College of Nurses of Ontario v. Elizabeth Found, 2023 ONCNO 149366

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Susan Roger, RN Chairperson

Carly Gilchrist, RPN Member

Morgan Krauter, NP Member

Lalitha Poonasamy Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) EMILY LAWRENCE for

) College of Nurses of Ontario

• and - )

ELIZABETH FOUND ) MONICA TESSIER for

Registration No. 11449346 ) Elizabeth Found

) CHRISTOPHER WIRTH

) Independent Legal Counsel

) Heard: November 20, 2023

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 20, 2023, 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 Elizabeth Found.

The Panel considered the submissions of the College and Member’s Counsel 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 Elizabeth Found.

The Allegations

College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs #1(vii) and #1(viii) of Schedule “A” in the Notice of Hearing dated October 10, 2023. The Panel granted this request. The remaining allegations against Elizabeth Found (the “Member”) are as follows:

IT IS ALLEGED THAT:

1. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that, while employed as a Registered Nurse at Extendicare Kawartha Lakes in Lindsay, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, with respect to your assessment, treatment and/or documentation regarding patients to whom you provided nursing care, the particulars of which are provide in the attached Schedule “A”.

2. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(13) of Ontario Regulation 799/93, in that, while employed as a Registered Nurse at Extendicare Kawartha Lakes in Lindsay, Ontario, you failed to keep records as required regarding patients to whom you provided nursing care, the particulars of which are provide in the attached Schedule “A” in Paragraphs 1 (iii), (iv), (v), (vi), (vii), (x), and/or (xi), Paragraph 2 (iii) and/or (iv), Paragraph 3 (ii), (iii), and/or (iv), Paragraph 4 (i), (ii), and/or (iii), and/or Paragraph 5 (i) and/or (ii).

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 employed as a Registered Nurse at Extendicare Kawartha Lakes in Lindsay, 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 as disgraceful, dishonourable or unprofessional, with respect to your assessment, treatment and/or documentation regarding patients to whom you provided nursing care, the particulars of which are provided in the attached Schedule “A”.

SCHEDULE “A”

1. During the period December 29 - December 30, 2019, with respect to [ ] “[Patient A]” you:

(i) administered 0.4 ml Hydromorphone to the patient at 0052 hours on December 30, 2019 although there was no clinical purpose and/or no documented clinical purpose for administering the prn medication;

(ii) administered 0.4 ml Hydromorphone to the patient on December 30, 2019 at 0015 hours, 0052 hours, 0115 hours, 0153 hours, 0215 hours and 0245 hours although it was ordered q1h prn;

(iii) failed to document that you administered 0.4 ml Hydromorphone to the patient on December 30, 2019 in the Medication Administration Record (“MAR”) at 0015 hours, 0115 hours, and 0245 hours;

(iv) failed to document that you administered 0.4 ml Hydromorphone to the patient on December 30, 2019 in the Individual Monitored Medication Record (“IMMR”) at 0052 hours and 0153 hours;

(v) failed to assess the patient and/or document an assessment of the patient before you administered 0.4 ml Hydromorphone at 2315 hours on December 29, 2019 and at 0015 hours, 0052 hours, 0115 hours, 0153 hours, 0215 hours and/or 0245 hours on December 30, 2019;

(vi) failed to document the effectiveness of the 0.4 ml Hydromorphone you administered to the patient at 0015 hours, 0115 hours, 0200 hours and 0245 hours on December 30, 2019;

(vii) [Withdrawn];

(viii) [Withdrawn];

(ix) administered 0.5 ml Lorazepam PRN to the patient at 2330 hours on December 29, 2019 instead of the 0.125 ml Lorazepam that was ordered;

(x) failed to document that you administered 0.5 ml Lorazepam PRN to the patient at 0230 hours on December 30, 2019 on the MAR;

(xi) failed to assess the patient and/or document an assessment before you administered 0.5 ml Lorazepam PRN at 0030 hours and at 0230 hours and 0.5 ml Nozinan at 0127 hours on December 30, 2019; and/or

(xii) administered 5L oxygen to the patient instead of 3L as was ordered in the medical directive.

2. On or about September 6, 2019, with respect to [ ] “[Patient B]” you:

(i) administered 0.5 ml Hydromorphone to the patient at 2030 hours although there was no clinical purpose and/or no documented clinical purpose for administering the prn medication;

(ii) failed to follow the order for 0.5 ml Hydromorphone prn q1h when you administered 0.5 ml Hydromorphone to the patient at 1930 hours and 2004 hours;

(iii) failed to document administration of 0.5 ml Hydromorphone to the patient at 1930 hours on the MAR; and/or

(iv) failed to assess the patient and/or document the assessment before you administered 0.5 ml Hydromorphone at 1930 hours, 2004 hours and 2136 hours.

3. During the period January 11, 2020 - January 12, 2020, with respect to [ ] “[Patient C]” you:

(i) administered 0.75 ml Morphine Sulphate to the patient on January 12, 2020 at 2034 hours although there was no clinical purpose and/or no documented clinical purpose for administering the prn medication;

(ii) failed to assess the patient and/or document an assessment before you administered 0.2 ml Morphine Sulphate to the patient on January 11, 2020 at 1813 hours;

(iii) failed to assess the patient and/or or document an assessment on January 12, 2020 before you administered Morphine Sulphate to the patient at 1629 hours, 1730 hours, 1935 hours and 2034 hours;

(iv) failed to document that you administered 0.75 ml Morphine Sulphate to the patient on January 12, 2020 at 1730 hours on the MAR; and/or

(v) failed to titrate Morphine Sulphate when you increased the dose administered to the patient on January 12, 2020 from 0.2 ml to 0.75 ml.

4. On or about December 15, 2019, with respect to [ ] “[Patient D]” you:

(i) failed to document that you administered 0.5 mg Morphine Sulphate to the patient at 1535 hours and 2000 hours on the MAR;

(ii) failed to document that you administered 0.5 mg Morphine Sulphate to the patient at 2200 hours on the IMMR; and/or

(iii) failed to assess the patient and/or document an assessment before you administered 0.5 mg Morphine Sulphate to the patient at 2200 hours.

5. On or about September 2, 2019, with respect to [ ] “[Patient E]” you:

(i) failed to assess the patient and/or document an assessment of the patient; and/or

(ii) failed to assess and/or document any changes to the patient’s condition over the course of the evening shift and/or any care provided to the patient.

Member’s Plea

The Member admitted the allegations set out in paragraphs #1, #2 and #3 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 admissions were 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

1. Elizabeth Found (the “Member”) initially registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on April 14, 2011.

2. The Member was employed in Extendicare Kawartha Lakes, a long-term care facility in Lindsay, Ontario (“the Facility”) as a part-time Charge Nurse from May 1, 2019 until February 10, 2020, when she was terminated as a result of the incidents below.

3. The Member is currently employed at other facilities.

4. The Member has no prior CNO disciplinary history.

THE FACILITY

5. The Facility has 64 residents across two units.

6. During the day and evening shifts, the Facility was staffed by an RN and an RPN as well as personal support workers (“PSWs”). On the night shift, the Facility was staffed with one RN and two PSWs (one for each unit) to care for the 64 residents.

7. The Member usually worked the evening shift.

8. For each Facility resident, staff were expected to complete documentation on multiple systems which were physically located in different areas of the Facility.

9. The Facility tracked narcotic administration on a document known as an Individual Monitored Medication Record (“IMMR”).

10. Staff were expected to complete the IMMR as well as maintain clear documentation of patient care in the electronic Medication Administration Record (“eMAR”), which included a Location of Administration Record (“LAR”), and in the chronological entry log, which tracked all manner of therapeutic intervention (“Progress Notes”).

11. Staff were also expected to record patient responses on a separate pain scale chart in the eMAR in concert with completing assessment notations. The scale graduates from 1 (least) to 10 (extreme).

12. If the Member were to testify, she would state that the Facility’s documentation system involving multiple platforms was difficult, and there were times when increased patient care demands made it challenging for her to document on all of the Facility’s documentation platforms and/or as thoroughly as she would have wanted to and was expected of her by the Facility and the standards of practice relating to documentation.

13. If the Member were to testify, she would also state that she often worked short-staffed shifts, and sometimes double-shifts.

14. She found documentation particularly challenging when a patient’s palliative status increased the patient-care demands. Such patients required greater attention and palliation orders and protocols often required and took extra time to execute.

INCIDENTS OF PROFESSIONAL MISCONDUCT

Investigations by the Facility and Ministry of Health

15. Concerns about the Member’s practice first arose and came to CNO’s attention when two PSWs voiced concerns about statements they said the Member made regarding Patient [A], a resident who died at the Facility on December 30, 2019. The two PSWs reported to the Facility that after Patient [A] died, the Member told them Patient [A] “did not go on her own and that she helped her.” The Member denied and continues to deny making the alleged statements.

16. The Ministry of Health and Long-Term Care (“MOHLTC”) conducted a three-day investigation. With respect to the care provided to the Facility’s residents, the MOHLTC concluded that the Facility failed to ensure that appropriate interventions were provided to residents in accordance with individualized care plans, that medication policies had not been followed, and documentation of patient interactions and responses pre- and post-medication administration were unsatisfactory. The MOHLTC also found that the Facility staff had not reported concerns promptly to Facility management or the MOHLTC, and the Facility had not investigated concerns promptly.

17. Following a review of concerns regarding Patient [A]’s death, the Coroner issued a statement indicating that Patient [A]’s death was attributed to complications of a distal femur fracture. Patient [A]’s death was not attributed to the Member’s treatment or care of Patient [A].

18. Patient [A]’s family, who had been present when she died, had no concerns about the care Patient [A] received in the hours leading up to her death and felt their mother had received good care from the Member.

19. The Facility then conducted a review of the Member’s care to the other Facility residents. Out of that review, the Facility identified the charts of four residents who died in the Member’s care or shortly after being in her care.

20. The review of the charts gave rise to allegations about the Member’s care and documentation practices involving four residents: [Patient B], [Patient C], [Patient D], and [Patient E].

Patient [A]

21. Patient [A] was a 90-year-old woman with heart disease, hypothyroidism, a fracture in her femur, and various health conditions. She was admitted to the Facility on July 18, 2011. Patient [A] was palliative, and her health had declined significantly in the months prior.

22. Patient [A] was under the Member’s care during her December 29-30, 2019 night shift. Patient [A] died at the Facility at 02:50 on December 30, 2019.

23. On the evening/night of December 29-30, 2019, the Member documented that Patient [A] had laboured breathing and Cheyne-Stokes pattern respirations which involve periods of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all. Cheyne-Stokes pattern respirations can be distressing to observe.

24. If the Member were to testify, she would state that her experience was that opioids (such as Hydromorphone) can ease the symptoms of respiratory dysfunction and Cheyne-Stoke breathing, allowing the patient to be more comfortable.

25. The Member admits that there were instances (set out below) during Patient [A]’s final hours when she administered pain medication to Patient [A] more frequently than the schedule that had been ordered for her. If the Member were to testify, she would state that this was only in an effort to make Patient [A]’s end of life as comfortable and pain free as possible.

26. The Member also admits that there were instances involving the care of Patient [A] (set out below) when she administrated medication without due regard to the medication orders, did not document rationales for pain medication administration, did not document the administration of pain medication, and did not document the effectiveness of pain medication. If the Member were to testify, she would state that these instances were due to time constraints and competing patient care demands, and her resulting inability to keep up with her documentation obligations. However, the Member acknowledges that she was required at all times to maintain the standards of practice and failed to do so. She would sincerely express regret over this conduct.

Allegations Relating to Lorazepam

27. There was a physician’s order dated December 27, 2019 for Patient [A] for:

• Lorazepam 0.5 mg (0.125 mL) s/c Q6H (subcutaneously every six hours), at 06:00, 12:00, 18:00, and 00:01; and

• Lorazepam 1-2 mg (0.25 mL-0.50mL) s/c Q2H PRN (subcutaneously every two hours, as needed).

28. On December 29, 2019, at 23:30, the Member administered Patient [A]’s routine of Lorazepam, but she administered 0.5 mL, the higher dose that was ordered for the PRN. The Member documented in the IMMR that she had administered 0.5 mL of Lorazepam at “1130” as a late entry for “routine dose”, not the PRN dose. Given the Member’s shift times, this entry was for 23:30. She admits that she failed to follow the order in respect of the appropriate dose.

29. For the remainder of the shift on the night of December 29/30, 2019, the Member’s documentation for both orders for Lorazepam was confusing and do not align with the orders.

30. On the eMAR, she documented the administration of the scheduled dose at 00:01 and 06:00, and one PRN dose at 00:30. On the IMMR, she documented three PRN doses at 00:30, 02:30, 04:15 (the last documented as wasted) and no scheduled doses. The scheduled 06:00 is not listed on the IMMR but is documented as given on the eMAR, although the client was by then deceased.

31. For the 00:30 dose, the Member failed to document that she did an assessment or what the assessment revealed. The Member’s Progress Notes reflect only that Patient [A] was “dying.”

32. The Member admits that she failed to document her assessment before she administered 0.5 mL Lorazepam PRN at 0030 hours and failed to document her administration of 0.5 mL of the 00:30 dose on the eMAR.

Allegations Relating to Hydromorphone

33. There was a physician’s order dated December 27, 2019 for Patient [A] for:

• Hydromorphone 4 mg s/c Q4H (subcutaneously every four hours) at 06:00, 10:00, 14:00, 18:00, 22:00, and 02:00; and

• Hydromorphone 4 mg s/c Q1H PRN (subcutaneously every hour as needed) for discomfort.

34. On December 29, 2019, the Member documented that she administered 4 mg PRN of Hydromorphone at 23:15 in the eMAR with a pain score of 10. The Member did not document the assessment of Patient [A] for pain prior to administration. The Progress Notes indicate only “Palliative and cheynestoking” at 22:26.

35. On December 30, 2019 (after midnight on the same shift), the Member documented on the eMAR the administration of 0.4mL of Hydromorphone PRN at 00:52, 01:53, and 02:15, and one dose of the scheduled dose at 02:00. On the IMMR, she documented the following administrations times: 00:15, 01:15, 02:15, 02:45, 02:00 (routine), and one wasted dose (with no time given).

36. The Member documented in her Progress Notes that “Resident is dying. PRN given as much as allowed” at 00:44, and “Gurgly breath sounds ++” at 00:52. She also documented at 01:52 “Dilaudid has been given every hour since the start of shift. The times displayed here are not accurate. Doses were at these times so far 11:15, 12:15, 01:15 and 01:45 (routine dose)”. At 02:15, she documented “PRN Administration was effective, Resident has passed, pain scale 0.”

37. The Member admits and regrets that she did not complete her documentation as thoroughly as expected by the Facility or as required by the standards of practice. She administered at least four PRN doses, one routine dose after midnight on December 30, 2019, and possibly more. However, it is impossible to discern from the Member’s documentation when she gave medication, why she gave various PRN medications, and the effect of the medication on Patient [A].

38. She admits that she administered PRN medication as she assessed it was needed instead of every hour between midnight and Patient [A]’s death at 02:50, that she failed to document the administration on the eMAR for doses at 00:15, 01:15 and 02:45, and failed to document doses at 00:52 and 01:53 on the IMMR.

39. The Member admits that she did not document a clinical purpose for the administration at 00:52, and failed to document assessments at 00:15, 00:52, 01:15, 01:53, 02:15 and/or 02:45. She also acknowledges that she failed to document the effectiveness at 00:15, 01:15, 02:00 and 02:45.

40. If the Member were to testify, she would state that she was monitoring and assessing Patient [A], including for pain, throughout this shift and that all of her treatment actions and decisions were executed with the goal of optimizing Patient [A]’s comfort as best as possible. Once Patient [A] passed, the Member documented greater detail in the Progress Notes, including her administration of “every PRN possible to keep [Patient [A]] comfortable”, her observations of Patient [A]’s condition and the pain control achieved after pain medication injections were administered.

Allegations relating to Nozinan

41. There was a physician’s order dated December 27, 2019 for Patient [A] for Nozinan 0.5 mL every eight hours PRN for agitation.

42. The Member documented on the eMAR that she administered the PRN at 01:27. The Member admits that she did not enter a Progress Note respecting this medication administration, or any assessment of Patient [A] that informed her decision to give Patient [A] this PRN dose.

43. If the Member were to testify, she would state that she was completing visual assessments throughout the time that she was caring for Patient [A], including before the 01:27 administration, but acknowledges that she did not document her assessment before administering the 01:27 PRN dose, which she regrets.

Allegation Relating to Oxygen

44. The Member admits that the oxygen order for Patient [A] specified she was to be given 3L via nasal prongs and that she administered oxygen at 5L without a physician’s order replacing the 3L directive. The Member explains she did so because she was unaware of the order in the medical directive, and had only been concerned about providing Patient [A] with sufficient oxygen to raise her oxygen saturation to 90% for her comfort. The Member’s position is that she did not consciously act outside her scope of practice.

Patient [B]

45. Patient [B] was a 95-year-old woman with dementia, a fracture and various health conditions. She was admitted to the Facility on December 21, 2015. She died at the Facility at 00:47 on September 7, 2019.

46. On September 6, 2019, Patient [B] was nearing her death. The Member was assigned to her that evening. The Member documented a medication administration note in the eMAR at 20:04 that Patient [B] “will not wake to any stimuli and is breathing heavily. Dilaudid given to keep comfortable and family called.”

47. Patient [B] had a physician’s order for Hydromorphone (Dilaudid) 0.25mL-0.5s/c q1h PRN (subcutaneously every hour, as required).

48. On September 6, 2019, the Member administered two doses of 0.5 mL of Dilaudid and wasted one dose. The Member failed to document the timing of these doses consistently in the eMAR, the IMMR, the LAR and the Progress Notes. She documented in the IMMR that she administered three doses of 0.5 mL of Dilaudid to Patient [B] at 19:30, 20:30, and 21:30. She also documented wasting 0.5 mL excess at 21:40, accompanied by a colleague’s signature. If the Member were to testify, she would state that her administration of Hydromorphone doses to Patient [B] that evening is most accurately reflected on the IMMR.

49. The Member acknowledges however, that in the LAR she documented only administering Dilaudid twice, at 20:04 and 21:36. If the Member were to testify, she would state that the time of administration as recorded on the LAR may not have been the exact time of administration, since the times would have been a reflection of the administration being inputted into the electronic chart as opposed to the time of the actual medication administration.

50. The Member documented administering a 0.5mL dose at 20:04, labelled “I" for “Ineffective.” The pain score was entered with an “X”. The 0.5mL dose at 21:36 was labelled “E”, indicating “Effective”. The Member noted Patient [B]’s reported pain score was a 10.

51. The Member’s Progress Note at 23:12 states: “at 2030 hours, administered 1mg. She will not wake to any stimuli, not even pain when I gave her the needle. She is breathing heavily, like Cheynestoking, so family called and have been here since 2130. Receiving hydromorph every hour.”

52. The night nurse, who took over the care of Patient [B] from the Member, documented that Patient [B] was unresponsive, with her family at her side. She died shortly thereafter.

53. The Member admits that her documentation was inconsistent in terms of the timing of the two doses of the Dilaudid and that the documentation does not provide a clear schedule of when she administered the doses. She admits, in the absence of clear documentation, that she administered 0.5 mL Hydromorphone on two occasions between approximately 19:30 and 20:30, failed to document administration of 0.5 mL Hydromorphone at 19:30 on the eMAR, and at approximately 20:30, did so without documenting clinical purpose for the administration given the lack of a pain assessment.

54. The Member further admits that the inconsistencies in her documentation make it very difficult to know the precise times that she administered the Hydromorphone doses to Patient [B] and that, as a result, the record cannot clearly reflect whether she followed the order for 0.5 mL Hydromorphone PRN q1h when she administered 0.5 mL Hydromorphone to Patient [B] on two occasions between 19:30 and 20:30. She gravely regrets not taking greater care to ensure that all of her documentation that shift accurately and reliably reflected the timing of the Hydromorphone administrations to [B].

55. In addition, the Member admits that her documentation did not include an appropriate assessment of Patient [B] prior to administering 0.5 mL doses of Dilaudid or a recording of her rationale for administration.

Patient [C]

56. Patient [C] was an 84-year-old man with cancer, heart disease, dementia and other health conditions. He was admitted to the Facility on June 5, 2015. He died at the Facility at 20:50 on January 12, 2020. At the time, he was palliative.

57. Patient [C] had a physician’s order for morphine sulphate 15 mg/mL, 0.2 mL Q1-2H (every 1-2 hours) PRN for pain, which could increase to 0.75mL q1h PRN, at a rate of 5 mLs at a time, 20 mL total.

58. The Member was assigned to Patient [C] on January 11, 2020 and on January 12, 2020.

59. On January 11, 2020, the Member documented three doses of morphine sulphate 0.2 mL at approximately 15:55, 18:13 and 21:00, on all documentation platforms.

60. Although the Member documented in the Progress Notes that she administered 0.2 mL of morphine sulphate on January 11, 2020 at 18:12 and 18:13 for “comfort measures”, she admits that she did not document an adequate assessment before she administered 0.2 mL morphine sulphate to Patient [C] on January 11, 2020 at 18:13.

61. During her shift on January 12, 2020, the Member documented the following administration of morphine sulphate prior to his death at 20:50, plus the wastage of 0.7ml:

• 0.2 mL at 16:29 (noted at 16:29 in the eMAR and 16:20 in the IMMR)

• 0.75 mL at 17:30 (This is documented in the IMMR at 17:30 as a late entry, but not on the eMAR)

• 0.75 mL at 18:30 (noted at 18:37 in the eMAR)

• 0.75 mL at 19:30 and (noted at 19:35 in the eMAR)

• 0.75 mL at 20:30 (noted at 20:34 in the eMAR)

62. She documented in the eMAR that Patient [C]’s pain was 10/10 or 9/10 on the pain scale for the last three doses of morphine sulphate noted above. These pain scores were not reflected in the Member’s Progress Notes.

63. The Member documented in the Progress Notes the following: at 18:37 that Patient [C] was shaky and needed more comfort “so larger dose was administered”, at 19:35 that Patient [C] was close to death, at 19:41 that the pain medication was effective (pain ranking from 8/10 to 7/10 since 18:36), at 20:29 that Patient [C] appeared to be more comfortable and did not wake up to any stimuli (pain ranking from 7/10 down to 6/10), at 20:34 that Patient [C] was Cheyne stoking, and that he died at 20:50.

64. The Member administered but did not document the 17:30 administration of 0.75ml morphine sulphate on the Patient [C]’s eMAR and Progress Notes, and did not document her having conducted assessments prior the administrations of medication above.

65. If the Member were to testify, she would state that she would have performed visual and Pain Scale assessments before administering the morphine sulphate to Patient [C].

66. The Member admits that her documentation, including her documentation regarding her assessments, should have been more thorough. If she were to testify, she would state that her documentation inadequacies were due to time constraints and the competing patient care demands.

67. The Member acknowledges that she failed to titrate the order for morphine sulphate 15 mg/mL, 0.2 mL Q1-2H (every 1-2 hours) which called to increase the dose 0.75 mL q1h PRN, at a rate of 5 mLs at a time, 20 mL total. If the Member were to testify, she would state that the 0.2 mL dose was proving ineffective in managing Patient [C]’s pain and Patient [C]’s daughter and wife had specifically asked that Patient [C] be provided with medical management to maximize his comfort level.

68. The Member acknowledges that she increased the morphine sulphate dose from 0.2 mL to 0.75 mL, contrary to the physician’s order, and without seeking to amend the physician’s order. If the Member were to testify, she would state that her goal at that point was to provide Patient [C] comfort measures given his condition, and she exercised her professional judgment when she increased the dose without titrating. However, the Member acknowledges that she did not have the authority to do so given the existing order and that she should have and could contacted the physician to request a new order.

Patient [D]

69. Patient [D] was a 95-year-old woman with an umbilical hernia, hyperparathyroidism and various health conditions. She was admitted to the Facility on October 29, 2018. She died at the Facility on December 28, 2019.

70. Patient [D] had an order for morphine sulphate injections within a range of 0.03 mL-0.13 mL every 30 minutes PRN for pain or shortness of breath.

71. The Member was assigned to Patient [D] on December 15, 2019.

72. If the Member were to testify, she would state that she performed visual assessments before administering the medication.

73. The Member administered doses of morphine sulphate to Patient [D]. She documented two doses at 15:35 and 20:00 on the IMMR, plus the wastage of the remainder of the ampoule at 2300, but failed to document the 15:35 and 20:00 doses on the eMAR. She documented the administration of a dose at 22:00 on the eMAR but not in the IMMR. Thus the IMMR showed two doses plus one wasted dose, and the eMar showed one dose, and the eMAR and IMMR were inconsistent with each other regarding the time(s) of administration. She also failed to document her assessment of Patient [D] before administering morphine sulphate at 22:00.

74. If the Member were to testify, she would acknowledge and again express sincere regret over her gaps in documentation.

Patient [E]

75. Patient [E] was an 89-year-old man with heart disease. He was admitted to the Facility on April 25, 2018. He died in hospital at 15:00 on September 7, 2019.

76. The Member provided care to Patient [E] on September 2, 2019 during the evening shift. The Member did not document any progress notes whatsoever about Patient [E] during her entire shift.

77. Later that night, on September 3, 2019 at 02:53, Patient [E] was sent to the hospital. Another RN documented that he was excessively sweating and was having “difficulty breathing”. The resident was sent to hospital later that evening.

78. If the Member were to testify, she would state that she assessed the resident and provided him with the appropriate patient care. However, she admits she did not document her assessments, the care she provided, or changes to the patient’s condition over the course of her shift.

CNO STANDARDS OF PRACTICE

79. CNO has published nursing standards to set out the expectations for the practice of nursing. CNO’s published standards inform nurses of their accountabilities and apply to all nurses regardless of their role, job description or area of practice.

Code of Conduct

80. CNO’s Code of Conduct is a standard of practice describing the accountabilities all Ontario nurses have to the public. The Code of Conduct consists of six principles:

81. Nurses respect the dignity of patients and treat them as individuals;

82. Nurses work together to promote patient well-being;

83. Nurses maintain patients’ trust by providing safe and competent care;

84. Nurses work respectfully with colleagues to best meet patients’ needs;

85. Nurses act with integrity to maintain patients’ trust; and

86. Nurses maintain public confidence in the nursing profession.

87. Maintaining public confidence requires that nurses provide clear documentation and follow orders during end-of-life care.

Professional Standards

82. CNO’s Professional Standards provides that each nurse is responsible for ensuring her or his practice and conduct meet legislative requirements and the standards of the profession. A nurse demonstrates the Professional Standards by providing, facilitating, and advocating the best possible care for patients while recognizing the potential for patient abuse or professional boundary crossing.

Medication Standard

83. CNO’s Medication Standard provides that administering, recommending and/or prescribing medication requires knowledge, technical skills and judgment.

84. Nurses meet the Medication Standard by:

a) assessing their own knowledge, skill and judgment to competently carry out medication administration, use medication equipment and intervene during an adverse reaction;

b) assessing the appropriateness of the medication practice by considering the [patient], the medication and the environment;

c) collaborating in the development, implementation and evaluation of system approaches that support safe medication practices within the health care team;

d) safeguarding [patient] interest and ensuring continued care by following up with health care team and prescriber when unclear about authorizing mechanisms;

e) following up with the prescriber when medication directives and/or orders are unclear, incomplete or inappropriate given the patient’s current condition, health history, medication history and other medications being currently administered;

f) scheduling dosing times for a medication, taking into consideration the effect of food intake or medication absorption, contraindications, required interventions before, during and after administration, and [patient] choice and preference; and

g) documenting, during and/or after medication administration, in the [patient’s] record according to documentation standards.

85. Nurses need the competence to assess the appropriateness of medication for a patient, manage adverse reactions, understand issues related to consent and make ethical decisions about medications.

Documentation Standard

86. CNO’s Documentation Standard helps nurses understand the importance of accurate and timely documentation, and how to apply the standards to their individual practice.

87. CNO’s Documentation Standard provides that nurses are accountable for ensuring their documentation of patient care is “accurate, timely and complete.” The standard further clarifies that a nurse meets the standard by:

a) ensuring documentation is a complete record of nursing care provided and reflects all aspects of the nursing process, including assessment, planning, intervention (independent and collaborative) and evaluation;

b) documenting both objective and subjective data; and

c) ensuring that relevant patient care information is captured in a permanent record.

88. For nurses to effectively meet patients’ needs, nurses are accountable for documenting assessments in a timely manner or as soon as possible after the treatment, intervention, or event. Documenting the date and time care was provided is important for therapeutic purposes, such as medication administration monitoring and pain management planning by all members of the health care team, which is why late entries should be clearly identified.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

89. CNO seeks leave from the Discipline Committee to withdraw paragraphs 1(vii) and 1(viii) of Schedule A in the Notice of Hearing.

90. The Member admits and acknowledges that her documentation in respect of patients [A], [B], [C], [D], and [E], was inadequate, incomplete, confusing and did not explain the assessments, treatments, and medication administrations in a coherent manner. Her documentation could not be relied upon by either herself or her colleagues due to its incompleteness, which rendered it challenging and, in some cases, impossible to confidently confirm medication administrations and patient responses. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1 of the Notice of Hearing and particularized in Schedule A of the Notice of Hearing, in that she breached the standards of practice in her care and documentation for patients [A], [B], [C], [D], and [E], specifically the standards in respect of Professional Standards, Documentation and Medication standards of practice, as described in paragraphs 21-78 above.

91. The Member admits that she committed the acts of professional misconduct as described in paragraphs 21-78 above, and as alleged in paragraph 2 of the Notice of Hearing and particularized in Schedule A of the Notice of Hearing, and in particular, that she failed to keep records as required regarding patients to whom she provided nursing care.

92. The Member admits that she committed the acts of professional misconduct as described in paragraphs 21-78 above, and as alleged in paragraph 3 of the Notice of Hearing and particularized in Schedule A of the Notice of Hearing, and in particular, that her conduct was unprofessional.

College Counsel’s Submissions on Liability

College Counsel submitted that while employed as a Registered Nurse (“RN”) at Extendicare Kawartha Lakes (the “Facility”), issues with the Member first arose and came to the attention of the College when two Personal Support Workers (“PSWs”) voiced concerns about statements made by the Member after the death of Patient [A]. College Counsel submitted that all the allegations against the Member involved patients who were either palliative or death was imminent. College Counsel submitted that it is quite clear from the Notice of Hearing and the Agreed Statement of Facts that there are no allegations that the Member hastened or contributed to the deaths of any patients.

College Counsel submitted that the alleged statements made by the Member regarding Patient [A]’s death triggered an investigation conducted by the Ministry of Health and Long-Term Care (“MOHLTC”) which revealed among other things significant documentation concerns. College Counsel submitted that the College was concerned about the haphazardness of the Member’s completed documentation, as well as the medication administration practices of the Member which arose when the Facility conducted a review of the Member’s care of other patients at the Facility. College Counsel submitted that the College acknowledged that the Facility’s documentation processes were multilayered and that having several documentation mechanisms to record the same events could lead to inconsistences. College Counsel submitted that the Member’s documentation revealed that it was not methodical, it was not organized, and, that members are expected to document in a manner that is coherent and provides a narrative that the appropriate assessments, the rationale and the interventions taken within their scope were conducted.

College Counsel submitted that having clear, timely and coherent documentation is particularly important when patients are at the end of their life. College Counsel submitted that providing end-of-life care is a challenging and necessary part of the scope of a nurses practice. In doing so, nurses have significant power over vulnerable patients and as a matter of public confidence nurses must demonstrate through their documentation that they are using that significant power appropriately. As a matter of public confidence there is a particular level of diligence and confidence that facilities and the public must have in nurses involved in end-of-life care.

College Counsel submitted that the Panel has before it three allegations: contravention of the standards of practice, a failure to keep records and disgraceful, dishonourable or unprofessional conduct. With respect to the standards of practice and failure to keep records, College Counsel submitted that the Agreed Statement of Facts has set out the standards that are applicable. College Counsel submitted that the Panel has sufficient evidence of what the standards are to be able to apply them to the facts in this case. College Counsel provided a road map for the Panel connecting particular paragraphs to the Schedule “A” allegations. For each of these patients it was the College’s submission, with respect to the standards of care and the Member’s failure to keep records, that the Member was required to have appropriate documentation and despite the issues around the numerous documentation formats and the busy shifts, the Member admitted that she failed to meet those standards.

In regard to allegation #3, College Counsel submitted that the task of the Panel is to determine whether the alleged misconduct is made out on the evidence provided. College Counsel submitted that this allegation requires two elements: is the Member’s conduct relevant to the practice of nursing and would it reasonably be regarded by members of the profession to be disgraceful, dishonourable or unprofessional? College Counsel submitted that to make a finding on this allegation, the conduct at issue needs to be only one of disgraceful, dishonourable or unprofessional. The Member has only admitted that her conduct was unprofessional.

The Member’s Counsel’s Submissions on Liability

The Member’s Counsel submitted that by her admissions, the Member has avoided the need for a lengthy hearing and confirmed that the Member has admitted to facts that support the admission of professional misconduct which are contained in paragraphs 90-92 in the Agreed Statement of Facts. The Member’s Counsel asked the Panel to accept the Agreed Statement of Facts and make findings in accordance with it.

Decision

The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities based upon clear, cogent and convincing evidence.

Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs #1, #2 and #3 of the Notice of Hearing. As to allegation #3, the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be 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 in the Notice of Hearing is supported by paragraphs 21-78 and 90 in the Agreed Statement of Facts.

Patient [A]

The Member admitted that there were instances when she administered Hydromorphone to Patient [A] more frequently than was ordered, did so without any regard to the medication orders, did not document the rationale for administering the pain medication, did not document the administration of the pain medication and did not document the effectiveness of the pain medication.

Patient [B]

The Member admitted that her documentation was inconsistent in dosage times and in the administration of the Hydromorphone medication to Patient [B].

Patient [C]

The Member admitted that she failed to document an adequate assessment and dosage times prior to administering Morphine Sulphate to Patient [C], failed to document appropriate pain scales in Patient [C]’s progress notes and acknowledged that she did not have the authority to increase the Morphine Sulphate that was contrary to the physician’s order.

Patient [D]

The Member admitted that her documentation of Patient [D]’s two dosages of Morphine Sulphate was inconsistent between the Medication Administration Record (“eMAR”) and the Individual Monitored Medication Record (“IMMR”) and that prior to administering the Morphine Sulphate, she performed a visual assessment but did not document the assessment or its findings.

Patient [E]

The Member admitted that she did not document any progress notes in Patient [E]’s chart on September 2, 2019. On the evening of September 3, 2019, Patient [E] was sent to the hospital. The Member admitted that she completed assessments on Patient [E] and provided him with appropriate care. However, she did not document her assessments, the care provided or the changes to Patient [E]'s condition over the course of her shift.

The College’s standards of practice set out the expectations of all nurses. The Member breached the College’s Code of Conduct by failing to provide safe and competent care, failing to maintain clear documentation of patient care, failing to document assessments of patients, administering medication more frequently than ordered and failing to document the administration and effectiveness of the medication as indicated in Schedule A of the Notice of Hearing. The Member also administered a larger dose of oxygen to patient [A] than what was ordered.

The Professional Standards provide that each nurse is responsible for ensuring their practice meets the legislative requirements and the standards of the profession. The Member breached this standard when she failed to assess, treat and accurately document her patients’ care as indicated in Schedule A of the Notice of Hearing.

The Medication Standard provides that administering, recommending and/or prescribing medication requires knowledge, technical skills and judgment. The Member failed to meet this standard of the profession when she failing to document during and/or after medication administration for five patients.

The Documentation Standard provides that nurses are accountable for ensuring that their documentation of patient care is accurate, timely and complete. The Documentation Standard also reflects that nurses must ensure that relevant patient care information is captured in the permanent record. The Member failed to meet this standard with all five patients as indicated in Schedule A of the Notice of Hearing. The Member failed to document any assessments and administration of medication. When she did document, there were inconsistences and discrepancies noted within her documentation.

Allegation #2 in the Notice of Hearing is supported by paragraphs 21-78 and 91 in the Agreed Statement of Facts.

Patient [A]

During the Member’s night shift on December 29-30, 2019, the Member failed to document the administration of Hydromorphone to Patient [A] in the eMAR and the IMMR. The Member failed to document the assessment of Patient [A] prior to and rationales for administering the Hydromorphone, as well as failed to document the effectiveness of the medication. The Member also failed to document the administration of Lorazepam on December 30, 2019, including her assessment of Patient [A] prior to the administration of the Lorazepam.

Patient [B]

The Member failed to document the assessment of Patient [B] prior to and rationales for administering the Hydromorphone, as well as failed to document the effectiveness of the medication. The Member admitted that her documentation was inconsistent in terms of the timing of the Hydromorphone.

Patient [C]

The Member failed to document the assessment of Patient [C] prior to and rationales for administering the Morphine Sulphate, as well as failed to document the effectiveness of the medication. Patient [C]’s pain scores were not reflected in the Member’s Progress Notes for Patient [C].

Patient [D]

The Member admitted that there were gaps in documentation in regard to Patient [D] The Agreed Statement of Facts indicated that the Member would state that she performed visual assessments on Patient [D] before administering the medication. The Member failed to document her assessment of Patient [D] prior to and rationales for administering the Morphine Sulphate, as well as failed to document the effectiveness of the medication.

Patient [E]

The Member failed to assess or document the assessment of Patient [E] prior to and rationales for administering the Morphine Sulphate. On September 2, 2019, the Member provided care to Patient [E] but did not document any progress notes for Patient [E] during her shift. On the evening of September 3, 2019, Patient [E] was transferred to the hospital. The Member admitted that she completed assessments on Patient [E] and provided him with appropriate care, however, she did not document her assessments, the care provided or the changes to Patient [E]'s condition over the course of her shift.

Allegation #3 in the Notice of Hearing is supported by paragraphs 21-78 and 92 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in failing to appropriately document assessments, treatments and the administration of medication was clearly relevant to the practice of nursing. It was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations in breaching the College’s Code of Conduct, the Professional Standards, the Medication Standard and the Documentation Standard.

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. Documentation, and

3. Medication;

iv. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires [and Nurses’ Workbook];

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 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 at least 14 days before 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. 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.

College Counsel reviewed with the Panel the principles applicable to Joint Submissions on Order.

College Counsel submitted that the aggravating factors in this case were:

• The Member’s conduct involved a number of incidents with five different patients; and

• The Member’s conduct took place in a long-term care facility with patients who by the nature of their age, their health conditions and their location were all vulnerable. These patients were at the end or near the end of their lives.

The mitigating factors in this case were:

• The Member had no prior disciplinary history with the College;

• The Member has cooperated with the College by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College thereby avoiding a lengthy hearing; and

• The Member has taken responsibility for her conduct and has provided specific expressions of remorse within the Agreed Statement of Facts.

College Counsel submitted that the Joint Submission on Order meets the goals of penalty as the proposed penalty provides for general deterrence through the 2-month suspension of the Member’s certificate of registration, which will send a message to the membership that the behaviour demonstrated by the Member is not acceptable and will not be tolerated.

The proposed penalty provides for specific deterrence through the oral reprimand and the 2-month suspension of the Member’s certificate of registration, which will send a message to the Member that this type of conduct is not acceptable and will not be tolerated.

The proposed penalty provides for remediation and rehabilitation through a minimum of 2 meetings with a Regulatory Expert and the review of the College’s publications, which will assist the Member with her transition back to ethical nursing practice and provide her with insight and understanding about how to meet the professional standards and to act in a professional manner.

Overall, the public is protected through the 12 months of employer notification, which will provide for a heightened level of employer oversight on the Member’s return to practice in a safe and ethical manner.

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. Robinson (Discipline Committee, 2021): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member failed to document the administration of medication, the wastage of medication, the care provided to patients, patient assessments or reassessments, documented inconsistent medication times and placed a colleague in a chokehold. The member was also previously cautioned by the College. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration, a minimum of 2 meetings with a Regulatory Expert, 18 months of employer notification and random spot audits of the member’s documentation.

CNO v. Pedzinski (Discipline Committee, 2020): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member failed to provide and document an adequate assessment of a complex patient, failed to note that a progress note was a late entry and failed to ensure transfer of accountability at the end of a shift. The penalty included an oral reprimand, a one-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and 12 months of employer notification.

CNO v. Parker (Discipline Committee, 2022): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member on a number of occasions failed to administer medication and documented that it had been administered. The member also had a prior discipline history with the College. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration, a minimum of 2 meetings with a Regulatory Expert, 12 months of employer notification, random spot audits of the member’s documentation and 12 months of no independent practice in the community.

Submissions were made by the Member’s Counsel.

The Member’s Counsel submitted that the Joint Submission on Order meets the four key objectives that discipline panels look for in considering a penalty for professional misconduct. The Member’s Counsel submitted that the proposed penalty meets the goals of specific deterrence to the Member, general deterrence to her peers in the nursing profession, rehabilitation, remediation and public protection. The Member’s Counsel submitted that the proposed penalty meets the goals of general deterrence through the 2-month suspension of the Member’s certificate of registration. This will send a clear message to the membership that failure to meet their professional obligations can result in serious disciplinary penalties. The 2-month suspension of the Member’s certificate of registration, as well as the terms, conditions and limitations imposed will signify to the profession at large and to the public that the nature of the misconduct, regardless of the Member’s intention is taken very seriously by the College and Discipline Committee. Clear, complete and reliable documentation with strict adherence to facility protocols and vigilance when it comes to carrying out all aspects of nursing is necessary regardless of the presenting circumstances. The Member’s Counsel submitted that the proposed penalty also meets the goals of specific deterrence through the 2-month suspension of the Member’s certificate of registration, the oral reprimand and the terms, conditions and limitations that will be placed on the Member’s certificate of registration. The oral reprimand will assist the Member in gaining greater insight into how her actions are perceived by both the profession and the public. The terms, conditions and limitations will provide monitoring of the Member’s practice as well as education. The Member’s Counsel submitted that the proposed penalty provides for rehabilitation and remediation through the Member’s 2 meetings with a Regulatory Expert, her review of relevant standards of the profession and completion of the reflective questionnaires. The Member’s Counsel submitted that these meetings would provide the Member with the opportunity to reflect on her conduct and how she could respond differently in the future. The goal of public protection is met through the learning activities and the 2 meetings with a Regulatory Expert, which will enhance the Member’s knowledge and judgment and assist her in formulating skills and strategies that will assist to avoid similar situations again. The Member’s Counsel submitted that the 12 months of employer notification will also promote the goal of public protection. The Member’s employer will be informed of the circumstances that brought the Member before the Panel and subsequently to the completion of her suspension, the Member’s employer will be vigilant in monitoring her and working collaboratively with her to avoid similar situations as she continues with her practice. The Member’s Counsel submitted that the penalty at a broad level will support the public’s continued confidence in the College’s ability to regulate the practice of nursing and will demonstrate that nursing as a profession is able to regulate itself.

The Member’s Counsel also submitted that the following were mitigating factors in this case:

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

• The Member has accepted responsibility through her admissions;

• The patients involved in this case ultimately passed away, the cause of death of these patients were unrelated and not in any way attributed to the Member’s conduct; and

• Patient [A]’s family had no concerns with the Member’s practice and care provided by the Member.

The Member’s Counsel submitted that end-of-life care can be very demanding and time consuming between caring for the patient and providing ongoing communication with the patient’s family members. The Member’s Counsel submitted that the Member tried her best to deliver on these aspects of care to patients and in some cases their families. The Member’s Counsel submitted that in some cases in doing so, the Member was trying to meet all of her accountabilities, the expectations of the College and the Facility and in doing so found this difficult. The Member’s Counsel submitted that although her actions and decisions amounted to professional misconduct, they were not malevolent in nature.

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. Documentation, and

3. Medication;

iv. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires [and Nurses’ Workbook];

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 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 at least 14 days before 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. 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 the 2-month suspension of the Member’s certificate of registration. General deterrence is achieved through the 2-month suspension of the Member’s certificate of registration. Rehabilitation and remediation are achieved through a minimum of 2 meetings with a Regulatory Expert and the review of the College’s publications. The public is protected through the 12 months of employer notification, which will allow future employers to be vigilant when the Member returns to practice giving the public reassurance that the College has the ability to regulate its nurses. While the Panel appreciates the magnitude of the Member’s work life, the standards of the profession cannot be set aside for the pressures or external factors of the nursing environment or within the healthcare system.

The penalty is also in line with what has been ordered in previous cases in similar circumstances as demonstrated by the cases submitted and referred to by College Counsel.

I, Susan Roger, 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.