment at Victorian Order of Nurses in Hamilton, Ontario (“VON”), with respect to the following incidents:

i) between June 1, 2017 and September 18, 2017, you requested to be paid, and/or were paid, for time you had not worked;

ii) between June 1, 2017 and September 18, 2017, you requested to be paid, and/or were paid, for overtime you had not worked;

iii) between June 1, 2017 and September 18, 2017, you falsely recorded visit times on the CellTrak application by logging out of a visit after you had already departed the visit;

iv) on or about September 19, 2017, during a joint supervisory visit, you failed to follow appropriate hand hygiene and infection control procedures;

v) [withdrawn];

vi) on or about September 19, 2017, during a joint supervisory visit, you failed to have in your possession an up-to-date medical directive for anaphylaxis epinephrine;

vii) on or about September 19, 2017, during a joint supervisory visit, you failed to check the medication Order prior to administering IV antibiotics; and/or

viii) on or about September 19, 2017, during a joint supervisory visit, you failed to prepare and administer medication safely by failing to check the 8 rights of medication administration (patient, medication, reason, dose, frequency, route, site and time);

b) your employment at Saint Elizabeth Health Care in Hamilton, Ontario (“St. Elizabeth”), with respect to the following incidents:

i) on or about April 25 and 26, 2018, you failed to document your wasting and/or disposal of Patient [A]’s medication, including hydromorphone;

ii) on or about April 25 and 26, 2018, you failed to document the practice draws of Patient [A]’s medication made by a preceptee nurse you were supervising, including of hydromorphone;

iii) on or about April 25 and 26, 2018, you failed to document the count remaining of Patient [A]’s medication after his death;

iv) on or about April 25 and 26, 2018, you failed to complete accurate documentation in respect of care provided to Patient [A], including the times of events;

v) on or about April 25 and 26, 2018, you failed to document your discussion with Patient [A]’s spouse about her administration of medication to Patient [A] prior to your arrival;

vi) on or about April 25 and 26, 2018, you failed to accurately and/or legibly document the time and dose of medication administered to Patient [A];

vii) on or about April 25 and 26, 2018, you failed to document the rationale for the administration of medication to Patient [A];

viii) on or about April 25 and 26, 2018, you failed to document the DNR status in the night chart of Patient [A];

ix) on or about April 25 and 26, 2018, in respect of Patient [A], you failed to document that you offered to call 911 on two occasions;

x) on or about April 25 and 26, 2018, you failed to document that you inserted a subcutaneous injection site for Patient [A];

xi) on or about April 25 and 26, 2018, you failed to document Patient [A]’s vital signs and blood pressure;

xii) on or about April 25 and 26, 2018, you failed to complete and document an appropriate care plan for Patient [A];

xiii) on or about April 25 and 26, 2018, you failed to record any assessment data for Patient [A];

xiv) on or about April 25 and 26, 2018, you failed to maintain the Nursing History and Physical Assessment and Palliative Care Pain and Symptom Screening Flow Sheet records for Patient [A] within the patient’s night chart;

xv) on or about April 25 and 26, 2018, you falsified the Palliative Care Pain and Symptom Screening Flow Sheet record in respect of April 21 and 22, 2018 for Patient [A];

xvi) on or about April 25 and 26, 2018, you improperly disposed of Patient [A]’s medication, including hydromorphone, by dumping it down the sink;

xvii) on or about April 25 and 26, 2018, you failed to seek authorization prior to practicing draws and disposing of Patient [A]’s medication;

xviii) on or about April 25 and 26, 2018, you failed to provide any education to Patient [A]’s spouse as to the safe disposal of Patient [A]’s medication;

xix) on or about November 30, 2017, you were sleeping while on duty caring for Patient [B];

xx) on or about November 30, 2017, you failed to adequately monitor Patient [B]’s oxygen saturation levels;

xxi) on or about November 30, 2017, you failed to adequately document assessment data and care provided to Patient [B];

xxii) on or about April 30, 2018, you were sleeping on duty while caring for Patient [C];

xxiii) on or about April 30, 2018, you failed to adequately monitor Patient [C];

xxiv) on or about April 30, 2018, you failed to respond to BiPAP alarms while caring for Patient [C];

xx5) on or about April 30, 2018, you failed to adequately document assessment data and care provided to Patient [C];

xxvi) on or about May 22, 2018, you failed to promptly reposition Patient [D] when she became agitated and/or uncomfortable after rolling onto her stomach; and/or

xxvii) on or about May 22, 2018, you failed to document the incident involving Patient [D] becoming agitated and/or uncomfortable after rolling onto her stomach and your need to obtain the assistance of Patient [D]’s daughter.

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(28) of Ontario Regulation 799/93, in that while employed as a RPN at VON, you submitted an account or charge for services that you knew was false or misleading, in that:

a) between June 1, 2017 and September 18, 2017 you requested to be paid, and/or were paid, for time you had not worked;

b) between June 1, 2017 and September 18, 2017 you requested to be paid, and/or were paid, for overtime you had not worked; and/or

c) between June 1, 2017 and September 18, 2017 you falsely recorded visit times on the CellTrak application by logging out of a visit after you had already departed the visit.

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(8) of Ontario Regulation 799/93, in that while employed as a RPN at VON, you misappropriated property from a patient or workplace, in that:

a) between June 1, 2017 and September 18, 2017 you requested to be paid, and were paid, for time you had not worked; and/or

b) between June 1, 2017 and September 18, 2017 you requested to be paid, and were paid, for overtime you had not worked.

4. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(13) of Ontario Regulation 799/93, in that while employed as a RPN at St. Elizabeth, you failed to keep records as required, in that:

a) on or about April 25 and 26, 2018, you failed to document your wasting and/or disposal of Patient [A]’s medication, including hydromorphone;

b) on or about April 25 and 26, 2018, you failed to document the practice draws of Patient [A]’s medication made by a preceptee nurse you were supervising, including of hydromorphone;

c) on or about April 25 and 26, 2018, you failed to document the count remaining of Patient [A]’s medication after his death;

d) on or about April 25 and 26, 2018, you failed to complete accurate documentation in respect of care provided to Patient [A], including the times of events;

e) on or about April 25 and 26, 2018, you failed to document your discussion with Patient [A]’s spouse about her administration of medication to Patient [A] prior to your arrival;

f) on or about April 25 and 26, 2018, you failed to accurately and legibly document the time and dose of medication administered to Patient [A];

g) on or about April 25 and 26, 2018, you failed to document the rationale for the administration of medication to Patient [A];

h) on or about April 25 and 26, 2018, you failed to document the DNR status in the night chart of Patient [A];

i) on or about April 25 and 26, 2018, in respect of Patient [A], you failed to document that you offered to call 911 on two occasions;

j) on or about April 25 and 26, 2018, you failed to document that you inserted a subcutaneous injection site for Patient [A];

k) on or about April 25 and 26, 2018, you failed to document Patient [A]’s vital signs and blood pressure;

l) on or about April 25 and 26, 2018, you failed to complete and document an appropriate care plan for Patient [A];

m) on or about April 25 and 26, 2018, you failed to record any assessment data for Patient [A];

n) on or about April 25 and 26, 2018, you failed to maintain the Nursing History and Physical Assessment and Palliative Care Pain and Symptom Screening Flow Sheet records for Patient [A] properly within the night chart;

o) on or about April 25 and 26, 2018, you falsified the Palliative Care Pain and Symptom Screening Flow Sheet record in respect of April 21 and 22, 2018 for Patient [A];

p) on or about November 30, 2017, you failed to adequately document assessment data and care provided to Patient [B];

q) on or about April 30, 2018, you failed to adequately document assessment data and care provided to Patient [C]; and/or

r) on or about May 22, 2018, you failed to document an incident involving Patient [D] becoming agitated and/or uncomfortable after rolling onto her stomach and your need to obtain the assistance of Patient [D]’s daughter.

5. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(14) of Ontario Regulation 799/93, in that while employed as a RPN at Saint Elizabeth, you falsified a record in relation to your practice, in that:

a) on or about April 25 and 26, 2018, you falsified the Palliative Care Pain and Symptom Screening Flow Sheet record in respect of April 21 and 22, 2018 for Patient [A].

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, while practicing as a RPN, you performed an act or acts relevant to the practice of nursing that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional, in relation to:

a) your employment at VON, with respect to the following incidents:

i) between June 1, 2017 and September 18, 2017 you requested to be paid, and/or were paid, for time you had not worked;

ii) between June 1, 2017 and September 18, 2017 you requested to be paid, and/or were paid, for overtime you had not worked;

iii) between June 1, 2017 and September 18, 2017 you falsely recorded visit times on the CellTrak application by logging out of a visit after you had already departed the visit;

iv) on or about September 19, 2017, during a joint supervisory visit, you failed to follow appropriate hand hygiene and infection control procedures;

v) [withdrawn];

vi) on or about September 19, 2017, during a joint supervisory visit, you failed to have in your possession an up-to-date medical directive for anaphylaxis epinephrine;

vii) on or about September 19, 2017, during a joint supervisory visit, you failed to check the medication Order prior to administering IV antibiotics; and/or

viii) on or about September 19, 2017, during a joint supervisory visit, you failed to prepare and administer medication safely by failing to check the 8 rights of medication administration (patient, medication, reason, dose, frequency, route, site and time);

b) your employment at St. Elizabeth, with respect to the following incidents:

i) on or about April 25 and 26, 2018, you failed to document your wasting and/or disposal of Patient [A]’s medication, including hydromorphone;

ii) on or about April 25 and 26, 2018, you failed to document the practice draws of Patient [A]’s medication made by a preceptee nurse you were supervising, including of hydromorphone;

iii) on or about April 25 and 26, 2018, you failed to document the count remaining of Patient [A]’s medication after his death;

iv) on or about April 25 and 26, 2018, you failed to complete accurate documentation in respect of care provided to Patient [A], including the times of events;

v) on or about April 25 and 26, 2018, you failed to document your discussion with Patient [A]’s spouse about her administration of medication to Patient [A] prior to your arrival;

vi) on or about April 25 and 26, 2018, you failed to accurately and/or legibly document the time and dose of medication administered to Patient [A];

vii) on or about April 25 and 26, 2018, you failed to document the rationale for the administration of medication to Patient [A];

viii) on or about April 25 and 26, 2018, you failed to document the DNR status in the night chart of Patient [A];

ix) on or about April 25 and 26, 2018, in respect of Patient [A], you failed to document that you offered to call 911 on two occasions;

x) on or about April 25 and 26, 2018, you failed to document that you inserted a subcutaneous injection site for Patient [A];

xi) on or about April 25 and 26, 2018, you failed to document Patient [A]’s vital signs and blood pressure;

xii) on or about April 25 and 26, 2018, you failed to complete and document an appropriate care plan for Patient [A];

xiii) on or about April 25 and 26, 2018, you failed to record any assessment data for Patient [A];

xiv) on or about April 25 and 26, 2018, you failed to maintain the Nursing History and Physical Assessment and Palliative Care Pain and Symptom Screening Flow Sheet records for Patient [A] within the patient’s night chart;

xv) on or about April 25 and 26, 2018, you falsified the Palliative Care Pain and Symptom Screening Flow Sheet record in respect of April 21 and 22, 2018 for Patient [A];

xvi) on or about April 25 and 26, 2018, you improperly disposed of Patient [A]’s medication, including hydromorphone, by dumping it down the sink;

xvii) on or about April 25 and 26, 2018, you failed to seek authorization prior to practicing draws and disposing of Patient [A]’s medication;

xviii) on or about April 25 and 26, 2018, you failed to provide any education to Patient [A]’s spouse as to the safe disposal of Patient [A]’s medication;

xix) on or about November 30, 2017, you were sleeping while on duty caring for Patient [B];

xx) on or about November 30, 2017, you failed to adequately monitor Patient [B]’s oxygen saturation levels;

xxi) on or about November 30, 2017, you failed to adequately document assessment data and care provided to Patient [B];

xxii) on or about April 30, 2018, you were sleeping on duty while caring for Patient [C];

xxiii) on or about April 30, 2018, you failed to adequately monitor Patient [C];

xxiv) on or about April 30, 2018, you failed to respond to BiPAP alarms while caring for Patient [C];

xxv) on or about April 30, 2018, you failed to adequately document assessment data and care provided to Patient [C];

xxvi) on or about May 22, 2018, you failed to promptly reposition Patient [D] when she became agitated and/or uncomfortable after rolling onto her stomach; and/or

xxvii) on or about May 22, 2018, you failed to document the incident involving Patient [D] becoming agitated and/or uncomfortable after rolling onto her stomach and your need to obtain the assistance of Patient [D]’s daughter.

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a)(i), (ii), (iii), (iv), (vi), (vii), (viii), #1(b)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), (xiii), (xiv), (xv), (xvi), (xvii), (xviii), (xix), (xx), (xxi), (xxii), (xxiii), (xxiv), (xxv), (xxvi), (xxvii), 2(a), (b), (c), 3(a), (b), 4(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m), (n), (o), (p), (q), (r), 5(a), 6(a)(i), (ii), (iii), (iv), (vi), (vii), (viii), 6(b)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), (xiii), (xiv), (xv), (xvi), (xvii), (xviii), (xix), (xx), (xxi), (xxii), (xxiii), (xxiv), (xxv), (xxvi) and (xxvii) 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 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. Paul Robert Couldridge (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on March 26, 1993. The Member resigned his certificate of registration on January 3, 2022.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

VON Incidents

2. The Member was employed by VON from December 2012 to September 21, 2017.

3. At the material time, the Member worked on a full-time basis as a staff nurse doing home visits. The Member worked with many patients on a long-term basis and often assisted with peritoneal home dialysis. While employed at VON, the Member engaged in time theft and unsafe work practices as described below.

Time Theft

4. The Member’s terms of employment with VON specified that he was paid on an hourly basis for actual hours worked, there was no guarantee of a specific number of hours per day or week, overtime hours were to be approved in advance of being performed if possible and that some days may provide for less than 7.5 hours of work and consequently less than 7.5 hours pay.

5. VON scheduled nurses for 7.5 hours and expected that they balance their days including mixing shorter visits with longer ones. VON expected nurses to work independently and if they finished their day early to call the office as soon as possible to see if other assistance is required. Visits were typically scheduled for 45 minutes and, while that did not mean nurses are expected to spend the full 45 minutes in the patient’s home, they were expected to contact a supervisor if they need more time or if there are any drastic changes to the time required.

6. VON utilized CellTrak, an application that offers mobile device management services for at-home care providers such as real-time alerting, automated mileage and visit reporting. CellTrak was installed on every visiting nurse’s device and tracked the time and length of patient visits as well as mileage on an address-to-address basis through Google Maps.

7. In addition, VON also utilized Procura software that keeps track of scheduled activities and patient visits. The information was then sent to CellTrak which generates data and a trail. The data was then sent back to Procura and then to SAP for payroll. All nurses including the Member received extensive training on the use of CellTrak and Procura.

8. VON had a longstanding concern with the Member finishing home visits in less than the scheduled time without reporting the shorter visit or seeking further work to fill his day.

9. VON conducted internal reviews and audits which established that between June 1, 2017 and September 18, 2017 the Member completed scheduled visits early, had not reported back to seek additional work and billed a 7.5 hour day. In addition, there were some occasions where the Member sought overtime beyond the 7.5 hour day even though he finished his work within 7.5 hours. The Member also falsely recorded visit times on CellTrack by logging out of a visit after he already departed the visit.

10. By way of example, the audit demonstrated that the Member claimed a portion of overtime on the following dates when his actual work hours were less than 7.5 hours:

• On June 27, 2017, the Member completed his visits early but claimed 8.26 hours of work when his actual work time was 6.27 hours. The balance of the time was unaccounted for. In respect of one patient, the audit revealed that the Member asked for a visit increase to one hour but was in the home for only 23 minutes;
• On July 2, 2017, the Member claimed 8 hours (0.5 of overtime), when he in fact worked from 07:45 to 12:20 and indicated in correspondence to client services that he was going home at 13:48;
• On August 15, 2017, the Member claimed 7.76 hours when his actual total work time was 6.19 hours; and
• On September 5, 2017, the Member claimed 8 hours worked when his actual work time was 7 hours.

11. Consequently, the Member requested and was paid for time that he did not actually work.

Unsafe Work Practices

12. As a result of concerns identified in respect of the short duration of the Member’s visits with certain patients on the dates audited, VON arranged two joint supervisory visits for the Member, first with a nurse educator and the second with a manager.

13. On September 19, 2017, Alicja Paczkowski, Manager of Nursing Services, completed a supervisory visit with the Member. Ms. Paczkowski noted that the member’s skills and care were generally good, but that some aspects of his care were not up to practice standards.

14. During the supervisory visit, Ms. Paczkowski observed and recorded a hand hygiene and infection control issue when the Member failed to change gloves between the removal of dressing and application of new dressing. Ms. Paczkowski also noted the Member’s failure to carry an anaphylaxis kit with an up-to-date signed medical directive, which he was required to have. In addition, she noted a concern related to medication administration including failing to check the medication order prior to administration as well as a failure to check the 8 rights of medication administration.

15. If the Member were to testify, he would say that Ms. Paczkowski did not interrupt his care to provide any contemporaneous correction, nor did she take over the care of the patient herself and the Member was permitted to continue his day providing care to patients. The Member would further testify that the anaphylaxis kit he was carrying was provided to him by VON.

16. On September 21, 2017, the Member received a letter of termination from VON. The Member’s termination letter from VON stated that the supervisory visit on September 19, 2017, confirmed unsafe work practices including not complying with sterile/septic techniques, standard hand hygiene practices and a lack of critical thinking and decision making that put patients at risk. If the Member were to testify, he would say that he ultimately resigned from his employment with VON.

SE Health Incidents

17. The Member was employed by SE Health as a home care nurse from August 10, 2015 until his resignation on June 6, 2018. The Member resigned in the midst of an internal investigation regarding his care provided to Patient [A], as described below. The Member had previously been on paid suspension since May 24, 2018, pending the outcome of SE Health’s investigation.

18. While the Member was employed at SE Health there were incidents of inadequate documentation, improper handling and disposal of medication and controlled substances, sleeping on shift and failing to properly monitor patients as detailed below.

Patient [B]

19. On November 30, 2017, the Member was completing a night shift with Patient [B], who was 15-years old and required tracheostomy and ventilator care. Patient [B] had pneumonia, so it was particularly important to be monitoring his oxygen saturation levels.

20. During the night shift, Patient [B]’s mother witnessed the Member sleeping. She turned on the suction machine which startled the Member. Patient [B]’s oxygen saturation level was 91% when it should have been maintained at 95%.

21. After the incident, Patient [B]’s mother told the Member to go home, complained to SE Heath and declined the Member’s services going forward.

22. The Member failed to make any notes in Patient [B]’s chart on this date except to initial the Medication Administration Record.

23. When interviewed by SE Health about the incident, the Member admitted to falling asleep and expressed remorse for what happened.

Patient [C]

24. On April 30, 2018, the Member was completing a shift with Patient [C]. Patient [C] was 17-years old and had muscular dystrophy. He required BiPAP and cough assist at night.

25. Patient [C]’s mother reported that during the shift the Member went outside several times for smoke breaks, which prevented him from adequately monitoring Patient [C]. She further reported that the Member was sleeping on the shift and that alarms were going off all night. The Member was expected to get up and ensure that Patient [C]’s mask was well positioned and sealed properly which would quiet the very sensitive alarm.

26. In addition, the Member failed to create any documentation in respect of his April 30, 2018 visit with Patient [C].

27. In his response to SE Health, the Member stated Patient [C]’s parents had informed him that it was acceptable to take smoke breaks and then changed their minds and told him not to do so. The Member further stated the room was freezing, he felt stuck in the room and that he fell asleep momentarily because Patient [C]’s mom was in the room.

28. SE Health informed the Member that this was the second time there has been such a complaint. The Member responded that “there is no valid explanation,” he needed to fix the problem and he understood the gravity of the situation. SE Health discussed a variety of strategies to stay awake with the Member.

Patient [D]

29. On May 22 to 23, 2018, the Member attended a palliative care night shift in the home of Patient [D]. Patient [D] had Stage 4 lung cancer with metastases and a history of COPD/emphysema requiring high flow oxygen.

30. At 03:00, Patient [D]’s daughter found Patient [D] laying on her stomach with the head of the bed positioned up and her arms stuck under her abdomen. She described Patient [D] as agitated and in pain. She believed the Member had not given Patient [D] her medication as nothing was noted in the chart and suspected the Member had fallen asleep.

31. On May 23, 2018, following an inquiry about the incident, the Member provided a response to SE Health which included the following information:

• There was an order for hydromorphone 2mg/ml 1ml q4h prn. The family wanted half that given q4h, so he administered a half dose at 02:00;
• Patient [D] later rolled onto her stomach and he attempted to assist her to roll back and she became agitated. He reapproached Patient [D] 20-30 minutes later and she again became agitated such that he enlisted the assistance of her daughter;
• Patient [D]’s daughter asked that she be given Haldol which was given and the Member suggested the balance of the ordered hydromorphone be given (i.e. the other half of the dose), the daughter agreed and it was given. Patient [D] received the entire 2mg dose of hydromorphone at 06:00; and
• Patient [D] seemed calm and pain-free when he left and the daughter did not indicate to him that she was dissatisfied.

32. The Member did not document the incident involving Patient [D] becoming agitated and uncomfortable after rolling onto her stomach and his need to obtain the assistance of Patient [D]’s daughter.

Patient [A]

33. The Member provided care to Patient [A] on a night shift from April 25 to 26, 2018. A nurse who was new to SE Health, [Nurse A], shadowed the Member during this shift, although she arrived late.

34. Patient [A] was receiving palliative care. He was diagnosed with stage 4 mucosal melanoma which had metastasized to his lung, liver and bones. The Member previously provided care to Patient [A] on the night shifts of April 21 to 22, 2018 and April 22 to 23, 2018.

35. Patient [A] passed away in the early morning of April 26, 2018. There had been new orders issued on April 25, 2018 for subcutaneous administration of hydromorphone, which Patient [A] had previously been taking orally, and a new medication, Nozinan.

36. After Patient [A]’s death, his spouse submitted a complaint to SE Health.

37. SE Health conducted an investigation, during which they interviewed the Member and [Nurse A] multiple times. As detailed below, the investigation revealed documentation issues and hydromorphone that was unaccounted for. The Member resigned from his employment with SE Health during one of the last of these interviews, stating that he was resigning because he felt everyone was blaming him for the narcotics being missing.

38. The Member’s documentation during his shift in the Medication Administration Record (“MAR”) included the transcription of physician’s orders of that date and the administration of Nozinan and hydromorphone. The Member also made two entries in the progress notes. In addition, the Member made a very late entry note dated May 29, 2018.

39. In the Member’s entry in the MAR with respect to the administration of Nozinan, the time and dose given are illegible. In the Member’s late entry note dated May 29, 2018, he records that he administered Nozinan at 23:45; however, during his interview with SE Health on May 25, 2018 he stated that the Nozinan notation should state 24:00 and that he gave a 6.25 mg dose. The Member admits the entry is illegible.

40. In the Member’s entry in the MAR with respect to the administration of hydromorphone, the time is illegible and the dose appears to state 1mg, but it is not clear. In the Member’s late entry note dated May 29, 2018, he records that he administered hydromorphone at 01:30.

41. The Member’s two entries in the progress notes recorded limited information as outlined below. Abbreviations and symbols have been eliminated below for ease of reading.

April 25 23:45: Client had an episode of unknown origin – diaphoretic, decreased level of consciousness, tachycardia, tachyapnea, resolved following 30-45 minutes - client responding appropriately and moving freely and at will.

April 26 03:00: Client was noted to be tachycardic again but with [not legible] like breathing - spouse was roused and Client was determined to be vital signs absent – LHIN, funeral home, [not legible] office and family all aware – chart retrieved including day chart.

42. There was no further documentation by the Member and [Nurse A] made no notes.

43. There were various deficiencies in the Member’s contemporaneous documentation in respect of the care he provided to Patient [A] as outlined below.

• The Member failed to document Patient [A]’s vitals, blood pressure and assessment data. In an interview with SE Health, the Member stated that he was unable to get a blood pressure because “it was that high.” The Member did not complete any SE Health data collection form such as Palliative Care Plan and Symptom Screening Flow Sheet. In addition, the Member noted that Patient [A] had tachycardia, but failed to note Patient [A]’s heart rate.
• The Member failed to document a discussion of his plan for Patient [A]’s care with Patient [A]’s spouse and her consent for the steps that would be taken that night. SE Health expected the Member to have discussed Patient [A]’s medication changes with Patient [A]’s spouse, obtained consent for administration and documented this.
• The Member failed to document the discussion he had with Patient [A]’s spouse on arrival for his shift including as to medication she had administered to Patient [A]. Patient [A]’s spouse stated that she told the Member when he arrived that she had administered Nozinan and oral hydromorphone 15mg + 2mg to Patient [A] at 22:00. In an interview with SE Health, the Member stated that he could not recall any detail regarding any such discussion, other than that Patient [A]’s spouse did not state that anything unusual had transpired in respect of Patient [A]’s medication.
• The Member failed to document the rationale for his administration of medication to Patient [A].
  • The order for Nozinan was prn medication and the Member made no note as to his rationale for administering it. In addition, in the Member’s interview with SE Health following the incident, he was unable to explain why he administered Nozinan when he did. He gave a variety of answers including stating that there was an established pattern of administration every six hours – 24:00 and 06:00; however, Nozinan was a new drug for Patient [A] such that there was no established pattern. The Member acknowledged in an interview with SE Health that he gave the Nozinan when Patient [A] was symptom-free.
  • The Member also failed to document his rationale for administering the hydromorphone which was also ordered prn medication. The Member also failed to document that he inserted a subcutaneous injection site.
• The Member failed to record the DNR obtained April 25, 2018 11:03, in the night chart. The DNR is recorded in the day chart progress notes, but not by the Member in the night chart.
• The Member failed to document that he offered to call 911 twice on the shift.
• The Member failed to accurately report times in that he recorded the death of Patient [A] under 03:00 when the time of death was determined to be 02:15. The Member states that he wrote the correct time on the pronouncement paper but not in the chart. In addition, the Member recorded the time of Patient [A]’s first “episode” as 11:45 but later explained in a recorded interview with the facility that this was the time he made the note which was after the episode had resolved.
• As detailed above, the Member’s notes on the MAR as to the time and dose of medication administered are illegible.
• The required Nursing History and Physical Assessment was not properly maintained in the chart. The document was not in the chart initially returned to SE Health and was provided at later date, along with another record that was by the Member’s own admission created after the fact by the Member, as addressed further below.

44. There were also issues with respect to the Member’s handling and documentation of hydromorphone. Patient [A] had received 15 vials of hydromorphone from the pharmacy that day. Each vial contained 1mL of 10mg/mL hydromorphone solution. There were three empty vials of hydromorphone in the sharps container when SE Health obtained the container, there was a box of 10 vials unopened, leaving two vials missing.

45. The Member and [Nurse A] both state that the Member wasted a significant amount of medication during the shift both through difficultly in drawing syringes and permitting [Nurse A] to do a number of practice draws. The Member also pre-drew some syringes. They also state that a significant quantity of medication was poured down the sink after Patient [A]’s death. The Member failed to seek authorization prior to practicing draws and disposing of Patient [A]’s medication. There is no documentation regarding hydromorphone that was pre-drawn, wasted, used for practice draws, disposed of or remaining. In an interview with SE Health, the Member admitted that he failed to document the medication he pre-drew on the MAR and stated that he did not document as there was no time.

46. Neither the Member nor [Nurse A] were certain as to which medication(s) was used and what quantities were involved. They also do not recall how much medication remained following the death of Patient [A] and what, specifically, was done with this medication. [Nurse A] recalled that at one point the Member had put two vials in his pocket when standing at the sink could not recall whether they were full or empty or what medication they contained.

47. The Member stated that it is his general practice to tell family members that they can return unopened medication to the pharmacy, but not medication from opened boxes. He stated to SE Health that his practice is to dispose of the medication from opened boxes since it cannot be returned to the pharmacy. There is no documentation in respect of the disposal of medications or education of family members and the Member did not provide any education to Patient [A]’s spouse as to the safe disposal of Patient [A]’s medication.

48. During an interview with SE Health regarding the documentation the Member admitted “it’s lacking”.

49. Furthermore, during SE Health’s investigation, the Member provided additional health records for Patient [A] which he completed after the fact. He believed that he had failed to complete a Palliative Care Pain and Symptom Screening Flow Sheet in respect of his night shift visits of April 21 and 22 and so he completed a new form. The Member provided the new form to SE Health during the investigation but then the original form was located in the chart. Notably, the new form shows different ESAS scores than he recorded contemporaneously. The Member explained the difference by stating that the original document was not in his night chart and he had placed it in the visiting chart in error, so he reconstructed it to the best of his recollection.

CNO STANDARDS

Professional Standards

50. 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.

51. 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:

• providing, facilitating, advocating and promoting the best possible care for [patients];
• seeking assistance appropriately and in a timely manner;
• assessing/describing the [patient] situation using a theory, framework or evidence-based tool and identifying/recognizing abnormal or unexpected [patient] responses and taking action appropriately;
• ensuring practice is consistent with CNO’s standards of practice and guidelines as well as legislation;
• taking action in situations in which [patient] safety and well-being are compromised;
• evaluating/describing the outcomes of specific interventions and modifying the plan/approach;
• taking responsibility for errors when they occur and taking appropriate action to maintain [patient] safety; and
• identifying and addressing practice-related issues.

52. In addition, CNO’s Professional Standards provides, in relation to the knowledge application standard, that nurses continually improve the application of professional knowledge. Nurses demonstrate this standard by actions such as:

• assessing/describing the [patient] situation using a theory, framework or evidence-based tool;
• identifying/recognizing abnormal or unexpected [patient] responses and taking action appropriately;
• recognizing limits of practice and consulting appropriately; and
• identifying and addressing practice-related issues.

53. 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.

54. The Member acknowledges that his practice was deficient and breached the CNO’s Professional Standards.

Ethics

55. 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.

56. 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.

57. CNO’s Ethics standard also provides, in relation to truthfulness, that truthfulness means speaking and acting without intending to deceive.

58. The Member acknowledges that his conduct in respect of the time theft incidents and the falsified record for Patient [A] was unethical and breached the CNO’s Ethics standard.

Medication

59. CNO’s Medication standard describes nurses’ accountabilities when engaging in medication practices. CNO’s Medication standard provides that three principles outline the expectations related to medication practices that promote public protection including authority, competence and safety.

60. CNO’s Medication standard provides, in relation to competence, that nurses ensure they have the knowledge, skill and judgment needed to perform medication practices safely. It further provides that nurses:

• ensure their medication practices are evidence-informed;
• assess the appropriateness of the medication practice by considering the [patient], the medication and the environment;
• know the limits of their knowledge, skill and judgment and get help as needed; and
• do not perform medication practices that they are not competent to perform.

61. CNO’s Medication standard provides, in relation to safety, that nurses promote safe care, and contribute to a culture of safety within their practice environments, when involved in medication practices. It further provides that nurses take appropriate action to resolve or minimize the risk of harm to a patient from a medication error or adverse reaction and they report medication errors, near misses or adverse reactions in a timely manner.

62. The Medication standard further provides that a nurse meets the standard by:

• assessing her or his own knowledge, skill and judgment to competently carry out medication administration, use medication equipment and intervene during an adverse reaction;
• preparing and administering the medication according to an evidence-based rationale, including:
  • scheduling dosing times for a medication, taking into consideration the effect of food intake or medication absorption, contraindications, required interventions before, during and after administration, and [patient] choice and preference;
  • applying principles of infection prevention and control when administering medication; and
  • verifying the 8 rights of medication administration; and
• documenting, during and/or after medication administration, in the [patient’s] record according to documentation standards.

63. The Member acknowledges that his medication practice was deficient and breached the CNO’s Medication standard.

Documentation

64. 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:

• 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;
• documenting in a timely manner and completing documentation during, or as soon as possible after, the care or event;
• indicating when an entry is late as defined by organizational policies; and
• ensuring that relevant [patient] care information is captured in a permanent record.

65. The Member acknowledges that his documentation practice was deficient and breached the CNO’s Documentation standard.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

66. The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 1(a)(i) to (iv) and 1(a)(vi) to (viii) and 1(b)(i) to (xxvii) of the Notice of Hearing in that he contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 2 to 65 above.

67. The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 2(a) to 2(c) of the Notice of Hearing in that he submitted an account or charge for services he knew was false or misleading, as described in paragraphs 4 to 11 above.

68. The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 3(a) and 3(b) of the Notice of Hearing in that he misappropriated property from a workplace, as described in paragraphs 4 to 11 above.

69. The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 4(a) to 4(r) of the Notice of Hearing in that he failed to keep records as required, as described in paragraphs 19 to 49 above.

70. The Member admits that he committed the acts of professional misconduct as alleged in paragraph 5(a) of the Notice of Hearing in that he falsified a record relating to his practice, as described in paragraphs 33 to 49 above.

71. The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 6(a)(i) to (iv) and 6(a)(vi) to (viii) and 6(b)(i) to (xxvii) of the Notice of Hearing, and in particular his conduct was dishonourable and unprofessional, as described in paragraphs 2 to 65 above.

72. With leave of the Discipline Committee, CNO withdraws the following allegations: 1(a)(v) and 6(a)(v).

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), (vi), (vii), (viii), 1(b)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), (xiii), (xiv), (xv), (xvi), (xvii), (xviii), (xix), (xx), (xxi), (xxii), (xxiii), (xxiv), (xxv), (xxvi), (xxvii), 2(a), (b), (c), 3(a), (b), 4(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m), (n), (o), (p), (q), (r), 5(a), 6(a)(i), (ii), (iii), (iv), (vi), (vii), (viii), 6(b)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), (xiii), (xiv), (xv), (xvi), (xvii), (xviii), (xix), (xx), (xxi), (xxii), (xxiii), (xxiv), (xxv), (xxvi) and (xxvii).

As to allegations #6(a)(i), (ii), (iii), (iv), (vi), (vii), (viii), 6(b)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), (xiii), (xiv), (xv), (xvi), (xvii), (xviii), (xix), (xx), (xxi), (xxii), (xxiii), (xxiv), (xxv), (xxvi) and (xxvii), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonourable and unprofessional.

Reasons for Decision

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

Allegations #1(a)(i), (ii), (iii), (iv), (vi), (vii), and (viii) in the Notice of Hearing are supported by paragraphs 2-16 and 50-66 in the Agreed Statement of Facts. The Member admitted to acts of professional misconduct in that he contravened or failed to meet the standards of practice of the profession.

As described in paragraph 9 of the Agreed Statement of Facts, VON conducted internal reviews and audits which established that between June 1, 2017 and September 18, 2017 the Member completed scheduled visits early, had not reported back to seek additional work and billed a 7.5-hour day. In addition, there were some occasions where the Member sought overtime beyond the 7.5-hour day even though he finished his work within 7.5 hours. The Member also falsely recorded visit times on CellTrack by logging out of a visit after he already departed the visit.

As described in paragraphs 13 and 14 of the Agreed Statement of Facts, on September 19, 2017, in a supervisory visit a manager observed and recorded a hand hygiene and infection control issue when the Member failed to change gloves between the removal of dressing and application of new dressing.

The manager also noted the Member’s failure to carry an anaphylaxis kit with an up-to-date signed medical directive, which he was required to have. In addition, she noted a concern related to medication administration including failing to check the medication order prior to administration as well as a failure to check the 8 rights of medication administration.

The Panel finds that the Member’s practice was deficient and breached the College’s Professional Standards. The Panel also finds that the incidents of time theft were unethical and breached the Ethics Standard. The Panel further finds that his medication practice was deficient as noted in the previous paragraph, and breached the Medication standard. Furthermore, the Panel finds that his documentation was deficient and failed to meet the College’s Documentation standard. Nurses are accountable for ensuring their documentation of patient care is accurate, timely and complete.

Allegations 1(b)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), (xiii), (xiv), (xv), (xvi), (xvii), (xviii), (xix), (xx), (xxi), (xxii), (xxiii), (xxiv), (xx5), (xxvi) and (xxvii) are supported by paragraphs 17 to 65 of the Agreed Statement of Facts. As described in paragraphs 17 and 18 of the Agreed Statement of Facts, the Member was employed by SE Health from August 10, 2015 to June 6, 2018. During his employment, there were incidents of inadequate documentation, which breached the College’s Documentation standard. There were also incidents of improper handling and disposal of medication and controlled substances, which breached the Medication standard. The evidence also shows incidents of sleeping on shift and failing to properly monitor patients, which breached the College’s Professional Standards.

Allegations #2(a), (b) and (c) in the Notice of Hearing are supported by paragraphs 4 to 11 and 67 in the Agreed Statement of Facts. The Member’s terms of employment with VON specified that he was paid on an hourly basis for actual hours worked, there was no guarantee of a specific number of hours per day or week, overtime hours were to be approved in advance of being performed if possible and that some days may provide for less than 7.5 hours of work and consequently less than 7.5 hours pay.

VON conducted internal reviews and audits which established that between June 1, 2017 and September 18, 2017 the Member completed scheduled visits early, had not reported back to seek additional work and billed a 7.5-hour day. In addition, there were some occasions where the Member sought overtime beyond the 7.5-hour day even though he finished his work within 7.5 hours. The Member also falsely recorded visit times on CellTrack by logging out of a visit after he already departed the visit. Consequently, the Member requested and was paid for time that he did not actually work.

The Panel finds that the Member committed professional misconduct in that he submitted an account or charge for services he knew was false or misleading, as described in paragraphs 4 to 11 in the Agreed Statements of Facts.

Allegations #3(a) and (b) in the Notice of Hearing are supported by paragraphs 4 to 11 and 68 in the Agreed Statement of Facts.

VON conducted internal reviews and audits which established that between June 1, 2017 and September 18, 2017 the Member completed scheduled visits early, had not reported back to seek additional work and billed a 7.5-hour day. In addition, there were some occasions where the Member sought overtime beyond the 7.5-hour day even though he finished his work within 7.5 hours. The Panel finds that the Member committed the acts of professional misconduct as alleged in paragraphs 3(a) and (b) in the Notice of Hearing in that he misappropriated property from a workplace, when he was paid for time and overtime that he had not worked, as described in paragraphs 4 to 11 in the Agreed Statement of Facts.

Allegations #4(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m), (n), (o), (p), (q), (r) in the Notice of Hearing are supported by paragraphs 19 to 49 and 69 in the Agreed Statement of Facts. The evidence in the Agreed Statement of Facts shows that on multiple occasions and with multiple patients, the Member failed to document sufficiently or in some instances, did not document at all. The Panel finds that the Member committed acts of professional misconduct in that he failed to keep records as required.

Allegation #5(a) in the Notice of Hearing is supported by paragraphs 33 to 49 and 70 in the Agreed Statement of Facts. The Panel finds that the Member committed acts of professional misconduct in that he falsified a record relating to his practice by providing, during SE Health’s investigation, an updated Palliative Care Pain and Symptom Screening Flow Sheet for Patient [A] which the Member completed after the fact. The Panel was concerned that the new form showed different ESAS scores than what he recorded contemporaneously.

Allegations #6(a)(i), (ii), (iii), (iv), (vi), (vii), (viii) and 6(b)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), (xiii), (xiv), (xv), (xvi), (xvii), (xviii), (xix), (xx), (xxi), (xxii), (xxiii), (xxiv), (xxv), (xxvi) and (xxvii) in the Notice of Hearing are supported by paragraphs 2-71 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. It demonstrated a serious and persistent disregard for his professional obligations. His practice was deficient and breached the College’s Professional Standards, Ethics Standard, Medication Standard and Documentation Standard.

The Panel also finds that the Member’s conduct was dishonourable. The Member’s conduct in regard to incidents of time theft and falsifying patient records constituted dishonesty and deceit and ultimately demonstrated to the Panel, an element of moral failing. The Member knew or ought to have known that his conduct fell below the standards of a professional.

Penalty

College Counsel and the Member 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 7 months. This suspension shall take effect from the date the Member obtains an active certificate of registration in a practicing class 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 his own expense and within 6 months from the date the Member obtains an active certificate of registration in a practicing class. If the Expert determines that a greater number of sessions are required, the Expert will advise CNO 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 the Member obtains an active certificate of registration in a practicing class. 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:

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 and decision tools (where applicable):

1. Code of Conduct,
2. Professional Standards,
3. Documentation, and
4. Medication;

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:

1. the acts or omissions for which the Member was found to have committed professional misconduct,
2. the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
3. strategies for preventing the misconduct from recurring,
4. the publications, questionnaires and modules set out above, and
5. the development of a learning plan in collaboration with the Expert;

vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards their report to CNO, 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 his 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 his certificate of registration;

b) For a period of 18 months from the date the Member returns to the practice of nursing, the Member will notify his employers 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 his employer(s) with a copy of:

1. the Panel’s Order,
2. the Notice of Hearing,
3. the Agreed Statement of Facts,
4. this Joint Submission on Order, and
5. a copy of the Panel’s Decision and Reasons, once available;

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

1. that they received a copy of the required documents,
2. that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession, and
3. that they agree to perform 3 random spot audits of the Member’s practice at the following intervals and provide a report to CNO regarding the Member’s practice after each audit:

a. the first audit shall take place within 3 months from the date the Member begins or resumes employment with the employer, b. the second audit shall take place within 6 months from the date the Member begins or resumes employment with the employer, and c. the third audit shall take place within 9 months from the date the Member begins or resumes employment with the employer;

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

1. reviewing a random selection of at least 5 of the Member’s charts to ensure they meet both CNO and employer standards, and
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’s practice is consistent with both CNO and employer standards, and

c) For a period of 12 months from the date the Member returns to the practice of nursing, the Member must meet with a Registered Nurse who is employed at the same employer as the Member and who is pre-approved by CNO (“Mentor”) to discuss his efforts to ensure that his care, medication administration and documentation are meeting the standards of practice of the profession. The Member must meet with the Mentor at such frequency as determined by the Mentor, but at least monthly. In order for the Mentor to be pre-approved by CNO, the Member must:

i. Provide the proposed mentor 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;

ii. Provide CNO with a copy of the proposed mentor’s résumé and a report confirming the following:

1. that the proposed mentor has received a copy of the documents identified in 3(c)(i) above, and
2. that the proposed mentor agrees to notify CNO and the Member’s employer immediately upon receipt of any information that the Member has breached the standards of practice of the profession.

d) After the 12-month period identified in 3(c) above, the Mentor will determine whether additional meetings with the Member are required and will arrange those meetings as necessary.

e) The Mentor will advise the Director in writing when the meetings have ended.

f) The Member shall not practice independently in the community for a period of 18 months from the date the Member returns to the practice of nursing.

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

Penalty Submissions

Submissions were made by College Counsel.

The aggravating factors in this case were:

• The Member’s conduct was serious and took place on multiple occasions over a period of time;
• The Member’s conduct breached the Professional Standards, the Ethics Standard, the Medication Standard and the Documentation Standard;
• The Member’s conduct at times involved dishonesty for personal gain; and
• Multiple patients were exposed to risk of harm due to the Member’s conduct, bringing discredit to the profession.

The mitigating factors in this case were:

• The Member had no prior disciplinary history with the College;
• The Member accepted responsibility and acknowledged his misconduct; and
• The Member cooperated with the College by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College.

The proposed penalty provides for specific deterrence through the oral reprimand and the 7-month suspension of the Member’s certificate of registration, which sends a message to the Member to not engage in similar conduct in the future. The proposed penalty provides for general deterrence through the 7-month suspension of the Member’s certificate of registration, which sends a message to other members of the profession to not engage in similar conduct.

The proposed penalty provides for rehabilitation and remediation through a minimum of 2 meetings with a Regulatory Expert, which will help the Member understand the seriousness of his conduct as well as deter him from repeating it in the future.

Overall, the public is protected through the 18 months of employer notification, 3 random spot audits of the Member’s practice, a 12-month period of mentoring after the Member returns to practice and no independent practice for 18 months.

The penalty demonstrates clearly that this misconduct will not be tolerated in the profession.

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. Stojiljkovic (Discipline Committee, 2019): In this case, the misconduct involved multiple failures in patient care and documentation. The penalty included an oral reprimand, a 3-month suspension of the member’s certificate of registration, a minimum of 2 meetings with a Regulatory Expert, 36 months of employer notification, an 18-month period of random spot audits of the member’s practice and no independent practice in the community for 36 months.

CNO v. Pouget (Discipline Committee, 2011): In this case, the member worked while in an unfit condition, slept on duty, and failed to document and keep records regarding clients. The penalty included an oral reprimand, a two-month suspension of the member’s certificate of registration, 2 sessions with a Nursing Expert, 12 months of employer notification and 12 months of no independent practice in the community.

CNO v. Nkwelle (Discipline Committee, 2018): In this case, the misconduct included falsifying records, resting on duty, and failing to perform patient checks every 15 minutes as ordered. The penalty included an oral reprimand, a three-month suspension of the member’s certificate of registration, two meetings with a Nursing Expert and 12 months of employer notification.

CNO v. Nolan (Discipline Committee, 2006): In this case, the misconduct included dishonesty, time theft and falsifying charts. The penalty included an oral reprimand, a 60-day suspension of the member’s certificate of registration, 12 months of employer notification and a $1,000.00 fine.

College Counsel noted that each of these four cases addressed a subset of the Member’s actions, and put together the 7-month suspension of the Member’s certificate of registration is appropriate.

CNO v. Willard (Discipline Committee, 2020): This case was more serious and included many acts of misconduct, including receiving payment for scheduled appointments the member failed to attend; and failing to adequately complete documentation for patients. The penalty included an oral reprimand, a 12-month suspension of the member’s certificate of registration, a minimum of 2 meetings with a Regulatory Expert, 24 months of employer notification, six random spot audits of the member’s documentation and 24 months of no independent practice in the community.

The Member advised the Panel that he agreed with College Counsel’s submissions.

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 7 months. This suspension shall take effect from the date the Member obtains an active certificate of registration in a practicing class 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 his own expense and within 6 months from the date the Member obtains an active certificate of registration in a practicing class. If the Expert determines that a greater number of sessions are required, the Expert will advise CNO 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 the Member obtains an active certificate of registration in a practicing class. 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:

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 and decision tools (where applicable):

1. Code of Conduct,
2. Professional Standards,
3. Documentation, and
4. Medication;

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:

1. the acts or omissions for which the Member was found to have committed professional misconduct,
2. the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
3. strategies for preventing the misconduct from recurring,
4. the publications, questionnaires and modules set out above, and
5. the development of a learning plan in collaboration with the Expert;

vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards their report to CNO, 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 his 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 his certificate of registration;

b) For a period of 18 months from the date the Member returns to the practice of nursing, the Member will notify his employers 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 his employer(s) with a copy of:

1. the Panel’s Order,
2. the Notice of Hearing,
3. the Agreed Statement of Facts,
4. this Joint Submission on Order, and
5. a copy of the Panel’s Decision and Reasons, once available;

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

1. that they received a copy of the required documents,
2. that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession, and
3. that they agree to perform 3 random spot audits of the Member’s practice at the following intervals and provide a report to CNO regarding the Member’s practice after each audit:

a. the first audit shall take place within 3 months from the date the Member begins or resumes employment with the employer, b. the second audit shall take place within 6 months from the date the Member begins or resumes employment with the employer, and c. the third audit shall take place within 9 months from the date the Member begins or resumes employment with the employer;

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

1. reviewing a random selection of at least 5 of the Member’s charts to ensure they meet both CNO and employer standards, and
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’s practice is consistent with both CNO and employer standards, and

c) For a period of 12 months from the date the Member returns to the practice of nursing, the Member must meet with a Registered Nurse who is employed at the same employer as the Member and who is pre-approved by CNO (“Mentor”) to discuss his efforts to ensure that his care, medication administration and documentation are meeting the standards of practice of the profession. The Member must meet with the Mentor at such frequency as determined by the Mentor, but at least monthly. In order for the Mentor to be pre-approved by CNO, the Member must:

i. Provide the proposed mentor 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;

ii. Provide CNO with a copy of the proposed mentor’s résumé and a report confirming the following:

1. that the proposed mentor has received a copy of the documents identified in 3(c)(i) above, and
2. that the proposed mentor agrees to notify CNO and the Member’s employer immediately upon receipt of any information that the Member has breached the standards of practice of the profession.

d) After the 12-month period identified in 3(c) above, the Mentor will determine whether additional meetings with the Member are required and will arrange those meetings as necessary.

e) The Mentor will advise the Director in writing when the meetings have ended.

f) The Member shall not practice independently in the community for a period of 18 months from the date the Member returns to the practice of nursing.

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

Reasons for Penalty Decision

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

The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility.

The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection. The proposed penalty provides for specific deterrence though the oral reprimand and the 7-month suspension of the Member’s certificate of registration, which will demonstrate to the Member that this type of conduct is unacceptable. General deterrence is achieved by the 7-month suspension of the Member’s certificate of registration, which will send a clear message to members of the profession that this type of conduct will not be tolerated.

Rehabilitation and remediation are provided for through a minimum of 2 meetings with a Regulatory Expert and various learning activities. Public protection is addressed through the 18 months of employer notification, 3 random spot audits of the Member’s practice, a 12-month period of mentoring after the Member returns to practice and no independent practice for 18 months.

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

I, David Edwards, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.