College of Nurses of Ontario v. Li, 2022 ONCNO 135439 — College of Nurses of Ontario Discipline Committee | minicounsel

PANEL: David Edwards, RPN Chairperson Andrea Arkell, Public Member Jean-Laurent Domingue, RN Member Andrea Norgate, RN Member Lalitha Poonasamy, Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO GLYNNIS HAWE for College of Nurses of Ontario

and -

CHEN LI Registration No. 08338514 DENA SMITH-SPRINGER for Chen Li CHRISTOPHER WIRTH, Independent Legal Counsel

Heard: August 8, 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 August 8, 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 name(s) of the patient(s), or any information that could disclose the identity(ies) of the patient(s), referred to orally or in any documents presented at the Discipline hearing of Chen Li.

The Panel considered the submissions of the College and the Member and decided that there be an order preventing public disclosure and banning the publication or broadcasting of the name(s) of the patient(s), or any information that could disclose the identity(ies) of the patient(s), referred to orally or in any documents presented at the Discipline hearing of Chen Li.

The Allegations

The allegations against Chen Li (the “Member”) as stated in the Notice of Hearing dated June 23, 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 Humber River Hospital in Toronto, Ontario, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession in that:

a) on or about December 17 to 18, 2018:

i. you failed to apply appropriate fall prevention interventions with respect to Patient [A], including but not limited to the activation of Patient [A]’s bed exit alarm; and/or

ii. you failed to appropriately assess and/or to document your assessments of Patient [A] following a fall;

b) on or about March 22 to 23, 2019, you failed to take appropriate nursing interventions and/or to conduct appropriate assessments of Patient [B] when Patient [B] exhibited signs of deteriorating health, including but not limited to a decreased Glasgow Coma Score;

c) on or about March 22 to 23, 2019, you failed to assess Patient [B] at appropriate and/or required intervals and/or you failed to accurately and/or completely document your assessments of Patient [B]; and/or

d) on or about March 23, 2019, you falsified Patient [B]’s health record when you documented conducting assessments of Patient [B] at 0400, when you had not;

You have committed an act of professional misconduct, as provided by subsection 51 (1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in paragraph 1(13) of Ontario Regulation 799/93, in that, while working as a Registered Nurse at Humber River Hospital in Toronto, Ontario, you failed to keep records as required, and in particular:

a) on or about December 17 to 18, 2018, you failed to document your assessments of Patient [A] following a fall;

b) on or about March 22 to 23, 2019, you failed to accurately and/or completely document your assessments of Patient [B]; and/or

c) on or about March 23, 2019, you falsified Patient [B]’s health record when you documented conducting assessments of Patient [B] at 0400, when you had not;

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 working as a Registered Nurse at Humber River Hospital in Toronto, Ontario, you falsified a record relating to your practice in that:

a) on or about March 23, 2019, you falsified Patient [B]’s health record when you documented conducting assessments of Patient [B] at 0400, when you had not; and/or

You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that, while working as a Registered Nurse at Humber River Hospital in Toronto, Ontario, 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 of the profession as disgraceful, dishonourable or unprofessional, and in particular:

a) on or about December 17 to 18, 2018:

i. you failed to apply appropriate fall prevention interventions with respect to Patient [A], including but not limited to the activation of Patient [A]’s bed exit alarm; and/or

ii. you failed to appropriately assess and/or to document your assessments of Patient [A] following a fall;

d) on or about March 23, 2019, you falsified Patient [B]’s health record when you documented conducting assessments of Patient [B] at 0400, when you had not.

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a)(i), (ii), (b), (c), (d), 2(a), (b), (c), 3(a), 4(a)(i), (ii), (b), (c) and (d) 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:

THE MEMBER

Chen Li (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on April 9, 2008. She is currently entitled to practice nursing in Ontario without restrictions.
The Member was employed at Humber River Hospital (the “Hospital”) from April 7, 2008 to May 21, 2019.
The Member is presently employed in teaching roles at Seneca College and Centennial College, and at UHN Princess Margaret Hospital on a casual basis.

PRIOR HISTORY

The Member has no prior disciplinary findings with CNO.

THE HOSPITAL

The Hospital is located in Toronto, Ontario.
At the time of the incidents described below, the Member worked on the Hospital’s In-patient Cardiology/Telemetry Unit on a part-time basis. The nurse-to-patient ratio during day shifts is 1:4 and 1:6 on night shifts.
The Hospital has a policy entitled “Alternative Level of Care (ALC) Standard of Care” (the “ALC Policy”). ALC refers to a patient who is occupying an acute care bed but is no longer acutely ill or does not require the intensity of acute care resources. The ALC Policy requires nurses to do the following:

a. Rounding on ALC patients every hour between 0900 – 1900 and every 2 hours between 2100 – 0700 to address patient needs including pain, positioning, continence, and cognitive checks in accordance with the Hospital’s Purposeful Rounding Guideline;

b. Observation of ALC patients every hour, day and night, for changes in their general appearance, patency of tubes and drains, respirations, and skincare; take vital signs and measure oxygenation once a week, on Wednesdays and PRN.

The Hospital also has a policy entitled “Cardiovascular Inpatient Generic Standard of Care” (the “Cardiovascular Policy”). Among other things, the Cardiovascular Policy requires nurses on the Unit to do the following:

a. Document all assessment findings and care provided;

b. Measure and document vital signs every 4 hours;

c. Conduct a neurological assessment for a change in baseline Glasgow Coma Scale (“GCS”) score greater than or equal to 2, including a complete assessment of (GCS) pupils, and a cognitive assessment; and

d. Complete purposeful rounding every 1 hour between 0900 – 1900 and every 2 hours between 2100 – 0700.

The Cardiovascular Policy applies to any patient admitted to the Cardiology inpatient unit, except for patients who are designated ALC; in which case, the ALC Policy applies.
To evaluate a patient’s GCS, a nurse assesses three patient responses:

a. Eye opening: on a scale of 1 – 4, where “spontaneous” eye movement equals 4 points, and where “none” equals 1;

b. Verbal response: on a scale of 1 – 5, where “oriented” equals 5 points and “none” equals 1; and

c. Motor response: on a scale of 1 – 6, where “obeys commands” equals 6 points, and “none” is 1.

The nurse adds the results of all three assessments to determine a patient’s GCS. The lowest GCS possible is a 3, meaning that the patient exhibited “none” in all three categories. The highest possible score is 15.
The Hospital has a policy entitled “Critical Care Response Team” (“CCRT Policy”). Where a patient is exhibiting signs of deterioration, such as systolic blood pressure less than 90mmHg or greater than or equal to 200, a heart rate of less than or equal to 40 or greater than or equal to 130 beats per minute, a decrease in their GCS assessment by greater than two points, and/or a urine output of less than 100mL over 4 hours, then a nurse is required to alert the CCRT to commence defined testing to address the patient’s status.
The Hospital has a policy entitled “Falls Prevention, Inpatient Units” (the “Falls Policy”). All admitted patients are required to have “universal fall risk” interventions implemented, including the bed placed in its lowest position and a call bell within reach. When a patient is identified as “high falls risk”, all universal interventions will be implemented, in addition to the following high-risk interventions:

a. A falls risk identification band placed on their arm/limb;

b. A yellow falling man icon on the room sign monitor outside the patient’s room;

c. Falls assessments to be conducted q24h and PRN;

d. Bed exit alarms to be activated; and

e. Falls injury prevention to be used.

The Falls Policy also provides information on the assessments, interventions, and documentation that must be completed following a fall. For an unwitnessed fall, the nurse must do the following:

a. Assessments: physical, vitals, neuro vitals (every 15 minutes for 1 hour, every hour for 4 hours, etc.), pain, falls risk safety assessment, corporate patient safety check, level of consciousness using GCS, pupillary response, limb movement;

b. Interventions: immediate care as necessary, review and implement falls prevention strategies, notify resource person, notify substitute decision-maker, communicate at shift report, post fall huddle, discuss with interprofessional team;

c. Documentation: complete Quality Review Management patient notification, document in Meditech as a “Write Note” to summarize the details of the event and actions.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

December 17 – 18, 2018: Patient [A]

[A] (“Patient A”) was 88 years old at the time of the incident. He had been admitted to the Unit a few weeks before the night shift of December 17 – 18, 2018, when the Member was assigned to his care. Patient A had congestive heart failure and a history of dementia.
Over the course of the Member’s shift on December 17 – 18, the Member assessed Patient A for falls on multiple separate occasions. On each occasion, the Member assessed Patient A as at a “high risk” for falls.
Around 0630 on December 18, 2018, the Member discovered Patient A laying on the floor beside his bed. He had experienced a large bowel movement and was covered in stool. Patient A suffered a facial laceration, facial bruising, and injury to his shoulder and elbow as a result of the fall.
Despite her assessment of Patient A as a “high risk” for falls, the Member had not turned on a bed alarm for Patient A.
If the Member were to testify, she would state that she was not in the practice of turning on bed alarms for high-risk patients unless the patient had a history of falls or a history of climbing out of bed, notwithstanding that the Falls Policy required otherwise. If the Member were to testify, she would state that she has since changed her practice and now activates the bed alarm for all patients identified as a high falls risk, after reflecting upon this incident.
After Patient A’s fall, the Member conducted and documented a GCS assessment, a falls safety risk assessment, and level of consciousness assessment.
At 0739, the Member entered a nursing note that she took vitals and completed a neuro vital assessment immediately post-fall, although the assessment is not documented in the patient’s chart.
The Member also failed to document any other post-falls nursing assessments or interventions required by the Falls Policy, such as physical, pain, and pupillary response assessments, or neuro vital assessments at the intervals required by the Falls Policy. If the Member were to testify, she would state that she did conduct the required post-falls assessments, although she admits that she failed to document those assessments and that in doing so, her conduct fell below the standards.

March 22 – 23, 2019: Patient [B]

The Member was assigned to the care of Patient [B] (“Patient B”) during the night shift on March 22 – 23, 2019, from 1930 to 0730.
Patient B was 81 years old at the time of the incident. She became a patient on the Unit on February 11, 2019. Patient B had sepsis and other co-morbidities, but she was not expected to die.
When Patient B was admitted to the Hospital, she was labelled acute but as of March 22, 2019, she was designated Alternative Level of Care or “ALC”. Patient B was supposed to be transferred to a complex continuing care unit at Baycrest on March 25, 2019.
At 2100, the Member documented that Patient B had a GCS 6, made up of 4 points for eye opening, 1 point for verbal response, and 1 point for motor response.
During the prior shift, Patient B’s GCS was recorded as an 8, made up of 3 points for eye opening, 2 points for verbal response, and 3 points for motor response.
The Member did not take or document any nursing assessments or interventions as result of the deterioration in Patient B’s GCS, nor did she report her assessment to a physician.
The provisions of both the Cardiovascular Policy and the ALC Policy required the Member to have alerted a physician to Patient B’s decreased GCS. Specifically, the ALC Policy states:

These Clinical Standards of Care are authoritative statements that describe a level of care or performance common to this patient care population. If, upon ongoing assessment, the patient’s condition warrants an increased level of care, interventions must be customized to reflect this. The physician must always be notified of changes in patient status. [Emphasis in original]

GCS 6 is a critically low score. The Member admits that given the patient’s history and condition, she ought to have notified Patient B’s physician of the change in GCS score.
Member was required to measure and document Patient B’s vital signs at least twice every shift. However, she did so only once during her shift, at 0541.
The Member did not enter any documentation in Patient B’s chart between 2100 and 0400 despite receiving a written warning in December 2018 that “charting by exception” was contrary to the Hospital’s policies and practices.
At 0400, the Member documented completing several assessments, including respiratory, pain and gastrointestinal. However, video footage reviewed and documented in detail by the Hospital showed that the Member did not enter Patient B’s room at any time between 2116 and 0539.
The Member also failed to conduct a urine output assessment at all over the course of her shift. Patient B was prescribed Lasix, a diuretic. Patients receiving Lasix must have their urine output monitored closely because lowered urine output is a sign of patient deterioration which requires immediate escalation to a physician.
The Member did not provide care to Patient B following the end of her shift in the morning of March 23, 2019. Patient B passed away two days later, on March 25, 2019.

CNO STANDARDS

CNO’s nursing standards set out expectations for the practice of nursing. CNO’s standards inform nurses of their accountabilities and apply to all nurses regardless of their role, job description, or area of practice.
CNO’s Professional Standards provide that each nurse is accountable to the public and responsible for ensuring that their practice and conduct meets legislative requirements and the standards of the profession. Nurses are accountable for conducting themselves in ways that promote respect for the profession.
The Professional Standards require that each nurse understands, upholds and promotes the values and beliefs described in CNO’s Ethics practice standard. Ethical nursing care means promoting the values of patient well-being, respecting patient choice, assuring privacy and confidentiality, respecting the sanctity and quality of life, maintaining commitments, respecting truthfulness and ensuring fairness in the use of resources. It also includes acting with integrity, honesty and professionalism in all dealings with the patient and other health care team members.
In accordance with CNO’s Documentation standard, nurses must ensure that documentation presents an accurate, clear and comprehensive picture of the patient’s needs, the nurse’s interventions and the patient’s outcomes.
The Documentation standard is met when a nurse ensures that documentation is a complete record of nursing care provided and reflects all aspects of the nursing process, including assessment, planning, intervention and evaluation.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1 (a) – (d) of the Notice of Hearing, in that, she contravened a standard of practice of the profession or failed to meet the standard of practice of the profession, as described in paragraphs 15 – 40 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2 (a) – (c) of the Notice of Hearing, in that, she failed to keep records as required, as described in paragraphs 21 – 22; 32 – 34; and 39 - 40 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3 (a) of the Notice of Hearing, in that, she falsified a record relating to her practice, as described in paragraphs 34 and 39 - 40 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 4 (a) – (d) of the Notice of Hearing, in that, she 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 of the profession as dishonourable and unprofessional, as described in paragraphs 15 – 40 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(a)(i), (ii), (b), (c), (d), #2(a), (b), (c), #3(a), #4(a)(i), (ii), (b), (c) and (d) of the Notice of Hearing. As to allegations #4(a)(i), (ii), (b), (c) and (d), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonourable and unprofessional.

Reasons for Decision

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

Allegation #1(a)(i) in the Notice of Hearing is supported by paragraphs 13-22 and 36-41 in the Agreed Statement of Facts. The Member failed to apply appropriate fall measures by not turning on the bed alarm. The Member admitted that she was not in the practice of turning on bed alarms for high-risk patients unless they had a history of falling or climbing out of bed even though the hospital policy required it. CNO’s professional standards state that nurses are accountable for conducting themself in a way that promotes respect for the profession, by deciding to not follow hospital policies these standards were not met.

Allegation #1(a)(ii) in the Notice of Hearing is supported by paragraphs 13-22 and 36-41 in the Agreed Statement of Facts. The Member made a nursing note that she had completed required vitals and falls assessment but did not document on Patient [A]’s chart. CNO’s document standards state nurses must ensure that documents are accurate. The document standard was not met.

Allegations #1(b), (c) and (d) in the Notice of Hearing are supported by paragraphs 8-12 and 23-41 in the Agreed Statement of Facts. The Member entered a nursing note that vitals and post-fall assessments were done although it was not documented on Patient [B]’s chart. The document standards states that nurses must ensure that documents present a clear, concise and accurate picture of the patient's needs, the nurse’s interventions and the patient’s outcome, this was not followed.

Allegation #2(a) in the Notice of Hearing is supported by paragraphs 8-14, 15-22 and 42 in the Agreed Statement of Facts. The Member failed to document on Patient [A]’s chart following a fall and thus failed to keep records as required.

Allegations #2(b) and (c) in the Notice of Hearing are supported by paragraphs 8-14, 23-35 and 42 in the Agreed Statement of Facts. The Member did not take or document a nursing assessment on Patient [B] and documented conducting an assessment of Patient [B] when she had not. The Panel finds the Member did not keep records as required.

Allegation #3(a) in the Notice of Hearing is supported by paragraphs 8-14, 23-34 and 43 in the Agreed Statement of Facts. The Member falsified Patient [B]’s chart by documenting an assessment was completed at 04:00 when it was not. Video footage at the hospital shows that the Member did not enter the patient’s room at any time between the hours of 21:16 and 5:39.

Allegation #4(a)(i) is supported by paragraphs 13-22, 36-38 and 44 in the Agreed Statement of Facts. Allegation #4(a)(ii) is supported by paragraphs 13-22, 36-40 and 44. Allegations #4(b), (c) and (d) are supported by paragraphs 8-12, 23-40 and 44 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in failing to apply fall preventions with regards to Patient [A] and failing to take appropriate nursing interventions and conduct appropriate assessments on Patient [B] to be unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of dishonesty and deceit through falsifying health records and indicating that she had completed assessments on patients that she had not. The Member also 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 3 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at the Member’s own expense and within 6 months from the date that this Order becomes final. 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 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
Documentation Standard;

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

that they received a copy of the required documents,
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession, and
that they agree to perform three random spot audits of the Member’s documentation practice at the following intervals over a 12-month period and provide a report to the Director regarding the Member’s practice after each audit:

a. the first audit shall take place within four months from the date the Member begins or resumes employment with the employer,

b. the second audit shall take place within eight months from the date the Member begins or resumes employment with the employer, and

c. the third audit shall take place within 12 months from the date the Member begins or resumes employment with the employer;

iv. The audits shall, on each occasion, involve reviewing a random selection of at least five of the Member’s charts to ensure they meet both CNO and employer standards.

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

Penalty Submissions

Submissions were made by College Counsel.

The aggravating factors in this case were:

The Member engaged in multiple types of misconduct;
The Member showed a serious disregard by breaching the standards and hospital policy;
The Member falsified documents which demonstrated intentional dishonesty; and
There was a serious risk of harm to patients.

The mitigating factors in this case were:

The Member had no previous discipline history with the College; and
The Member has accepted responsibility, expressed remorse and co-operated by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College.

The proposed penalty provides for general deterrence through the 3-month suspension of the Member’s certificate of registration as it signals to members of the profession that this conduct is serious and will not be tolerated.

The proposed penalty provides for specific deterrence through the oral reprimand and the 3-month suspension of the Member’s certificate of registration as it demonstrates to the Member the seriousness of her conduct.

The proposed penalty provides for remediation and rehabilitation through a minimum of 2 meetings with a Regulatory Expert. This gives the Member an opportunity to learn from her experience and understand how to prevent this conduct in the future.

Overall, the public is protected through the 18 months of employer notification and the three random spot audits of at least five of the Member’s charts. The penalty sends a message to the public about the profession’s ability to self-regulate and to ensure that similar conduct is not repeated.

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. Valdez (Discipline Committee, 2022): In this case, the hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. Similar to the case before this Panel, the member had indicated that she had completed a vital sign evaluation on patients which she had not. The member made alterations to the chart of a patient that had died on her shift. The member also indicated that she had administered medications, which she had not. The penalty included an oral reprimand, a 3-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert, 18 months of employer notification and 3 random spot audits of at least 5 of the member’s charts.

CNO v. Ohiegbomwan (Discipline Committee, 2020): In this case, the hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member failed to ensure that the patients received appropriate treatment and failed to assess or monitor the patients’ conditions. The penalty included an oral reprimand, a three-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, a nursing course, 18 months of employer notification and three random spot audits of at least five of the member’s charts.

CNO v. Popo (Discipline Committee, 2020): In this case, the hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member was assigned to care for a patient on night shift. At around 0300, the member’s nursing colleague found the patient with a decreased oxygen saturation and in response, completed a number of interventions over a 25-minute period. The member’s nursing colleague reported the interventions to the member. After receiving the report, the member did not personally assess the patient over the night shift. The patient was found without vital signs at around 0710. The penalty included an oral reprimand, a three-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, and 18 months of employer notification.

Submissions were made by the Member’s Counsel.

The Member’s Counsel asked the Panel to accept the Joint Submission on Order and submitted the following mitigating factors:

The Member had been a nurse for 32 years and also taught nursing students;
The Member was well respected by co-workers and had no prior discipline history with the College; and
Staffing shortages and workload lead to unsafe patient assignments which had been raised with management but no action had been taken by management.
The member had engaged in deep self-reflection since the incident and was aware that there is always need for growth and learning.

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 3 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:

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
Documentation Standard;

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 the Member’s behaviour;

b) For a period of 18 months from the date the Member returns to the practice of nursing, the Member will notify the Member’s 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 the Member’s 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;

that they received a copy of the required documents,
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession, and
that they agree to perform three random spot audits of the Member’s documentation practice at the following intervals over a 12-month period and provide a report to the Director regarding the Member’s practice after each audit:

a. the first audit shall take place within four months from the date the Member begins or resumes employment with the employer,

b. the second audit shall take place within eight months from the date the Member begins or resumes employment with the employer, and

c. the third audit shall take place within 12 months from the date the Member begins or resumes employment with the employer;

iv. The audits shall, on each occasion, involve reviewing a random selection of at least five of the Member’s charts to ensure they meet both CNO and employer standards.

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

Reasons for Penalty Decision

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

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

The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection. The oral reprimand, the suspension and the employer notification requirements provide for specific deterrence. The oral reprimand conveys to the Member the disapproval of her conduct by members of the profession and the public. The suspension is significant enough in length to deter the member from repeating this behaviour again, and the employer notification requires the member to be open and accountable to the employer and members of the public. The length of the suspension is a general deterrent for members of the profession. The meeting with the Expert will provide the Member with opportunity for reflection and remediation.

The penalty is 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.