College of Nurses of Ontario v. Cindy Yaworski, 2023 ONCNO 149348

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Sherry Szucsko-Bedard, RN Chairperson Andrea Arkell Public Member Karen Laforet, RN Member Sandra Larmour Public Member Donna May, RPN Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) ALYSHA SHORE for ) College of Nurses of Ontario

• and - )

CINDY YAWORSKI ) MARIE-PIER DUPONT for Registration No. 9719949 ) Cindy Yaworski ) CHRISTOPHER WIRTH ) Independent Legal Counsel ) Heard: May 26, 2023 and June 5, 2023

DECISION AND REASONS ON PENALTY

In its Decision and Reasons on Liability released on May 19, 2023, this panel of the Discipline Committee (the “Panel”) made findings of professional misconduct against Cindy Yaworski (the “Member”). In particular, the Panel found that the Member committed acts of professional misconduct as alleged in paragraphs #1(a), (b), #3(a) and (b) of the Notice of Hearing. As to allegations #3(a) and (b), the Panel found that the Member engaged in conduct that would reasonably be regarded by members of the profession to be unprofessional and dishonourable.

The Panel did not find that the Member committed acts of professional misconduct as alleged in paragraphs #1(c), #2 and #3(c) and therefore dismissed these allegations.

The Panel reconvened on May 26, 2023 at the College of Nurses of Ontario (the “College”), via videoconference for the penalty hearing. The Panel’s decision and reasons on penalty are set out below.

Evidence on Penalty

College’s Evidence

Ms. Sarah Hellmann (“Ms. Hellmann”) testified on behalf of the College. Ms. Hellmann has been a Prosecution Associate with the College since April 2021. Ms. Hellmann is responsible for referrals to the Discipline Committee and testified that she is familiar with the case before the Panel as she was assigned to the investigation.

College Counsel directed the Ms. Hellmann to Exhibit #2 that outlines the Member’s registration history. Ms. Hellmann testified that the College’s Inquiries, Complaints and Reports Committee (“ICRC”) received a mandatory report from the Ottawa-Carleton Detention Centre (“OCDC”) regarding the Member’s practice on August 8, 2016 (Exhibit #31).

Ms. Hellmann testified that the ICRC completed an investigation and decided that the Member be required to complete a specified continuing education or remediation program (“SCERP”). The elements of the SCERP included:

• Review of the College’s Practice Standards for Professional Standards, Medication and Documentation;

• Complete a Reflective Questionnaire following review of the Practice Standards;

• Complete the College’s online learning modules with respect to Professional Standards and Documentation;

• Review of the College’s Medication Practice Standard: An Overview webcast and complete the Online Participation Form for the modules and webcast;

• Attend a meeting with an approved regulatory expert; and

• Complete the above terms within three months of the date of the correspondence, or within a time period that is agreeable to the Director of Professional Conduct.

Ms. Hellmann testified that the Member completed the SCERP in November 2020.

College Counsel asked Ms. Hellmann when the allegations of professional misconduct were received by ICRC. Ms. Hellmann testified that the complaint was received on February 24, 2021 and the review started as soon thereafter as possible.

The Member’s Counsel did not have any questions for Ms. Hellmann.

Member’s Evidence

The Member’s Counsel called the Member to testify. The Member testified that she was unemployed in February 2021 and that she found work from June 2021 to January 2022. The Member testified that from January 2022 onward she applied for more than 100 nursing positions and that approximately 6 prospective employers implied the reason she was not hired was due to the charge of abuse.

The Member’s Counsel asked the Member if the inability to work had any impact on her. The Member testified that she has been on social assistance when not working and the amount provided does not cover the cost of food so family members have been helping her out. The Member also testified that the financial strain has exacerbated her medical condition and is very stressful.

The Member’s Counsel directed the Member to the Panel’s findings on liability. The Member testified that she understands the reasons for the findings and that she has learned that she should have checked with the Victorian Order of Nurses (“VON”) regarding the turning of palliative patients rather than the word of a doctor who was not part of the patient’s team and that she should have been proactive in finding a replacement nurse as soon as friction with [the Patient]’s daughter was noted.

The Member’s Counsel asked the Member if she had completed any training or independent learning. The Member testified that she has attended the ECHO palliative care, pain management and wound care programs on-line, and took free courses from Wounds Canada and 3M.

The Member’s Counsel asked the Member to provide context to the mandatory report from OCDC and the ICRC decision. The Member testified that she had started to take medication for her arthritis and was not aware of the side effects that resulted in medication errors. The Member further testified that she was suspended then dismissed from her job.

College Counsel’s Cross-Examination

College Counsel asked the Member a series of questions regarding her employment history including where she had worked prior to February 2021 and after January 2022. The Member testified that she had worked at Acclaim Health but resigned from it and was a part-time instructor at Seneca College for one semester after moving to Ottawa during the pandemic.

The Member testified that she worked at Addiction Recovery Network until the business closed due to legal issues, then worked at Bayshore as a transition unit charge nurse sometime between February and June 2021 when she was terminated with cause.

The Member testified that she worked at Starwood Extended Care from June 2021 to January 2022 and was terminated from this position. The Member further testified that she does not remember the reason for the termination as it was very stressful working in long-term care during COVID, and being involved with the College’s discipline proceedings, and that the situation aggravated her medical condition.

The Member testified that she applied for work outside of nursing, worked with a call centre, and worked at Carefor Health & Community Services in their nursing clinic, however, she was unable to keep up with the workload due to arthritis. The Member testified that she is currently unemployed.

The Member’s Counsel did not re-examine the Member.

Penalty

Penalty Submissions

College Counsel’s Submissions

College Counsel provided the Panel with the College’s Submission on Order dated May 26, 2023 which reads as follows:

THE COLLEGE OF NURSES OF ONTARIO (“CNO”) SUBMITS that, in view of the Panel of the Discipline Committee’s (the “Panel”) findings of professional misconduct, the Panel should 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 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.

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 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. 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, 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):

1. Code of Conduct,

2. Medication Standard,

3. Therapeutic Nurse-Client Relationship Standard;

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

v. 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 and Nurses’ Workbook]

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

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

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

3. strategies for preventing the misconduct from recurring,

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

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

vii. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards 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;

viii. If the Member does not comply with any 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 12 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, and

3. 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; and

3. 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.

College Counsel submitted that goals of penalty are to protect the public and maintain public safety while considering the Member’s circumstances. The penalty needs to meet 3 criteria: provide specific deterrence to the Member, general deterrence to the members of the profession and provide rehabilitation and remediation when it is appropriate to so.

College Counsel submitted that the penalty sought by the College provides the outcome of protecting public safety by addressing three key factors:

1. Reflects the aggravating and mitigating factors;

2. Meets the goals of penalty; and

3. Is consistent with prior decisions.

The aggravating factors in this case were:

• The seriousness of the findings of the Member’s misconduct;

• [The Patient] was in a vulnerable position requiring in-home palliative care, was non-mobile and non-communicative;

• The Member failed to reposition [the Patient]—a standard of care for immobile patients. Failing to reposition [the Patient] as a comfort measure when asked to do so is comparable to neglect;

• The Member breached the accountability standard by failing to follow the nursing care plan;

• The Member failed to follow the Power of Attorney for Personal Care’s requests to reposition [the Patient] and to give pain medication prior to care;

• The Member failed to follow the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) in that she failed to establish and maintain a therapeutic relationship with [the Patient]’s family especially at her end-of-life and she failed to listen to [the Patient]’s daughter and Power of Attorney for Personal Care;

• The Member breached the Professional Standards by failing to provide pain management as requested by [the Patient]’s daughter and as ordered by [the Patient]’s physician;

• The Member breached the Medication Standard when she failed to wait for the pain medication to take effect prior to treatment;

• The Member demonstrated an element of moral failing by not providing comfort measures and pain management at [the Patient]’s end-of-life;

• The Member has a prior disciplinary history with the College and was issued a caution related to the Medication Standard;

• The Member testified that she has had a difficult time remaining employed as a nurse related to proacted concerns; and

• The Member shows limited insight regarding her practice with [the Patient].

College Counsel submitted that there are no mitigating factors.

College Counsel submitted that the Submission on Order, in view of the Panel’s findings of professional misconduct and the Member’s circumstances meets the goals of penalty.

College Counsel submitted that the proposed penalty provides for specific deterrence through the oral reprimand and the 3-month suspension of the Member’s certificate of registration. General deterrence will be achieved through the 3-month suspension of the Member’s certificate of registration. Rehabilitation and remediation will be addressed through the 2 meetings with a Regulatory Expert and provides the Member the opportunity to review the Medication Standard, the Professional Standards and the TNCR Standard, gain insight into her misconduct ensuring this will not be repeated. The public will be protected through the 12 months of employer notification.

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. Greig (Discipline Committee, 2022): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member worked in a long-term care facility and was responsible for caring for a palliative patient. The member failed to complete a pain assessment and administer pain medication in a timely manner. The member used a dirty towel to clean the patient’s mouth. The member committed acts of professional misconduct similar to the Member in the case before this Panel and breached the Professional Standards and the TNCR Standard. The mitigating factors included that the member took accountability and showed remorse. The penalty included an oral reprimand, a 2-month suspension of the member’s certificate of registration, 2 meetings with a Regulatory Expert and 12 months of employer notification.

CNO v. Fu (Discipline Committee, 2020): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The professional misconduct involved a single incident with a patient with dementia in long-term care. The member was found to have committed professional misconduct that included verbal, physical and emotional abuse of the patient. The member accepted responsibility for her actions and started remedial work before her hearing. The penalty included an oral reprimand, a 2-month suspension of the member’s certificate of registration, 2 meetings with a Regulatory Expert and 9 months of employer notification.

CNO v. Bridge (Discipline Committee, 2021): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member was found to have committed professional misconduct in that she failed to cooperate and participate in the College’s Quality Assurance Program’s Practice Assessment. The penalty included an oral reprimand, a 2-month suspension of the member’s certificate of registration, and two meetings with a Regulatory Expert. The 2-month suspension was viewed as a serious penalty to provide general deterrence to the membership.

CNO v. Dockery (Discipline Committee, 2020): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member failed to complete activities directed by the College’s Quality Assurance Committee. The penalty included an oral reprimand, a 2-month suspension of the member’s certificate of registration and two meetings with a Regulatory Expert.

College Counsel summarized her submissions stating that it would be inconsistent to advocate for the same or less penalty for the Member who engaged in professional misconduct with a vulnerable patient at their end-of-life and received a caution by the ICRC. Therefore a 3-month suspension is reasonable.

The Member’s Counsel’s Submissions

The Member’s Counsel submitted that the 3-month suspension of the Member’s certificate of registration is in dispute and requested the Panel to consider a 1-month suspension or no suspension as part of the penalty.

The Member’s Counsel informed the Panel that she would address three of the submissions made by College Counsel. College Counsel’s submission that the findings were serious and related to neglect is not supported by the evidence. The Member did not turn [the Patient] for one shift and elected to let her sleep rather than turn her. The Member explained her rationale for not turning [the Patient] and there is no evidence that she neglected her.

Secondly, the Member’s Counsel addressed College Counsel’s submission that the Member does not have a clean disciplinary record. The prior history with the ICRC is not a disciplinary history and there were no facts to support that history. The ICRC investigative process showed that the Member came forward and identified that her behaviour was due to medication side effects. The Member’s prior history is irrelevant to this hearing.

The third submission the Member’s Counsel addressed was regarding the Member’s employment history including her terminations with cause and that they are or may be a detriment to her practice. The Member has health issues and she is committed to nursing and working in an environment that will support her current state. The fact that the Member has health issues is completely irrelevant to this case.

The Member’s Counsel submitted the following mitigating factors:

• The Member had no prior disciplinary history with the College from 1993 – 1997 as an RPN and from 1997 – 2019;

• The ICRC was one incident prior to the hearing;

• The Member was straightforward and did not lie or try to avoid working with the College. She stated that she did not give a bolus. The Panel found that the Member failed to wait for the appropriate time to begin care following the bolus;

• The Member did not disregard the responsibilities of the profession and one of the findings by the Panel was the Member’s ‘thoughtful considerations’ regarding [the Patient]’s care;

• The Member has stated that she wants to continue her nursing practice in a way that suits her needs and health issues;

• The Member stated that she was remorseful and regrets her actions. The law is quite clear that remorse is a mitigating factor while the absence of remorse is not an aggravating factor (D’Mello v. The Law Society of Upper Canada, 2015 ONSC 5841 (Divisional Court)); and

• The hardship suffered by the Member due to the misconduct allegation, while not usual, is to be considered.

The Member’s Counsel submitted that the Member has had difficulty finding employment over the last 2 years because of the allegation of abuse, which she was found not to have committed, and that this has created hardship for her. The Member’s Counsel submitted that if there had not been an abuse allegation the Member would have been subject to an investigation and caution. Therefore, the Member’s Counsel submitted to the Panel the following penalty that she deemed appropriate for the findings of professional misconduct and the Member’s circumstances:

• An oral reprimand to address specific deterrence;

• 2 meetings with a Regulatory Expert to address practice issues directly linked to this case. The Member found this exercise beneficial in the past; and

• 6 months of employer notification.

The Member’s Counsel questioned if suspension of the Member’s certificate of registration was necessary to achieve the goals of deterrence and public safety. The Member’s Counsel submitted that the Member has essentially had her certificate of registration suspended for 2 years. The Member has suffered from the allegation of abuse that was not founded. Most of the decisions presented by College Counsel are from uncontested hearings and with Agreed Statement of Facts and Joint Submissions on Order. In this case, the Member fought the allegations as it was her right to do so. The Panel is not bound by precedence and must be seen to be reasonable in their decisions.

The Member's Counsel submitted the following cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases, including 2 cases where the members received 2-month suspensions for behaviour far more serious than in the case before this Panel:

CNO v. Jacob (Discipline Committee, 2022): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member failed to take appropriate nursing interventions for a hypotensive patient that included failure to conduct a patient assessment at appropriate intervals, failure to document and failure to call a Code or to do CPR. The mitigating factors included that the unit was short staffed, busy and the nurse was unable to leave one patient. The penalty included an oral reprimand, a 2-month suspension of the member’s certificate of registration, a minimum of 2 meetings with a Regulatory Expert and 18 months of employer notification.

CNO v. Pottruff (Discipline Committee, 2006): This case proceeded with an Agreed Statement of Facts and a Joint Submission on Order. The member was found guilty of professional misconduct that included physical and verbal abuse of a patient with dementia. The penalty included an oral reprimand, a 2-month suspension of the member’s certificate of registration, completion of a self-directed learning package, 18-month employer notification to the Director of Investigations and Hearings, 2 meetings with a Practice Consultant and the member was ordered to pay costs to the College in the amount of $100.00.

Ontario (College of Pharmacists) v. Premji (Discipline Committee, 2022): In this case the member was found to have breached professional boundaries when he managed the finances for one of his clients. The panel chose to not include a suspension as a message of general deterrence to the profession as the panel deemed it would serve no purpose.

CNO v. The Member (Discipline Committee, 2005): This case was a contested hearing with a Joint Submission on Penalty. The member was found to have failed to meet the standards of practice with respect to the care, treatment and communication with a patient. The penalty was an oral reprimand.

CNO v. Hunter (Discipline Committee, 2011): This case proceeded as a contested hearing. The member failed to intervene appropriately with a client. The penalty included an oral reprimand and a one-month suspension, and two meetings with a Nursing Expert.

The Member’s Counsel submitted that the 3-month suspension of the Member’s certificate of registration and the 12 months of employer notification in the terms, conditions and limitations are being disputed. The Member agrees to the oral reprimand, the 2 meetings with a Regulatory Expert and 6 months of employer notification. However, based on the Panel’s findings and when compared to other decisions for more serious misconduct, a 3-month suspension of the Member’s certificate of registration is too severe, especially since she has had difficulty finding employment working as a nurse since the allegation of abuse was brought forward.

This case was contested based on the serious allegation of patient abuse and breach of the standards and it was the Member’s right to have a hearing; therefore, she should not be penalized for exercising her rights. The Member admitted that she failed to turn [the Patient], failed to wait for the medication to take effect and failed to maintain a therapeutic relationship with the family. The Panel’s finding did not include threatening or aggressive behaviour. The Member has a sincere interest in continuing to be a nurse.

The Member’s Counsel concluded that general deterrence can be achieved without a suspension as demonstrated in the previous decisions; therefore, she asked the Panel to only order a 1-month or no suspension and 6 months of employer notification.

College Counsel’s Reply

College Counsel submitted that she did not agree with the Member’s Counsel’s submissions that the Panel’s findings were only for one night for not turning and not waiting a sufficient time following administering the medication before proceeding with care. The Member was told to give a bolus by [the Patient]’s daughter, who was the Power of Attorney for Personal Care, knew the doctor had written an order as such and failed to do so. In addition, the Member did not wait for the medication to take effect before providing care.

The Member’s contemporaneous emails show a persistent disregard for the Professional Standards. While remorse may be a mitigating factor, it cannot be an aggravating factor. In this case, there is limited evidence of remorse and so it is not a significant mitigating factor. The Member’s testimony did not demonstrate insightful remorse given the findings made by the Panel.

The argument made by the Member’s Counsel that the allegation of abuse and the length of time since the allegations has essentially ‘suspended’ the Member is not factually correct. The Member was unemployed in February 2021 when the allegations were made. In June 2021, after the allegations were posted, the Member was terminated due to her inability to keep up with the work. The Member testified that she worked at Extendicare from January to March 2022, after the allegations were posted as well as other employment which the Member confirmed in her testimony.

College Counsel submitted that the Member did not suffer due to lack of employment. If this was the case, the Member would not have had a job due to the abuse allegation and there is no evidence to support this contention. The Member has not been suspended and every nurse facing allegations is in a similar position which speaks to the fairness of the legislative requirement.

College Counsel submitted that not having a suspension period is not appropriate for the penalty as there is no general deterrence without a suspension. Furthermore, a suspension is important for specific deterrence due to the findings the Panel has made.

College Counsel addressed the cases cited by the Member’s Counsel:

CNO v. Pottruff (Discipline Committee, 2006): This case has limited precedential value due to the length of time since the decision was decided.

CNO v. Jacob (Discipline Committee, 2022): The member’s conduct in this case is more severe and the member received a 2-month suspension due to the distinct features and mitigating factors which included that the nursing unit was short staffed, the member acknowledged this, accepted responsibility and worked with the College resulting in the hearing proceeding by way of an Agreed Statement of Facts and a Joint Submission on Order.

CNO v. The Member (Discipline Committee, 2005): This case has limited precedential value due to the length of time since the decision was made and the fact that the member showed immediate remorse at the time of the incident and took immediate remedial steps. This is not what happened in the case before this Panel.

College Counsel submitted that a suspension needs to be included for the public’s protection and given the facts in this case, a 3-month suspension is appropriate. This is in opposition to the Member’s Counsel who is requesting an oral reprimand, 2 meetings with a Regulatory Expert, 6 months of employer notification and no suspension period.

During its deliberations the Panel advised Counsel that it was considering the following terms and conditions for the penalty order and sought Counsels’ submissions on them:

1. A restriction on independent practice by the Member for a period of time; and

2. A requirement that 6 months after the Member’s return to practice, the Member has a follow-up meeting with the Regulatory Expert to discuss how she has implemented the strategies recommended during the Member’s initial meetings with the Regulatory Expert. This term being noted by the Panel in the Pottruff case.

College Counsel’s Submissions

College Counsel submitted that the restriction on the Member’s ability to practice independently was intentionally not proposed as this term is reserved for cases where a member has breached the patient’s trust (i.e., theft), the clinical concerns are more serious and persistent than in this case, or there is patient abuse. In those situations, the College is concerned with preventing patient harm and monitoring practice closely. The College does not believe such a restriction is required in this case.

With regard to the inclusion of a meeting with the Regulatory Expert 6 months after the Member returns to work, College Counsel indicated that the term has not been included in more recent Discipline Committee orders, however, there is no principled reason this cannot be included. If the Panel believes the term from the Pottruff case would assist in meeting the objectives of penalty, it would be appropriate to include such a term in its order.

The Member’s Counsel Submissions

The Member’s Counsel submitted that she agrees with College Counsel’s submissions as it relates to the restriction on the Member’s practice. In addition, the restriction on independent practice would further restrict the Member’s ability to find meaningful employment, which would hinder the Member from being rehabilitated into the profession. This restriction, combined with other components of the penalty requested by the College would be unduly severe and out of proportion with the findings of misconduct made by the Panel.

With regard to the follow-up meeting with the Regulatory Expert, the Member’s Counsel is not opposed to the meeting so long as the number of meetings is still 2 meetings, one being planned for 6 months after the Member’s return to practice as more than 2 meetings with a Regulatory Expert would be very onerous on the Member. The meetings are expensive, and the Member has struggled to find employment as a result of this disciplinary proceeding.

Penalty Decision

The Panel makes the following order as to penalty:

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 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. 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, and

3. 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. Medication Standard,

3. Therapeutic Nurse-Client Relationship Standard;

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

v. 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 and Nurses’ Workbook.

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

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

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

3. strategies for preventing the misconduct from recurring,

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

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

vii. Within 30 days after the Member has completed the second 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;

viii. Within six months after returning to practice following her suspension, the Member shall have a third meeting with the Expert at her own expense to discuss how she has implemented the strategies recommended during the previous two meetings with the Expert.

ix. Within 30 days after the third meeting, the Member will confirm that the Expert forwards their report to CNO, in which the Expert will confirm:

1. the date the Member attended the session, and

2. the Expert’s assessment of the Member’s implementation of the recommended strategies.

x. If the Member does not comply with any 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 12 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, and

3. 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; and,

3. 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 made its determination with respect to penalty having considered the evidence, the seriousness of the findings of misconduct, the aggravating and mitigating factors, the Member’s circumstances and the goals of penalty.

The Panel notes that there were many aggravating factors and few mitigating factors in this case and the Member’s conduct was found to be unprofessional and dishonourable.

The Member’s misconduct included breaching the Medication Standard, the Professional Standards and the TNCR Standard.

The Panel agreed that the cases provided by both Counsel offered guidance specific to the type and degree of the Member’s professional misconduct, however, these cases are not binding.

The Panel understands that the penalty ordered should protect the public and enhance public confidence in the College’s ability to govern its members. This is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation.

The Panel deliberated on College Counsel’s and the Member’s Counsel’s submissions regarding the 12-month restriction on independent practice and the additional Regulatory Expert meeting. The Regulatory Expert meetings and required education and exercises were determined by the Panel as necessary to protect the public and to support the Member’s intent to continue to practice nursing.

The Panel concurred with both Counsel that the allegations of misconduct in this case do not support the restrictions on practice setting, especially as the Panel was unable to support the allegation of physical abuse. After reviewing case law, the Panel determined that adding a practice restriction would be viewed as punitive rather than rehabilitative.

The penalty imposed by the Panel takes into account specific deterrence, general deterrence and remediation and rehabilitation, all with a view to public protection.

Specific deterrence is achieved through the oral reprimand and the 2-month suspension of the Member’s certificate of registration, sending a clear message to the Member that non-adherence to the Professional Standards will not be tolerated. The Panel determined that the 2-month suspension was appropriate for the goals of penalty and was an important specific deterrence given the findings the Panel had made. The suspension was in-line with previous Discipline Committee decisions provided by College Counsel and took into consideration the Member’s circumstances.

General deterrence is achieved through the 2-month suspension of the Member’s certificate of registration, sending a strong message to the members of the profession that nurses are to adhere to the TNCR Standard and provide best possible care to patients—especially those who are at end-of-life.

Rehabilitation and remediation will be achieved through the 2 meetings with a Regulatory Expert, the learning activities and the 6-month post returning to practice meeting with the Regulatory Expert. After reviewing case law, the Panel determined adding the additional meeting with the Regulatory Expert would strengthen the goals of rehabilitation and remediation for the Member.

The Panel gave careful consideration regarding the addition of a Regulatory Expert meeting 6 months after resuming practice. The Member came before the ICRC in 2019 following a complaint regarding her ability to adhere to the Medication Standard. As part of the caution received, the Member was required to, and did complete the Medication Standard self-learning module, reflective questions and a meeting with a Regulatory Expert. These conditions were completed in 2020 and the Member’s Counsel indicated that the Member found these exercises beneficial.

However, the Panel made findings of professional misconduct regarding breach of the Medication Standard in this case, approximately one year following the completion of the remedial work required by the ICRC decision. The Member has come before the College twice for medication-related practice issues within the last few years. The Panel therefore decided an additional meeting with the Regulatory Expert once she returned to practice would assist and support the Member in the implementation of her learning plan, provide opportunities for knowledge application, make her a stronger member of the profession, and support her desire to continue nursing.

The public will be protected through the 12 months of employer notification which will make the employer aware of the misconduct so they may appropriately monitor the Member on her return to practice.

The Panel concluded that the proposed penalty is reasonable, in the public interest and in line with what has been ordered in previous cases in similar circumstances.

I, Sandra Larmour, Public Member, sign this decision and reasons for the decision on behalf of the Chairperson and members of this Discipline Panel.