College of Nurses of Ontario v. Patricia Ravelo, 2023 ONCNO 149378 — College of Nurses of Ontario Discipline Committee | minicounsel

PANEL: Grace Fox, NP Chairperson

Jean-Laurent Domingue, RN Member

Sandra Larmour Public Member

Lalitha Poonasamy Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) DOUGLAS MONTGOMERY for

) College of Nurses of Ontario

and - )

PATRICIA RAVELO ) CARINA LENTSCH for

Registration No. JD81861 ) Patricia Ravelo

) CHRISTOPHER WIRTH

) Independent Legal Counsel

) Heard: August 16, 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 August 16, 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 Patricia Ravelo.

The Panel considered the submissions of College Counsel 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 Patricia Ravelo.

The Allegations

The allegations against Patricia Ravelo (the “Member”) as stated in the Notice of Hearing dated June 20, 2023 are as follows:

IT IS ALLEGED THAT:

You have committed an act of professional misconduct as provided by subsection 51(1)(b.1) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, in that while registered with the College of Nurses of Ontario as a Registered Practical Nurse and/or while employed at Bruyère Continuing Care in Ottawa, Ontario, you sexually abused a patient, in that in or about 2015, you engaged in physical sexual relations, and/or touching of a sexual nature, and/or behaviour or remarks of a sexual nature with [the Patient].
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 registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse and/or while employed at Bruyère Continuing Care in Ottawa, Ontario (the “Facility”), you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession in that:

a. in or about 2015, you engaged in physical sexual relations, and/or touching of a sexual nature, and/or behaviour or remarks of a sexual nature with [the Patient];

b. in or about 2015, you failed to maintain the boundaries of the therapeutic nurse-client relationship with [the Patient], including but not limited to:

i. you exchanged personal messages by Facebook and/or text message; and/or

ii. you provided [the Patient] with money; and/or

c. in or about 2015, you failed to report to the Facility and/or CNO that you had information that your nursing colleague, J.G., had engaged in a personal and/or sexual relationship with a patient.

You have committed an act of professional misconduct as provided by sub-section 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and subsection 1(7) of Ontario Regulation 799/93 in that, while registered with the College of Nurses of Ontario as a Registered Practical Nurse and/or while employed at Bruyère Continuing Care in Ottawa, Ontario, you abused a patient, verbally, physically and/or emotionally in that:

a. in or about 2015, you engaged in physical sexual relations, and/or touching of a sexual nature, and/or behaviour or remarks of a sexual nature with [the Patient]; and/or

b. in or about 2015, you failed to maintain the boundaries of the therapeutic nurse-client relationship with [the Patient], including but not limited to:

i. you exchanged personal messages by Facebook and/or text message; and/or

ii. you provided [the Patient] with money.

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(25) of Ontario Regulation 799/93, in that while registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse and/or while employed at Bruyère Continuing Care in Ottawa, Ontario (the “Facility”), you failed to report an incident of unsafe practice or unethical conduct of a health care provider to the employer or other authority responsible for the health care provider, in that you in or about 2015, you failed to report to the Facility and/or CNO that you had information that your nursing colleague, J.G. had engaged in a personal and/or sexual relationship with a patient.
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 registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse and/or while employed at Bruyère Continuing Care in Ottawa, Ontario (the “Facility”), you engaged in conduct that would reasonably be regarded by members as disgraceful, dishonourable or unprofessional with respect to the following incidents:

a. in or about 2015, you engaged in physical sexual relations, and/or touching of a sexual nature, and/or behaviour or remarks of a sexual nature with [the Patient];

b. in or about 2015, you failed to maintain the boundaries of the therapeutic nurse-client relationship with [the Patient], including but not limited to:

i. you exchanged personal messages by Facebook and/or text message; and/or

ii. you provided [the Patient] with money; and/or

c. in or about 2015, you failed to report to the Facility and/or CNO that you had information that your nursing colleague, J.G. had engaged in a personal and/or sexual relationship with a patient.

Member’s Plea

The Member admitted the allegations set out in paragraphs #1, #2(a), (b)(i), (ii), (c), #3(a), (b)(i), (ii), #4 and #5(a), (b)(i), (ii) and (c) in the Notice of Hearing. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.

Agreed Statement of Facts

College Counsel and the Member’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited and without the exhibits referenced therein, as follows:

THE MEMBER

Patricia Ravelo (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on May 27, 2004. The Member has no prior disciplinary findings with CNO.
The Member was employed at Bruyère Continuing Care - Élisabeth Bruyère Hospital, in Ottawa, Ontario (the “Facility”) at the time of the incidents. The Member worked at the Facility’s Photo Dermatology Clinic (the “Clinic”). The Clinic provides photo therapy, meaning the provision of ultraviolet treatment for various skin diseases such as eczema and vitiligo.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Relationship with [the Patient]

(the “Patient”) was a patient at the Clinic between February 25, 2015, to May 27, 2015. The Member provided the Patient with care on at least one occasion during this period. The Member met the Patient at the Clinic, and she did not previously know him outside of the Clinic.
While the Patient was receiving care at the Clinic, the Member and the Patient commenced a personal and sexual relationship that lasted approximately two months and occurred while the Patient was receiving treatment at the Clinic (the “Relationship”).
The Member and the Patient initially communicated on Facebook and subsequently exchanged cell phone numbers and communicated by text message.
If the Member were to testify, she would state that the Patient initiated contact with her through Facebook, and then provided his telephone number to her.
During the Relationship, the Member gave the Patient money and bus tickets to attend the Clinic. The Member also provided the Patient with money for the Patient to pay his rent.
If the Member were to testify, she would state that the Patient told her he did not have money to come to the Clinic and she felt bad for him and that she gave him money and bus tickets so that he could come in for treatment. The Member would further testify that the Patient asked her for cigarettes and money for rent and she gave him $300 for rent, which she regretted.
During the Relationship, the Member and the Patient met outside of the Clinic four times and they engaged in sexual intercourse at least once after the Member had given the Patient the rent money.
If the Member were to testify, she would state that she regretted her lapse in judgment and felt remorseful and that she therefore chose to end the Relationship with the Patient, following which he became hostile and verbally aggressive towards her.
In or around 2015, the Member told her colleague, Johanne Groulx, RPN (“Colleague J.G.”) that she had a sexual relationship with the Patient.
In 2020, the Facility interviewed the Member about her relationship with the Patient. The Member admitted to the Facility that she had engaged in a personal and sexual relationship with the Patient, as described above, and that she was remorseful.

Failure to Report Sexual Abuse of a Patient

In or around 2015, the Member’s nursing colleague, Colleague J.G., told the Member that she had had a sexual relationship with [ ] (“Patient [B]”), another patient at the Clinic. The Member did not report Colleague J.G.’s sexual relationship with Patient [B] to the Facility or CNO at this time.
If the Member were to testify, she would state that she understood that Colleague J.G. was trying to comfort her by disclosing Colleague J.G.’s relationship with Patient [B]. The Member would further testify that while she understood Colleague J.G.’s encounter with Patient [B] was a sexual encounter, they did not discuss any details and the Member did not know when the relationship between Colleague J.G. and Patient [B] happened.
In July 2020, the Facility interviewed the Member as part of the Facility’s investigation into Colleague J.G.’s relationship with Patient [B]. The Member initially told the Facility that Colleague J.G. had shared the information about her relationship with Patient [B] a few weeks before the meeting. The Member later admitted she had learned of Colleague J.G.’s relationship with Patient [B] in approximately 2015. The Member did not report Colleague J.G.’s relationship with Patient [B] to CNO after her meeting with the Facility.
As a result of the incidents described above, the Facility suspended the Member for 10 days and she was required to complete a learning plan.
If the Member were to testify, she would state that she sincerely regrets her decisions with a deepfelt sense of remorse and acknowledges that she should not have engaged in a personal and sexual relationship with the Patient. The Member would further testify that she apologizes for not reporting Colleague J.G. and that she accepts responsibility for her conduct.

HEALTH PROFESSIONS PROCEDURAL CODE

The Health Professions Procedural Code (Schedule 2 to the Regulated Health Professions Act, 1991, SO 1991, c 18 (“Code”) defines sexual abuse of a patient by a member in s. 1(3) as:

(a) sexual intercourse or other forms of physical sexual relations between the member and the patient,

(b) touching, of a sexual nature, of the patient by the member, or

Section 85.1(1) of the Code requires members to file a report with the College when the member has reasonable grounds, obtained in the course of practicing the profession, to believe that another member of the same College has sexually abused a patient.

CNO STANDARDS

Professional Standards

CNO’s Professional Standards, in force at the time of the incidents, provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by CNO. It includes seven broad standard statements pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership and relationships.
CNO’s Professional Standards provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring their practice and conduct meets the legislative requirements and the standards of the profession. Nurses are responsible for their actions and the consequences of those actions as well as for conducting themselves in ways that promote respect for the profession. Nurses demonstrate this standard by:

Ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation;
Reporting to the appropriate authority any health care team member or colleague whose actions or behaviours toward [patients] are unsafe or unprofessional, or indicate physical, verbal and emotional abuse; and
Reporting sexual abuse of a [patient] by a regulated health professional to the appropriate regulatory college, as legislated in the Regulated Health Professions Act, 1991

CNO’s Professional Standards further provides, in relation to the ethics standard, that ethical nursing includes acting with integrity, honesty and professionalism in all dealings with the patient and other health care team members. A nurse demonstrates having met this standard by identifying ethical issues and communicating them to the healthcare team.
CNO’s Professional Standards provides, in relation to the relationship standard and the therapeutic nurse-patient relationship, that a nurse demonstrates this standard by:

Maintaining boundaries between professional therapeutic relationships and non-professional personal relationships;
Ensuring [patients’] needs remain the focus of nurse-[patient] relationships; and
Ensuring his or her personal needs are met outside of the therapeutic nurse-[patient] relationships.

In addition, CNO’s Professional Standards further provides, in relation to the leadership standard, that a nurse demonstrates leadership role-modelling professional values, beliefs and attributes.
Attached as Exhibit “A” are copies of CNO’s Professional Standards that were in force at the time of the incidents and have since been retired.

Therapeutic Nurse-Client Relationship

CNO’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) contains four standard statements which describe nurses’ accountabilities with respect to therapeutic communication, patient-centred care, maintaining boundaries and protecting the patient from abuse. The TNCR Standard provides that the nurse-patient relationship is built on trust, respect, empathy, professional intimacy and requires the appropriate use of power inherent in the care provider’s role.
CNO’s TNCR Standard defines a boundary in the nurse-patient relationship as “the point at which the relationship changes from professional and therapeutic to unprofessional and personal.” CNO’s TNCR Standard places the responsibility for establishing and maintaining the limits and boundaries in the therapeutic nurse-patient relationship on the nurse. CNO’s TNCR Standard provides that:

Crossing a boundary means that the care provider is misusing the power in the relationship to meet his/her personal needs, rather than the needs of the [patient], or behaving in an unprofessional manner with the [patient].

CNO’s TNCR Standard provides, in relation to maintaining boundaries, that nurses meet this standard by:

Setting and maintaining the appropriate boundaries within the relationship, and helping [patients] understand when their requests are beyond the limits of the therapeutic relationship;
Abstaining from disclosing personal information, unless it meets an articulated therapeutic need of the [patient];
Continually clarifying her/his role in the therapeutic relationship, especially in situations in which the [patient] may become unclear about the boundaries and limits of the relationship;
Abstaining from engaging in financial transactions unrelated to the provision of care and services with the [patient] or the [patient’s] family/significant other;
Consulting with colleagues and/or the manager in any situation in which it is unclear whether a behaviour may cross a boundary of the therapeutic relationship, especially circumstances that include self-disclosure or giving a gift to or accepting a gift from a [patient]; and
Ensuring that the nurse-[patient] relationship and nursing strategies are developed for the purpose of promoting the health and well-being of the [patient] and not to meet the needs of the nurse, especially when considering self-disclosure, giving a gift to or accepting a gift from a [patient].

CNO’s TNCR Standard defines abuse as:

[T]he misuse of the power imbalance intrinsic in the nurse-[patient] relationship. It can also mean the nurse betraying the [patient]’s trust, or violating the respect or professional intimacy inherent in the relationship, when the nurse knew, or ought to have known the action could cause, or could be reasonably expected to cause physical, emotional or spiritual harm to the [patient].

CNO’s TNCR Standard provides that abuse may be verbal, emotional, physical, sexual, financial, or take the form of neglect. The TNCR Standard further provides that sexual abuse includes, but is not limited to, consensual and non-consensual:

Touching of a sexual nature or touching that may be perceived by the [patient] or others to be sexual; and
Sexual intercourse or other forms of sexual contact with a [patient].

CNO’s TNCR Standard requires nurses to protect the patient from harm by ensuring that abuse is prevented or stopped and reported. With respect to protecting the patient from abuse, a nurse demonstrates having met the TNCR Standard by:

Not entering a friendship, or a romantic, sexual or other personal relationship with a [patient] when a therapeutic relationship exists; and
Not engaging in behaviours with a [patient] or making remarks that may reasonably be perceived by other nurses and/or others to be romantic, sexually suggestive, exploitive and/or sexually abusive (for example, spending extra time together outside of the [patient’s] care plan).

Attached as Exhibit “B” is a copy of CNO’s TNCR Standard that was in force at the time of the incidents.
The Member admits and acknowledges that she contravened Professional Standards and the TNCR Standard when she:

Engaged in physical sexual relations, touching of a sexual nature, and behaviour or remarks of a sexual nature with the Patient;
Failed to maintain the boundaries of the therapeutic nurse-client relationship with the Patient when she exchanged personal messages with the Patient by Facebook and text message and provided the Patient with money; and
Failed to report to the Facility and CNO that she had information that Colleague J.G. had engaged in a personal and/or sexual relationship with Patient [B].

ADMISSIONS OF PROFESSIONAL MISCONDUCT

The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1 of the Notice of Hearing in that she sexually abused the Patient, as described in paragraphs 3 to 18 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2 (a), (b) and (c) of the Notice of Hearing in that she contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 3 to 33 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3 (a) and (b) of the Notice of Hearing in that she emotionally abused the Patient, as described in paragraphs 3 to 17 and 29 to 32 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 4 of the Notice of Hearing in that she failed to report an incident of unsafe practice or unethical conduct of a health care provider to the employer or other authority responsible for the health care provider or to CNO, as described in paragraphs 13 to 17 and 19 to 25 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 5 (a), (b) and (c) of the Notice of Hearing, and in particular her conduct was disgraceful, dishonourable and unprofessional, as described in paragraphs 3 to 33 above.

College Counsel’s Submissions on Liability

College Counsel asked the Panel to accept the Agreed Statement of Facts, as well as the Member’s admissions to all the allegations as set out in paragraphs 34 to 38 of the Agreed Statement of Facts and, on the basis of those facts and admissions, make findings of professional misconduct with respect to the allegations in the Notice of Hearing. College Counsel submitted that the Panel has taken the Member’s plea, conducted a verbal plea inquiry, and received a written plea inquiry which confirmed that the plea was voluntary, informed, and made on the advice of experienced Counsel. College Counsel submitted that based on the Agreed Statement of Facts, which specifically describes the facts in relation to the allegations, the Panel has enough evidence to find that the Member committed professional misconduct as set out in all of the allegations in the Notice of Hearing.

College Counsel reviewed allegations #2(a), (b)(i), (ii), (c) and #5(a), (b)(i), (ii) and (c) with the Panel. With regard to allegations #2(a), (b)(i), (ii) and (c), College Counsel submitted that these allegations are supported by the Agreed Statement of Facts, which contained evidence of the relevant College standards of the profession, as well as the Member’s admissions that those standards were breached.

With respect to allegation #3, College Counsel submitted that the facts in the Agreed Statement of Facts support a finding of emotional abuse.

With regard to allegations #5(a), (b)(i), (ii) and (c), College Counsel submitted that the parties agreed that the Member’s conduct is relevant to the practice of nursing and is unprofessional, dishonourable and disgraceful. College Counsel submitted that this agreement is part of a resolution reached between the College and the Member.

College Counsel reminded the Panel that although these terms are disjunctive, the Panel should find that the Member’s conduct is all three and submitted that, having regard to all of the circumstances, members of the profession would consider the Member’s conduct to be disgraceful, dishonourable and unprofessional. The Member’s conduct is unprofessional as it demonstrated a disregard for her professional obligations. The Member’s conduct is dishonourable as the Member knew or ought to have known that her conduct fell below the standards of a professional and involved an element of moral failing in that she failed to uphold the therapeutic boundaries with [the Patient] despite knowing that such conduct is unacceptable. The Member’s conduct is disgraceful as sexual abuse brings the reputation of the nursing profession into disrepute. College Counsel submitted that preventing abuse is central to the practise of nursing and that transgressing therapeutic boundaries is the type of conduct that is disgraceful to the nursing profession.

The Member’s Counsel’s Submissions on Liability

The Member’s Counsel submitted that the Member has been forthright to the extent that she admitted to the conduct. The Member’s Counsel also submitted that the Agreed Statement of Facts outlines the facts to which the Member has admitted, and it includes the College Standards and the Code provisions that were in effect at the time of the conduct.

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(a), (b)(i), (ii), (c), #3(a), (b)(i), (ii), #4 and #5(a), (b)(i), (ii) and (c) of the Notice of Hearing. As to allegations #3(a), (b)(i) and (ii), the Panel finds that the Member emotionally abused a patient. With regard to allegations #5(a), (b)(i), (ii) and (c), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be disgraceful, dishonourable and unprofessional.

Reasons for Decision

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

Allegation #1 in the Notice of Hearing is supported by paragraphs 3 to 18 and 34 in the Agreed Statement of Facts. The Member admitted that while employed as a Registered Practical Nurse (“RPN”) at Bruyère Continuing Care (the “Facility”) she sexually abused [the Patient] when she engaged in sexual intercourse with him. When making its finding, the Panel considered Section 1(3)(a) of the Health Professions Procedural Code (the “Code”) which defines sexual abuse of a patient by a member as “sexual intercourse or other forms of physical sexual relations between the member and the patient” and Section 1(6)(a) of the Code which defines a patient as “an individual who was a member’s patient within one year or such longer period of time as may be prescribed from the date on which the individual ceased to be the member’s patient”. Paragraphs 3 and 4 of the Agreed Statement of Facts provide, and the Panel confirmed with both College Counsel and the Member’s Counsel that the sexual intercourse took place between February 25, 2015 to May 27, 2015, which was within the one year time period provided by the Code before making its finding of sexual abuse.

Allegation #2(a) in the Notice of Hearing is supported by paragraphs 3 to 12, 20 to 33, and 35 in the Agreed Statement of Facts. The Member admitted that between February 25, 2015 and May 27, 2015 after having given care to [the Patient] on at least one occasion, she and [the Patient] met outside of the Facility and engaged in sexual intercourse at least once. When making its finding, the Panel carefully considered the “protecting clients from abuse” provision in the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”). Among other things, this provision states that “The nurse meets the standard by: […] d) not entering a friendship, or a romantic relationship, sexual or other personal relationship with a client when a therapeutic relationship exists; […] f) being cautious about entering into a personal relationship, such as a friendship or romantic or sexual relationship, with a former client or a former client’s significant other after the termination of a therapeutic relationship if: it is determined that such a relationship would not have a negative impact on the future care of the client...”.

Both College Counsel and the Member’s Counsel agreed that the sexual intercourse took place while the therapeutic relationship between the Member and [the Patient] was ongoing.

Therefore, the Panel found that the Member contravened the TNCR Standard. The TNCR Standard in force at the time provided that the responsibility for establishing and maintaining the limits and boundaries of a therapeutic nurse-client relationship was that of the nurse and that crossing this boundary means that the care provider is misusing the power in the relationship to meet their personal needs, rather than the needs of the patient. Among other things, the TNCR Standard provided, in relation to maintaining boundaries, that nurses meet this standard by continually clarifying their role in the therapeutic relationship, especially in situations in which the patient may become unclear about the boundaries and limits of the relationship, and that nurses should consult with colleagues and/or the manager in situations where it is unclear whether a behaviour may cross a boundary of the therapeutic relationship. Regarding abuse, the College’s TNCR Standard requires nurses to protect patients from harm by not entering a friendship, or a romantic, sexual or other personal relationship with a patient when a therapeutic relationship exists. By engaging in sexual intercourse with [the Patient] while being in a therapeutic nurse-client relationship with him, the Member failed to protect [the Patient] from harm.

The Panel also finds that the Member contravened the College’s Professional Standards in force at the time. The College’s Professional Standards, in relation to the accountability standard, provides that nurses are accountable to the public and responsible for ensuring their practise and conduct meets the legislative requirements and the standards of the profession. It further states that nurses are responsible for their actions and the consequences of those actions as well as for conducting themselves in ways that promote respect for the profession. In relation to the relationship standards, the Professional Standards provide that nurses are responsible for maintaining boundaries between professional therapeutic relationships and non-professional personal relationships and for ensuring patients’ needs remain the focus of nurse-patient relationships. By engaging in sexual intercourse with [the Patient] while being in a therapeutic nurse-client relationship with him, the Member violated legislative requirements related to sexual abuse, as defined in the Code, and conducted herself in a manner that reflected poorly on the profession.

Allegations #2 (b)(i) and (ii) in the Notice of Hearing are supported by paragraphs 3 to 33 and 35 in the Agreed Statement of Facts. The Member admitted to exchanging personal messages by Facebook and text messages with [the Patient]. The Member also admitted to providing [the Patient] with bus tickets for him to get to and from the Facility, and to giving him $300.00 for rent. When making its finding, the Panel considered the “protecting clients from abuse” provision in the TNCR Standard. Although the Agreed Statement of Facts alone did not provide the Panel with evidence to determine whether the Member had ended the therapeutic nurse-client relationship before messaging [the Patient] and providing him with bus tickets and money, following the Panel request for additional submissions from College Counsel and the Member’s Counsel as noted above, it was satisfied that this conduct took place while the therapeutic relationship between the Member and [the Patient] was ongoing. The Panel finds that the Member contravened the TNCR Standard as she failed to maintain the boundaries of the nurse-client relationship to the extent that she had a personal relationship with [the Patient], where she exchanged messages and money with him outside of the care plan, while being engaged in a therapeutic nurse-client relationship with him.

The Panel also finds that the Member contravened the College’s Professional Standards in force at the time. Specifically, in relation to the relationship standards, the Professional Standards provide that nurses are responsible for maintaining boundaries between professional therapeutic relationships and non-professional personal relationships and for ensuring patients’ needs remain the focus of nurse-patient relationships. In relation to the Ethics Standard, the Professional Standards state that ethical nursing includes acting with integrity, honesty and professionalism in all dealings with the patient, and that a nurse demonstrates having met this standard by identifying ethical issues and communicating them to the healthcare team. By exchanging messages and money with [the Patient] outside of the therapeutic nurse-client relationship and by failing to identify this conduct as being ethically problematic, the Member’s conduct was unethical, and it failed to maintain the boundaries between professional therapeutic relationships and non-professional personal relationships.

Allegation #2(c) in the Notice of Hearing is supported by paragraphs 13 to 33 and 35 in the Agreed Statement of Facts. The Member admitted to failing to report to the Facility and to the College that she had information that her nursing colleague had engaged in a personal and/sexual relationship with a patient. The Member contravened the College’s Professional Standards, and in particular the accountability standard, which states that nurses should report to the appropriate authority any health care team member or colleague whose actions or behaviours toward patients are unsafe or unprofessional, or indicate physical, verbal and emotional abuse; and report sexual abuse of a patient by a regulated health professional to the appropriate regulatory college. The Panel finds that by failing to report to the Facility and to the College that she had information that her nursing colleague had engaged in a personal and/or sexual relationship with a patient, the Member engaged in conduct that is contrary to what the public would expect of nurses.

Allegations #3(a), (b)(i) and (ii) in the Notice of Hearing are supported by paragraphs 3 to 17, 29 to 32 and 36 in the Agreed Statement of Facts. The Member admitted to emotionally abusing [the Patient] by exchanging personal communications through Facebook and text messages with him, by providing [the Patient] with bus tickets and money to pay his rent, and by having sexual intercourse with [the Patient]. When making its finding, the Panel considered the TNCR Standard’s definition of abuse, which is “the misuse of the power imbalance intrinsic in the nurse-client relationship. It can also mean the nurse betraying the client’s trust or violating the respect or professional intimacy inherent in the relationship, when the nurse knew, or ought to have known, the action could cause, or could be reasonably expected to cause, physical, emotional or spiritual harm to the client”. The Panel finds that the Member’s failure to maintain the boundaries of a therapeutic nurse-client relationship by engaging in personal and sexual conduct with [the Patient] amounted to emotional abuse to the extent that such conduct violated the professional intimacy inherent to the therapeutic relationship.

Allegation #4 in the Notice of Hearing is supported by paragraphs 13 to 17, 19 to 25 and 37 in the Agreed Statement of Facts. The Member admitted to failing to report to the Facility and to the College that they had information that a nursing colleague had engaged in a personal and/or sexual relationship with a patient.

Allegations #5(a), (b)(i), (ii) and (c) in the Notice of Hearing are supported by paragraphs 3 to 33 and 38 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in exchanging personal communications through Facebook and text messages with [the Patient], providing [the Patient] with bus tickets and money to pay his rent, and engaging in sexual intercourse with [the Patient] was relevant to the practice of nursing. It was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of dishonesty, deceit and moral failing. The Member failed to uphold the therapeutic boundaries between herself and [the Patient]. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional.

Finally, the Panel finds that the Member’s conduct was disgraceful as it shames the Member and by extension the profession. The Member’s conduct casts serious doubt on the Member’s moral fitness and inherent ability to discharge the higher obligations the public expects professionals to meet. The Panel agreed with College Counsel’s submission that preventing abuse is central to the practise of nursing and that sexual and emotional abuse is the type of conduct that is disgraceful to the nursing profession.

Penalty

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

Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
Requiring the Member to reimburse CNO for funding provided for [the Patient] under the program required by s. 85.7 of the Health Professions Procedural Code, up to the amount of $5,000, if [the Patient] accesses the fund.
Directing the Executive Director to immediately revoke the Member’s certificate of registration.

Penalty Submissions

College Counsel’s Submissions on Penalty

Penalty Submissions

College Counsel submitted that the penalty is composed of three elements, a reprimand, reimbursement of the College for funding up to $5,000.00 should [the Patient] access a therapeutic program and the revocation of the Member’s certificate of registration. Given that the Member was found to have sexually abused [the Patient], by engaging in sexual intercourse, College Counsel submitted that pursuant to Section 51(5) of the Code, the Panel had no discretion and must order a reprimand and the revocation of the Member’s certificate of registration. As for the reimbursement of up to $5,000.00 to the College, College Counsel submitted that this is authorized by Section 51(2)(5.1) of the Code.

The aggravating factors in this case were:

The personal and intimate relationship the Member engaged in with [the Patient] constitutes a breach of trust and a violation of boundaries;
The Member’s conduct (exchange of personal messages, exchange of money and sexual intercourse) is incompatible with the practise of nursing;
The Member’s failure to report the sexual relationship between a nursing colleague and another patient compounds the gravity of her own sexual abuse of [the Patient]; and
The Member’s overall conduct is in departure from the conduct generally expected of nurses.

The mitigating factors in this case were:

The Member has no prior discipline history with the College;
If the Member were to testify, she would express remorse and apologize for her conduct;
The Member admitted to the relationship with [the Patient];
The Member took accountability for her conduct with the College by admitting to the allegations and entering into an Agreed Statement of Facts and a Joint Submission on Order with the College preventing a contested hearing, which saved time, money and emotional aggravation for all parties involved, including [the Patient].

The proposed penalty provides for general deterrence through the revocation of the Member’s certificate of registration, which sends a strong message to all members of the profession that such conduct is not acceptable, nor will it be tolerated.

The proposed penalty provides for specific deterrence through the oral reprimand and the revocation of the Member’s certificate of registration.

College Counsel also submitted that in cases where the penalty sought includes the revocation of a member’s certificate of registration, rehabilitation and remediation need not be considered.

Overall, the public is protected as the Member’s certificate of registration would be revoked and she would no longer be practicing as an RPN.

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. Pezzano (Discipline Committee, 2020): In this case, the hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member admitted to having communicated with a patient via text messages and telephone outside of the nurse-client therapeutic relationship. The member was found to have had a personal, sexual and romantic relationship with a patient. The penalty included an oral reprimand, revocation of the member’s certificate of registration and reimbursement by the member to the College for funding provided to the patient for therapy or counselling of up to $5,000.00, if the patient accessed the fund, which is identical to the penalty being sought in the case before this Panel.

CNO v. McArthur (Discipline Committee, 2023): In this case, the member did not admit to the allegations and did not attend the Discipline Committee hearing. The member was found to have entered into a personal and sexual relationship with a patient beyond the nurse-client therapeutic relationship. The penalty included an oral reprimand, revocation of the member’s certificate of registration and reimbursement by the member to the College for funding provided to the patient for therapy or counselling, if the patient accessed the fund. This penalty is identical to the penalty being sought in the case before this Panel with the exception that in this case there was no dollar limit on the amount to be reimbursed to the College should the patient attend a therapeutic program, rather it was the amount permitted by Ontario Regulation 59/94.

The Member’s Counsel’s Submissions on Penalty

The Member’s Counsel submitted that the Member agreed to the penalty and has taken responsibility for her conduct. The Member’s Counsel agreed with the submissions made by College Counsel. The Member’s Counsel reiterated that the Member had been a nurse since 2004 without prior history of discipline with the College. The Member’s Counsel further submitted that documentation from the Facility highlighted that there were no professional problems with the Member other than the issues brought before the Panel. The Member’s Counsel submitted that it was the Member who came forward on her own; it was not [the Patient] that brought forth the concerns, nor was he part of the investigation by the College. The Member’s Counsel submitted that it takes great courage to take accountability for what happened because without this admission, there would not have been a Discipline Committee hearing. The Member’s Counsel further submitted that in the Pezzano case, the Panel found that it was appropriate to limit the reimbursement to $5,000.00, and therefore asks that the Panel accept the Joint Submission on Order.

College Counsel’s Reply

College Counsel reminded the Panel that only the facts contained in the Agreed Statement of Facts should be considered in their deliberations regarding penalty.

Penalty Decision

The Panel accepts the Joint Submission on Order and accordingly orders:

The Member is required to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
The Member is required to reimburse CNO for funding provided for [the Patient] under the program required by s. 85.7 of the Health Professions Procedural Code, up to the amount of $5,000, if [the Patient] accesses the fund.
The Executive Director is directed to immediately revoke the Member’s certificate of registration.

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.

Pursuant to Section 51(5)(1) and 51(5)(3) of the Code, the Panel had no discretion regarding the mandatory reprimand and the revocation of the Member’s certificate of registration due to the nature of the professional misconduct, namely sexual abuse. As for the reimbursement of $5,000.00 to the College should [the Patient] access a therapeutic program, the Panel found that this provision of the penalty was in line with what has been ordered in similar cases, such as in the Pezzano case. The Panel found that limiting the amount of the reimbursement to $5,000.00 was appropriate in light of the mitigating factors in this case.

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 also finds that the penalty satisfies the principles of specific and general deterrence and public protection. General deterrence is satisfied through the revocation of the Member’s certificate of registration as it sends a strong message to all members of the profession that such conduct is not tolerated. Specific deterrence is met through the oral reprimand and the revocation of the Member’s certificate of registration, which sends a message to the Member that this type of behaviour is unacceptable. Furthermore, revocation of the Member’s certificate of registration means that the Member will not be able to engage in similar conduct again in the context of the nursing profession. Revocation is the ultimate form of specific deterrence. The Panel agreed with College Counsel’s submission that in cases where the penalty sought includes the revocation of a member’s certificate of registration, rehabilitation and remediation need not be considered.

Public protection is met through the Member’s mandatory revocation which will prevent future conduct and demonstrate the ability of the College to self-regulate. The Panel recognizes the seriousness of this case and understands the legislative requirements to revoke the Member’s certificate of registration for conduct involving sexual abuse. The Panel also supports the accountability of the Member to financially support counselling for [the Patient] if he chooses to access the College fund for this purpose.

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

I, Grace Fox, NP, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel.