College of Nurses of Ontario v. Sonia Jacob, 2022 CanLII 135823

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Mary MacNeil, RN Chairperson Tim Crowder Public Member Tyler Hands, RN Member Sherry Szucsko-Bedard, RN Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO

• and - SONIA JACOB Registration No. 14072530

COUNSEL: GLYNNIS HAWE for College of Nurses of Ontario VANESSA YANAGAWA for Sonia Jacob CHRISTOPHER WIRTH Independent Legal Counsel

Heard: November 17, 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 November 17, 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 Sonia Jacob.

The Panel considered the submissions of College Counsel and the Member’s Counsel 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 Sonia Jacob.

The Allegations

The allegations against Sonia Jacob (the “Member”) as stated in the Notice of Hearing dated October 13, 2022 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 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 on or about March 23 to 25, 2019:

a) you failed to take appropriate nursing interventions and/or to conduct appropriate assessments of [the Patient] when [the Patient] exhibited signs of deteriorating health, including but not limited to hypotension and decreased urine output;

b) you failed to assess [the Patient] at appropriate and/or required intervals and/or you failed to accurately and/or completely document your assessments of [the Patient]; and/or

c) when you discovered [the Patient] without vital signs, you failed to perform resuscitation and/or to initiate a Code Blue with respect to [the Patient], despite their plan of care requiring intervention;

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 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 on or about March 23 to 25, 2019:

a) you failed to accurately and/or completely document your assessments of [the Patient];

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(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, on or about March 23 to 25, 2019:

a) you failed to take appropriate nursing interventions and/or to conduct appropriate assessments of [the Patient] when [the Patient] exhibited signs of deteriorating health, including but not limited to hypotension and decreased urine output;

b) you failed to assess [the Patient] at appropriate and/or required intervals and/or you failed to accurately and/or completely document your assessments of [the Patient]; and/or

c) when you discovered [the Patient] without vital signs, you failed to perform resuscitation and/or to initiate a Code Blue with respect to [the Patient], despite their plan of care requiring intervention.

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a), (b), (c), 2(a), 3(a), (b) and (c) in the Notice of Hearing. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.

Agreed Statement of Facts

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

THE MEMBER

1. Sonia Jacob (the “Member”) initially registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on January 20, 2014. The Member resigned her registration as an RPN and subsequently registered with CNO as a Registered Nurse (“RN”) on November 17, 2014. She is currently entitled to practice nursing in Ontario without restrictions.

2. The Member was employed at Humber River Hospital (the “Hospital”) from February 2, 2015 to May 15, 2019.

3. The Member is currently employed at North York General Hospital.

PRIOR HISTORY

4. The Member has no prior disciplinary findings with CNO.

THE HOSPITAL

5. The Hospital is located in Toronto, Ontario.

6. At the material time, the Member worked in the Hospital’s In-patient Cardiology/Telemetry Unit (the “Unit”) on a full-time basis. The nurse-to-patient ratio during the day shifts is 1:4 and 1:6 on night shifts.

Relevant Hospital Policies

Alternative Level of Care (ALC) Standard of Care (the “ALC Policy”)

7. 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.

8. 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; and

c. Take vital signs and measure oxygenation once a week, on Wednesdays and PRN.

9. The ALC Policy requires nurses to notify a physician of any changes in patient status. 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]

Cardiovascular Inpatient Generic Standard of Care” (the “Cardiovascular Policy”)

10. 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 pupils, and a cognitive assessment; and

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

11. The Cardiovascular Policy applies to any patient admitted to the Unit, except for patients who are designated ALC, in which case the ALC Policy applies.

Code Blue – Adult Cardiorespiratory Arrest – Medical Emergency (the “Code Blue Policy”)

12. The Code Blue Policy states that when a patient experiences a cardiopulmonary arrest (witnessed or unwitnessed) where their care plan requires resuscitation, the primary nurse must establish unresponsiveness, press the Code Blue button, delegate the contacting of dispatching, check the patient’s pulse, and begin CPR.

Critical Care Response Team (the “CCRT Policy”)

13. When a patient is exhibiting signs of deterioration, such as systolic blood pressure less than 90mmHg or greater than or equal to 200 mmHg, a decrease in their GCS assessment by greater than two points, and/or a urine output of less than 100 mL over 4 hours, then a nurse is required to alert the CCRT to commence defined testing to address the patient’s status.

THE PATIENT

14. (the “Patient”) was 81 years old at the time of the incident.

15. The Patient became a patient of the Unit on February 11, 2019. The Patient had sepsis, acute renal failure, and other co-morbidities. When the Patient was admitted she was labelled acute. As of March 22, 2019, she was designated Alternative Level of Care or “ALC”.

16. The Patient was scheduled to be transferred to a complex continuing care unit at Baycrest on March 25, 2019.

17. The Patient was prescribed Lasix, a diuretic. Patients receiving Lasix require close monitoring of their urine output. Lowered urine output may be a sign of patient deterioration which requires immediate escalation to a physician. The Patient’s care plan also specified that she had challenges expelling urine and required specific monitoring and documentation of urine output. The goal was for the patient to expel around 30mL/kg of urine per hour. The plan of care also required attempts at resuscitation in the event of a cardiopulmonary arrest.

18. The Member was the primary nurse assigned to the care of the Patient during the night shift, 1930 – 0730, on both March 23 – 24, 2019, and March 24 – 25, 2019.

19. The Patient passed away at or around 0530 on March 25, 2019.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

March 23 – 24, 2019:

20. During the Member’s shift on March 23 – 24, 2019, the Member took the Patient’s vitals (including her blood pressure) three times. At 00:22 hours, the Patient’s blood pressure was 81/39. At 03:21 hours, the Patient’s blood pressure read 87/43. Two hours later, the third blood pressure reading was 90/46 mmHg. All three readings demonstrated that the Patient was hypotensive.

21. Despite these findings, the Member did not take any nursing interventions, did not conduct further assessment of the patient beyond taking vitals, and did not alert a physician, which was contrary to the Hospital’s CCRT Policy.

22. The Member documented the Patient’s urine output only once during her shift on March 23 – 24, 2019. At 23:59, the Member documented that the Patient had released 150mL of urine, equal to 0.08mL/kg/hr over the course of the prior 24 hours. The Member charted the patient’s urine output as “small.”

23. Urine output less than 100 mL over 4 hours is a sign of patient deterioration identified in the CCRT Policy. The Patient was at particular risk of low urine output, as highlighted in her plan of care. As such, the Member ought to have alerted the CCRT and the Patient’s physician of her low urine output. The Member did neither.

March 24 – 25, 2019:

24. The Member did not conduct and/or document required assessments of the Patient over the course of her shift on March 24 – 25, 2019, including vitals.

25. At 23:59 on March 24, 2019, the Member documented that the Patient had expelled 500 mL of urine, equal to 0.28ml/kg/hr. However, the Member did not conduct and/or not document any assessment of the Patient’s urine character (such as that it was cloudy or brightly coloured).

26. The Member also failed to round on the Patient for over five hours, between 2338 on March 24, 2019, and 0530 on March 25, 2019, even though the minimal requirement of rounding is every two hours on night shifts.

27. When the Member entered the Patient’s room at 0530 on March 25, 2019, she discovered that the Patient did not have any vital signs.

28. The Member did not call a Code Blue, nor did she attempt to resuscitate the Patient, as required by the Patient’s plan of care.

29. If the Member were to testify, she would state that she did not initiate resuscitation because she believed there was no reasonable prospect of resuscitation. After finding the Patient without vital signs, the Member states that she called the charge nurse and the on-call physician to report the Patient’s death. The Member acknowledges, however, that she ought to have initiated resuscitation and called a Code Blue.

30. If the Member were to testify, she would state that the night shift of March 24, 2019 was unusually busy and the patient assignments were heavy, a concern the Member raised with her charge nurse at the beginning of the shift. The charge nurse responded that she would assist with the Member’s assignment. Despite escalating her concern about her patient assignment, the Member admits she did not complete a Professional Responsibility Workload Report Form. Video surveillance indicates that the Member spent a majority of her shift caring for a post-operative patient with a bleeding disorder.

31. The Member nonetheless regrets that she did not round on the Patient at the required intervals and acknowledges that she should have initiated CPR in accordance with the Patient’s plan of care and Hospital policy. If the Member were to testify, she would state that her colleagues stated they would round on her patients, consistent with the team approach adopted on the Unit. However, the Member admits that she did not confirm with her colleagues that the rounds were completed on her patients. The Member regrets her actions and has communicated her remorse to her employer and CNO.

CNO STANDARDS

32. 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.

33. 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.

34. 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.

35. 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.

36. 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

37. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1 (a), 1 (b), and 1 (c) of the Notice of Hearing, 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 7-36 above.

38. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2 (a) of the Notice of Hearing, in that, she failed to keep records as required, as described in paragraphs 17, 22, 24-25, 35, and 36 above.

39. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3 (a) – (c) 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 7-36 above.

Submissions on liability were made by College Counsel.

College Counsel asked the Panel to accept the Agreed Statement of Facts, as well as the Member’s admissions to all the allegations as set out at paragraphs 37 to 39 of the Agreed Statement of Facts, and that it make findings of professional misconduct with respect to the allegations in the Notice of Hearing.

The Member’s Counsel also asked the Panel to accept the Agreed Statement of Facts.

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), (b), (c), 2(a), 3(a), (b) and (c) of the Notice of Hearing. As to allegations #3(a), (b) and (c), 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) in the Notice of Hearing is supported by paragraphs 7-9 and 12-37 in the Agreed Statement of Facts. The Member admitted that she contravened a standard of practice of the profession or failed to meet the standard of practice of the profession. On March 23-24, 2019 while working the night shift as a Registered Nurse (“RN”) at Humber River Hospital (the “Facility), the Member failed to take appropriate nursing interventions when [the Patient] was hypotensive and had low urine output. The Member did not conduct further assessment of [the Patient] beyond taking vitals nor did she notify the physician. The Member documented [the Patient]’s blood pressures ranging from 81/39 to 90/46 mmHg during her shift and did not notify the Critical Care Response Team as laid out in the Facility’s Critical Care Response Team Policy (“CCRT Policy”). The College’s Professional Standards sets out that ethical nursing care means, among other things, promoting the values of patient well-being, respecting the sanctity and quality of life and maintaining commitments. The Member’s failure to follow the Facility’s Policy to ensure proper patient assessment and care amounts to a breach of the College’s Professional Standards.

Allegation #1(b) in the Notice of Hearing is supported by paragraphs 7-37 in the Agreed Statement of Facts. On March 24-25, 2019, the Member did not conduct and/or document required assessments of [the Patient] over the course of her shift, including vitals. The Member did not conduct and/or document any assessment of [the Patient]’s urine character (such as that it was cloudy or brightly coloured) and also failed to round on [the Patient] for over five hours during her shift. The Facility’s Alternate Level of Care Policy (“ALC Policy”) documents rounding is to be done on patients every 2 hours between 2100-0700 hours to address patient needs and to assess for changes in their appearance. The Member’s conduct amounts to a breach of the College’s Documentation Standard as she failed to assess and/or document care that was provided to the patient during the shift. The Member is accountable to the public and to her employer to follow the Facility’s policies which she did not do. The Member breached the Professional Standards and showed disregard for her professional obligations when she blatantly ignored the Facility’s policies that directed patient care.

Allegation #1(c) in the Notice of Hearing is supported by paragraphs 7-37 in the Agreed Statement of Facts. On the morning of March 25, 2019, the Member found [the Patient] without vital signs and did not call a Code Blue or attempt to resuscitate [the Patient] as required by [the Patient]’s plan of care. The Member breached the College’s Ethics Practice Standard when she did not respect the sanctity of life or respect [the Patient]’s wishes.

Allegation #2(a) in the Notice of Hearing is supported by paragraphs 17, 22, 24-25, 35-36 and 38 in the Agreed Statement of Facts. The Member admitted, and the Panel finds, that she failed to keep records as required during her shifts on March 23 to 25, 2019 when she did not conduct and/or document required assessments of [the Patient].

Allegations #3(a), (b) and (c) in the Notice of Hearing are supported by paragraphs 7-36 and 39 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in failing to take appropriate nursing interventions and/or to conduct and document appropriate assessments at required intervals of [the Patient] was clearly relevant to the practice of nursing and was unprofessional as it demonstrated a serious disregard for her professional obligations as set out in the Professional Standards and the Documentation Standard.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing through the Member’s failure to follow up on her assessments and escalate the need for further assessment. The Member also failed to perform resuscitation and/or to initiate a Code Blue when she found [the Patient] without vital signs despite [the Patient]’s plan of care requiring intervention. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional.

Penalty

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

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

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

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 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:

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, and

3. 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:

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 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. Inform any employer of the decision prior to commencing or prior to resuming employment in any nursing position;

ii. 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;

iii. Provide the Member’s 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;

iv. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to CNO, in which it will confirm:

1. that they received a copy of the required documents, and

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.

3. Within 12 months from the date that this Order becomes final, or a longer time period as approved by the Director, the Member shall successfully complete at her own expense, a nursing course (with clinical or laboratory or other practical components) that have received prior approval from the Director regarding: Health Assessment. The Member must pass the course. If the course is graded, the Member must receive a minimum passing grade of 65%. The Member must provide the Director with proof of enrolment, successful completion of the course and the specific grade received (if applicable).

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 failed to document and monitor [the Patient] over 2 shifts, therefore not a single incident;

• The Member failed to respond to [the Patient]’s deteriorating health condition; and

• The Member’s failure to provide basic care expected of a nurse such as monitoring and documentation led to the potential for a serious risk of harm.

The mitigating factors in this case were:

• The Member accepted full responsibility for her conduct by admitting to all the allegations and entering into an Agreed Statement of Facts and a Joint Submission on Order with the College;

• The Member responded promptly to the College and cooperated; and

• The Member attended the hearing and accepted responsibility for her actions.

The proposed penalty provides for specific deterrence through:

• The oral reprimand. An oral reprimand allows the Member to gain insight into how her actions would be perceived by the nursing profession and the public; and

• The 2-month suspension of the Member’s certificate of registration.

The proposed penalty provides for general deterrence through:

• The 2-month suspension of the Member’s certificate of registration.

General deterrence sends a signal to other members that the College takes professional misconduct seriously.

The proposed penalty provides for remediation and rehabilitation through:

• A minimum of 2 meetings with a Regulatory Expert as it will provide insight to the Member of her conduct and therefore she will not be likely to repeat it; and

• The completion of a Health Assessment nursing course will further the Member’s learning and provide insight into her conduct, therefore it will not be repeated.

Overall, the public is protected by the 18 months of employer notification as this will ensure the Member’s employer is aware of the misconduct and will make the Member accountable to her employer. The employer will be afforded the oversight on the Member’s practice on her return to the profession. This demonstrates to the public that the nursing profession is capable of self-governance.

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. Nkwelle (Discipline Committee, 2018): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member failed to complete checks on a patient during the night shift, slept during his shift and falsified documentation in regards to close observation of a suicidal patient. 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. There are similarities to the case before this Panel as both members failed to monitor the patient and failed to adequately document.

CNO v. Popo (Discipline Committee, 2020): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member failed to appropriately monitor, failed to take appropriate action when the patient’s condition changed and falsified documentation. 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. There are similarities to the case before this Panel as both members failed to monitor the patient and failed to take appropriate action when the patient’s condition changed.

College Counsel submitted that these cases are similar to the case before this Panel except that the Member in the case before this Panel did not falsify documentation. Because of this difference, a shorter suspension of 2 months instead of 3 months is being proposed. Completion of the Health Assessment nursing course will add to the rehabilitation and remediation of the Member.

Submissions were made by the Member’s Counsel.

The Member’s Counsel submitted the following mitigating factors:

• The Member has a long unblemished career, first starting in India for 7 years and then continuing in Canada for the past 8 years;

• The Member has dedicated herself to thousands of patients during her time as a nurse;

• The Member has no prior discipline history with the College or the Facility;

• The Member is presently employed in nursing and is supported by her employer;

• The Member has accepted responsibility and has reflected on her practice to ensure this does not happen again;

• These events are not an accurate reflection of who the Member is; and

• The Member has become an advocate for better working conditions as this experience occurred on a busy floor where she felt she had little support.

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 2 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.

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 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:

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, and

3. 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:

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 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. Inform any employer of the decision prior to commencing or prior to resuming employment in any nursing position;

ii. 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;

iii. Provide the Member’s 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;

iv. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to CNO, in which it will confirm:

1. that they received a copy of the required documents, and

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.

3. Within 12 months from the date that this Order becomes final, or a longer time period as approved by the Director, the Member shall successfully complete at her own expense, a nursing course (with clinical or laboratory or other practical components) that have received prior approval from the Director regarding: Health Assessment. The Member must pass the course. If the course is graded, the Member must receive a minimum passing grade of 65%. The Member must provide the Director with proof of enrolment, successful completion of the course and the specific grade received (if applicable).

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. Specific deterrence is achieved through the oral reprimand and a 2-month suspension of the Member’s certificate of registration, which will send a clear message to the Member that professional misconduct will not be tolerated. General deterrence is achieved by the 2-month suspension of the Member’s certificate of registration, which will send a strong message to the professional membership that failing to meet the profession’s standards and committing professional misconduct will not be tolerated. Rehabilitation and remediation will be achieved through a minimum of 2 meetings with a Regulatory Expert and learning activities as well as the completion of the Health Assessment nursing course. The public will be protected through the 18 months of employer notification, which will make the employer aware of the misconduct so that the employer can appropriately monitor the Member on her return to practice.

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

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