DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Michael Hogard, RPN Chairperson Tina Colarossi, NP Member Nazlin Hirji, RN Member Sylvia Douglas Public Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ALYSHA SHORE for College of Nurses of Ontario
- and -
PAUL WIDDOWSON Registration No. AE133767 NO REPRESENTATION for Paul Widdowson
CHRISTOPHER WIRTH Independent Legal Counsel
Heard: May 25, 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 May 25, 2023, via videoconference.
Although Paul Widdowson (the “Member”) was not present nor represented, College Counsel advised the Panel that the College had been in touch with the Member, that he was aware of the hearing, had decided he would not attend it and had signed all the necessary documents for the hearing to proceed in his absence.
In that regard, College Counsel provided the Panel with evidence that the Member had been sent the Notice of Hearing on February 14, 2023 by way of an affidavit from Kristen Kellett, Prosecutions Clerk, dated February 15, 2023, confirming that Ms. Kellett sent correspondence, which included the Notice of Hearing, on February 14, 2023 to the Member’s last known address on the College Register.
In addition, College Counsel also provided the Panel with the affidavit of Sarah Hellmann, Prosecutions Associate, dated May 25, 2023, which confirmed that the Member had entered into a resolution with the College on an uncontested basis, had signed all the necessary documents and that he would not be attending the hearing.
The Panel was satisfied that the Member had received adequate notice of the time, place and purpose of the hearing and of the fact that if he did not attend it, the hearing may proceed in his absence. Accordingly, the Panel decided to proceed with the hearing in the Member’s absence.
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 Paul Widdowson.
The Panel considered the submissions of College 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 Paul Widdowson.
The Allegations
The allegations against the Member as stated in the Notice of Hearing dated February 13, 2023 are as follows:
IT IS ALLEGED THAT:
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that while you were employed as a Registered Practical Nurse at Fiddicks Nursing Home Ltd. in Petrolia, Ontario, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession as follows:
a. on or around August 12, 2019, when receiving a shift report from Colleague M.H. you used inappropriate language, including words to the effect of “that fucking idiot” and/or “where is that fucking asshole” and/or you shook the computer screen at the nursing station;
b. on or around August 15, 2019, after Patient [A] fell, you:
i. failed to complete an adequate assessment of the patient, respond to the patient’s injuries and/or complete the necessary documentation; and/or
ii. permitted and/or assisted the patient in moving from the floor to the bed;
c. on or around August 15 to 16, 2019, after Patient [B] had an allergic reaction to a condom catheter, you failed to:
i. conduct adequate assessments of the patient during your shift;
ii. intervene when the patient was experiencing signs and symptoms of an allergic reaction and/or administer Benadryl; and/or
iii. insert an in and out catheter on the patient despite evidence of urinary retention;
d. in November 2019, you made inappropriate comments to Patient [C] while providing care, as follows:
i. on or about November 6, 2019, after the patient pinched and dug her nails into your hand, you said words to the effect of “You fucking bitch” and/or “do you even know what I could do to you? I could drop you on the floor” and/or refused to provide care to the patient;
ii. on or about November 7 or 8, 2019, after the patient grabbed at you in the air near your mid-area, you said words to the effect of “careful [ ] you might grab my dick”; and/or
iii. on or about November 13, 2019, after the patient grabbed at you, you said words to the effect of “I would love to just head butt you right in the head”;
- 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(7) of Ontario Regulation 799/93, in that while you were employed as a Registered Practical Nurse at Fiddicks Nursing Home Ltd. in Petrolia, Ontario, you abused Patient [C] verbally, physically, and/or emotionally in November 2019 when you made inappropriate comments to Patient [C] while providing care, as follows:
a. on or about November 6, 2019, after the patient pinched and dug her nails into your hand, you said words to the effect of “You fucking bitch” and/or “do you even know what I could do to you? I could drop you on the floor” and/or refused to provide care to the patient;
b. on or about November 7 or 8, 2019, after the patient grabbed at you in the air near your mid-area, you said words to the effect of “careful [ ] you might grab my dick”; and/or
c. on or about November 13, 2019, after the patient grabbed at you, you said words to the effect of “I would love to just head butt you right in the head”;
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 Practical Nurse at Fiddicks Nursing Home Ltd. in Petrolia, Ontario, you failed to keep records as required when you failed to complete the necessary documentation after Patient [A] fell on or about August 15, 2019; and/or
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that, while you were employed as a Registered Practical Nurse at Fiddicks Nursing Home Ltd. in Petrolia, 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, as follows:
a. on or around August 12, 2019, when receiving a shift report from Colleague M.H. you used inappropriate language, including words to the effect of “that fucking idiot” and/or “where is that fucking asshole” and/or you shook the computer screen at the nursing station;
b. on or around August 15, 2019, after Patient [A] fell, you:
i. failed to complete an adequate assessment of the patient, respond to the patient’s injuries and/or complete the necessary documentation; and/or
ii. permitted and/or assisted the patient in moving from the floor to the bed;
c. on or around August 15 to 16, 2019, after Patient [B] had an allergic reaction to a condom catheter, you failed to:
i. conduct adequate assessments of the patient during your shift;
ii. intervene when the patient was experiencing signs and symptoms of an allergic reaction and/or administer Benadryl; and/or
iii. insert an in and out catheter on the patient despite evidence of urinary retention;
d. in November 2019, you made inappropriate comments to Patient [C] while providing care, as follows:
i. on or about November 6, 2019, after the patient pinched and dug her nails into your hand, you said words to the effect of “You fucking bitch” and/or “do you even know what I could do to you? I could drop you on the floor” and/or refused to provide care to the patient;
ii. on or about November 7 or 8, 2019, after the patient grabbed at you in the air near your mid-area, you said words to the effect of “careful [ ] you might grab my dick”; and/or
iii. on or about November 13, 2019, after the patient grabbed at you, you said words to the effect of “I would love to just head butt you right in the head”.
Member’s Plea
The Member admitted the allegations set out in paragraphs #1(a) insofar as it relates to the use of inappropriate language, #1(b)(i), (ii), #1(c)(i), (ii), (iii), #1(d)(i), (iii), #2(a), #2(c), #3 #4(a) insofar as it relates to the use of inappropriate language, #4(b)(i), (ii), #4(c)(i), (ii), (iii), #4(d)(i) and (iii) in the Notice of Hearing.
The Member did not admit to allegation #1(a) as it pertained to shaking the computer screen at the nursing station, #1(d)(ii), #2(b), #4(a) as it pertained to the shaking of the computer screen at the nursing station, or #4(d)(ii).
In that regard, as noted above, College Counsel provided the Panel with Exhibit #3, the affidavit of Sarah Hellmann, Prosecutions Associate at the College which sets out that the Member entered into a resolution with the College in which the matter would proceed before a panel of the College’s Discipline Committee on an uncontested basis. It also sets out that College Counsel had at least two telephone conversations with the Member to explain the process and the consequences of a guilty plea. During those conversations, the Member advised College Counsel that he had resigned his certificate of registration with the College and had no intention of reapplying to the College in the future.
On May 23, 2023, in accordance with the agreement between the College and the Member, the Member signed the Agreed Statement of Facts, the Joint Submission on Order and the appended Undertaking and Agreement, Waiver of Appeal, and completed the written Plea Inquiry. The Member emailed these documents to College Counsel on May 24, 2023.
The Panel received the written plea inquiry and accordingly, was satisfied that the Member’s admissions were voluntary, informed and unequivocal.
Agreed Statement of Facts
College Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which as amended reads, unedited, as follows:
THE MEMBER
Paul Widdowson (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on November 30, 2015. The Member resigned his certificate of registration on March 16, 2023.
At the material time, the Member was employed at Fiddicks Nursing Home Ltd., in Petrolia, Ontario (the “Facility”), where he had been working since June 13, 2016.
PRIOR HISTORY
- The Member has no prior disciplinary findings with CNO.
THE FACILITY
The Facility has multiple long-term care units and a retirement unit. The Member worked on the long-term care side of the Facility.
The Member worked primarily 8-hour night shifts on a full-time basis, floating back and forth between two of the long-term care units, one of which is dedicated to patients with dementia and/or reactive behaviours.
When fully staffed on nights, the Facility would have six Personal Support Workers (“PSW”s), one Registered Nurse (“RN”) and one RPN. Each unit would have one PSW posted to it and two PSWs moving back and forth between the long-term care units to perform interventions on any resident that needed two people to perform the intervention safely.
At the time of the incidents detailed below, the Member was the only RPN on the night shift. He was responsible for 62 residents (31 beds in each of the two units he floated between).
The Facility has since expanded the number of RPNs working on the night shift.
Relevant Facility Policies
The Facility’s Workplace Violence, Harassment and Discrimination Policy/Program establishes that all employees are entitled to enjoy a work environment free of behaviours such as discrimination, harassment, disruptive workplace conflict, disrespectful behaviour and workplace violence.
Employees have a responsibility to act respectfully towards others and to ensure their own personal safety in the event of workplace violence, harassment and discrimination.
Harassment involves engaging in a course of vexatious comment or negative conduct against a worker in a workplace relating to any prohibited grounds that is known or ought to be known to be unwelcome and includes bullying. Bullying is described in the policy as threatening, humiliating or intimidating behaviours, work interference/sabotage that prevents work from getting done and verbal abuse.
With respect to resident care and risk management in the context of falls and similar incidents, staff are expected to manage the situation in accordance with the Falls Preventions and Management Policy (“Policy A-187”).
Policy A-187 states that when a resident has fallen, the resident will be assessed regarding the nature of the fall and associated consequences, the cause of the fall and the post fall care management needs. The person witnessing the fall, or finding the resident after the fall, is to:
Assess the environment, for clues as to objects which may have struck the Resident during the fall or caused the fall.
Not move the Resident if there is suspicion or evidence of injury until a full head to toe assessment has been conducted and appropriate action determined by Registered Staff (e.g. transfer to hospital).
Notify the Registered Nursing staff.
Complete the Interdisciplinary post-fall assessment if a Resident is having multiple falls or has resulted in injury.
Registered nursing staff have additional accountabilities. Amongst other things, they are expected to: complete the head to toe assessment; move the resident (only if assessed to be safe), ensuring that the proper lifting procedures are performed (2 person lift if the resident is able to weight-bear, otherwise a 2 person lift using a mechanical lift); observe for pain or difficulty weight bearing if no injury is evident; notify the attending physician, Power of Attorney (“POA”)/Substitute Decision-Maker (“SDM”) of the fall, interventions and status of the resident.
If a head injury has occurred, registered nursing staff are further guided by the Facility’s Head Injury Policy (“Policy A-181”). Any sudden impact or blow to the head, with or without loss of consciousness is considered a head injury.
A “Head injury routine” (HIR Appendix A to Policy A-181) will be initiated for any resident who suffers an un-witnessed fall or self-reported fall.
As the first step of the HIR, all registered nursing staff are required to determine the vital signs of the resident: temperature, pulse, respiration and blood pressure. Policy A-181 states, in part, “NOTE: If calling ambulance, do not remove the resident from location except to avoid further hazard.”
All observations and monitoring of the resident are to be recorded in the resident’s progress notes. Accurate sequential documentation is noted to be critical for medical assessment.
The Facility also requires staff to complete a “Risk Management” within the electronic charting system for every resident fall. All injuries are to be indicated on a diagram and the level of pain recorded both at time of the incident and after the incident. The Facility’s instructions for completing the “Risk Management” specifically note the need for timely communication with a resident’s POA when an incident occurs:
**It is imperative that the POA is notified of any and all incidents. The POA is to be notified between the hours of 7am -10pm. If the incident results in significant injury, transfer to hospital or death, the POA is to be notified IMMEDIATELY, it does not matter the time.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
August 12, 2019: Inappropriate Interaction with Colleague M.H.
On August 12, 2019, Marissa Hawkins, RPN, worked the evening shift. She was covering for another colleague, Jordan Schieman, RPN.
The Member was scheduled to work the night shift.
At approximately 22:30, Ms. Hawkins was providing a shift report to the Member. During the report, the Member became upset about a note completed the day before by Mr. Schieman. The note related to bed alarms and stated something to the effect of, “all licensed employees are responsible for the bed alarms they are not to be unplugged.”
The Member reacted strongly to the content of the note and appeared to interpret it as if it was directed to him specifically. He became visibly angry and hostile. The Member made comments like “that fucking idiot” and asked where Mr. Schieman was while saying, “where is that fucking asshole,” or words to similar effect.
Ms. Hawkins asked the Member to calm down. He continued to swear and express frustration at Ms. Hawkins directly and also with respect to Mr. Schieman.
The Member’s behaviour left his co-worker feeling uncomfortable and anxious.
If the Member were to testify, he would acknowledge that he was upset by the note completed by his colleague Mr. Schieman and became more frustrated when he felt that his concerns were then discounted by Ms. Hawkins. The Member would further state that, despite this, he knows that he is responsible for managing his own triggers and reactions; is deeply regretful for his conduct; and understands that his reaction was inappropriate.
In response to this incident, the Facility provided the Member with a written warning letter and required him to review the Workplace Violence and Harassment Prevention Policy Bill 132 and complete a reflection and action plan.
August 15, 2019: Response to Patient [A] Fall
Patient [A] was a resident in one of the long-term care units. She had been diagnosed with dementia along with several other medical conditions and notable behaviours including a history of dizziness, restlessness and agitation.
On the night of August 15, 2019, patient [A] fell in her bathroom while she was alone. The Member heard her cries for help and came to help patient [A] who was on the floor of the bathroom.
The Member called the charge RN, Jennifer Cylwa, to advise her of the fall. He told Ms. Cylwa that there was lots of blood. He explained that it looked like the patient cut her nose, but he was not sure if the blood was also coming from elsewhere. The Member had not checked the patient’s vital signs or addressed the injury in any manner at this point.
Ms. Cylwa came to assess patient [A] and observed that she was on the floor bleeding profusely. The patient had a laceration on her head and there was blood covering the sink and floor. Ms. Cylwa asked the Member if he had completed an assessment of the patient and the Member indicated that he had not. Ms. Cylwa directed the Member to get the necessary equipment and check vitals.
If the Member could not complete the vitals because the equipment was not in the room and did not want to leave the patient alone to retrieve the equipment, he could have asked a PSW to assist with obtaining the necessary equipment.
Ms. Cylwa also asked the Member to start organizing the paperwork that would need to travel with the patient to the hospital. The Member said there was an issue with the printer on the unit and he did not know how to print the documents.
Ms. Cylwa was still trying to determine the source of the blood, as she was wiping the patient’s face, taking vitals and trying to reduce swelling. When she turned around, she found that the Member and PSW had left her alone with the patient.
After being called back, Ms. Cylwa instructed the Member to stay with the patient, and specifically advised the Member not to move her while she went to print the necessary paperwork. The patient had a head injury, and Ms. Cylwa was concerned that there may be a c-spine fracture and the patient would need a collar. Ms. Cylwa left the Member with the patient, assuming he would stay with the patient and not move her, while she gathered everything in order to transfer the patient to Emergency Medical Services (EMS).
When Ms. Cylwa returned to the unit with EMS, she found that the patient had been moved from the bathroom floor to her bed. Another PSW had moved the patient. When Ms. Cylwa asked the PSW why she had moved the patient, she said that she was never told by the Member not to move the patient.
If the Member were to testify, he would state the patient made multiple attempts to get up off the floor. He tried to explain why it was dangerous for her to move, but she kept trying. The Member was concerned about improperly restraining the patient and also did not want her to get up on her own without assistance and cause further injury. He made the judgment call to assist her in moving from the bathroom floor to her bed in the circumstances.
If the patient was uncomfortable on the floor, the Member could have made attempts to comfort the patient by getting a blanket or pillow.
Ms. Cylwa documented in the patient’s progress notes at 05:05 and 05:59.
The Member documented in the patient’s progress notes at 05:59 and 06:21. In the later entry, he stated that he “assessed resident for indication of broken limbs or other injuries, resident legs appeared of equal length and she was moving them on her own. No indication of further injury at this time” and then listed her vital signs.
At the Facility, a number of documents must be completed after a resident falls as described above. In particular, after a fall, nurses are expected to assess the patient, which includes writing up an incident report, a diagram indicating injuries, vital signs, falls assessment, a risk assessment, and documentation in the patient’s progress notes.
The Member started to fill in the Incident Report/ Risk Management documents but did not complete them.
August 15 to 16, 2019: Response to Patient [B] Allergic Reaction
Patient [B]’s medical conditions included dementia. He had been a resident at the Facility since 2016.
On August 15, 2019, patient [B] developed an allergic reaction to a condom catheter which contained latex. The RN attending the patient during the day consulted with a physician and obtained an order for prednisone, PRN Benadryl, and betamethasone cream to be applied immediately. The progress note completed by the RN at 14:55 indicated that evening staff were to second check the order and monitor the area closely and update the POA of the situation and any new orders.
Mr. Schieman, RPN, charted applying the betamethasone cream at 21:03 with positive effect. At 21:04, Mr. Schieman noted that patient [B] continued to have edema to his penis with some reduction in swelling since the beginning of the shift. The chart further reflects the following assessment:
Tylenol and IM Benadryl effective, resident was cheerful and came for dinner which he usually declines. Resting in bed at present, call bell is within reach and he has been instructed to call for assistance if needed. Reiterated this few times and resident nods head yes when told to ring for help. No catheterization was performed as 14fr was too big and ADRC advised to hold off and see if resident voids on his own.
On August 15-16, 2019, the Member worked the night shift. At approximately 0445, the Member called Ms. Cylwa to advise that patient [B] had significant swelling on his penis, was distended and had not voided.
Ms. Cylwa came to the unit to assess the patient. The Member had not completed a set of vitals and had not attempted to insert an in/out catheter or administer Benadryl (which was a PRN) to offset the reaction. Ms. Cylwa grabbed a catheter and supplies and asked the Member to obtain vitals in the meantime.
Ms. Cylwa’s attempts to insert a catheter were unsuccessful. She called the patient’s POA as he needed to be sent to hospital. Ms. Cylwa printed off all necessary documents and called EMS.
After the patient was transferred, Ms. Cylwa asked the Member to call the POA and advise her of the hospital name. Later, around 0640, Ms. Cylwa received a call from the POA asking where the patient was sent. The Member had not called her with this information.
The patient’s progress notes demonstrate that Ms. Cylwa was the person in touch with the POA throughout the incident.
Another RPN also spoke with the patient’s sister on August 16, 2019 as Ms. Cylwa had informed the RPN that the patient’s sister was upset set due to not being informed of her brother’s changing condition. The RPN provided the patient’s sister with a detailed timeline of the events leading up to the patient’s transfer to hospital and apologized for the miscommunication.
The Facility issued a warning letter to the Member and required him to review certain CNO videos, practice standards and complete associated learning modules. In the reflections and learning models submitted by the Member, he admitted that he neglected this patient by failing to complete a proper assessment of his GU tract and skin when he first observed him during shift.
The Member admits that he did not assess patient [B] himself at the start of his shift. If the Member were to testify, he would state that he received a report from the nurse on the evening shift regarding patient [B]’s allergic rection and based on this, the Member understood that the patient was doing fine and had Benadryl cream if needed. When he completed his second set of rounds at 0430, the Member discovered the concerns as described above. He regrets not being more proactive during the shift. He did not attempt to administer Benadryl at 0430 because he felt it was too late and that the patient needed to go to the hospital.
November 2019: Inappropriate comments to Patient [C]
Patient [C]’s medical conditions included dementia. She was noted to have a tendency to fall with restricted mobility. [Patient C] was verbal but appeared to be selective as to when she chose to communicate verbally.
On or about November 6, 2019, Jesslyn Rudowicz, PSW, and the Member were in patient [C]’s room. Ms. Rudowicz was gathering [patient C]’s clothing from her closet when the Member began providing the patient with care. Patient [C] pinched and dug her nails into the Member’s hand (as she did with most staff daily).
Ms. Rudowicz heard the Member respond very aggressively, close to the patient’s face. With a raised voice, he stated “you fucking bitch…do you even know what I could do to you? I could drop you on the floor”. The Member then left the room, leaving the patient with the bed raised and bed rail up.
Ms. Rudowicz began providing care to [patient C]. The Member then re-entered the room, his eyes were teary and he advised that he refused to provide patient [C] with further care.
On November 13, 2019, the Member and Ms. Rudowicz were again providing care to patient [C].
The patient was sitting on the side of the bed about to be hooked up to the sit and stand lift when [patient C] grabbed at the Member. The Member grabbed [patient C]’s hand and assisted it to the handle. He then stated something to the effect of “would love to just head butt her right in the head”. The comment was made in close proximity to the patient’s face.
Ms. Rudowicz was disturbed by her interactions with the Member. When he was brought back to work following his grievance, she resigned.
If the Member were to testify, he would note that the night before the interaction on November 13, 2019, he had watched a violent movie called Jon Wick which had a lot of references to head butting. The Member offers this as an explanation for why the comment “just came out of his mouth” at the time. He wishes to emphasize that he immediately regretted making the comment and is deeply remorseful.
CNO STANDARDS
CNO’s Professional Standards 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 through several indicators, including: by providing, facilitating, advocating and promoting the best possible care for clients; advocating on behalf of clients; seeking assistance appropriately and in a timely manner; taking action in situations in which client safety and well-being are compromised and ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation.
CNO’s Professional Standards provides, in relation to the knowledge application standard, that nurses apply knowledge to practice using nursing frameworks, theories and/or processes. They employ knowledge in the performance of clinical skills because the technical and cognitive aspects of care are closely related and cannot be separated.
The leadership standard requires self-knowledge (understanding one’s beliefs and values and being aware of how one’s behaviour affects others), respect, trust, integrity, shared vision, learning, participation, good communication techniques and the ability to be a change facilitator. The leadership expectation is not limited to nurses in formal leadership positions and all nurses, regardless of their position, have opportunities for leadership. Nurses demonstrate this standard by providing, facilitating and promoting the best possible care/service to the public. Nurses meet the leadership standard by role-modelling professional values, beliefs and attributes.
The Professional Standards also address the standards expected of nurses with respect to professional relationships and specify the need to use a wide range of communication and interpersonal skills to effectively establish and maintain collegial relationships.
The Documentation Standard establishes that nurses are accountable for ensuring their documentation of client care is accurate, timely and complete. A nurse meets the Documentation Standard by: ensuring that 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. Nurses are also expected to document significant communication with family members/significant others, substitute decision-makers and other care providers.
At the core of nursing is the therapeutic nurse-client relationship. As set out in the Therapeutic Nurse-Client Relationship Standard, the nurse establishes and maintains this key relationship by using nursing knowledge and skills, as well as applying caring attitudes and behaviours. The relationship is based on trust, respect, empathy and professional intimacy and requires appropriate use of the power inherent in the care provider’s role.
A misuse of power is considered abuse. Abuse may be verbal, emotional, physical, sexual, financial or take the form of neglect. Nurses protect the client from harm by ensuring that abuse is prevented, or stopped and reported. The nurse meets the standard by not engaging in behaviours toward a client that may be perceived by the client and/or others to be violent, threatening or intending to inflict physical harm; not exhibiting physical, verbal and non-verbal behaviours toward a client that demonstrate disrespect for the client and/or are perceived by the client and/or others as abusive.; and not neglecting a client by failing to meet or withholding their basic needs.
Appendix A to the Therapeutic Nurse-Client Relationship Standard lists examples of abusive behaviours and expressly states that verbal and emotional abuse includes, but is not limited to: sarcasm; intimidation, including threatening gestures/actions; teasing or taunting; swearing; inappropriate tone of voice, such as one expressing impatience.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 1 (a), 1(b), 1(c), and 1(d)(i) and (iii) of the Notice of Hearing, in that he contravened a standard of practice of the profession or failed to meet the standard of practice of the profession as described in paragraphs 9 to 71 above.
The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 2 (a) and 2(c) of the Notice of Hearing, in that he abused Patient [C] verbally and/or emotionally, as described in paragraphs 54 to 61; and 69 to 71 above.
The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 3 of the Notice of Hearing, in that he failed to keep records as required when he failed to complete the necessary documentation after Patient [A] fell, as described in paragraphs 28 to 42; and 62 to 68 above.
The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 4(a), 4(b), 4(c) and 4(d)(i) and (iii) of the Notice of Hearing, in that his conduct would reasonably be regarded by members of the profession as disgraceful, dishonourable and unprofessional, as described in paragraphs 9 to 71 above.
Submissions of College Counsel
College Counsel asked the Panel to make findings with respect to the allegations admitted by the Member and supported in the Agreed Statement of Facts. College Counsel confirmed that evidence had not been led on the allegations to which the Member had not made admissions.
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.
The evidence before the Panel in this case is contained within the Agreed Statement of Facts.
Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs #1(a) insofar as it relates to the use of inappropriate language, #1(b)(i), (ii), #1(c)(i), (ii), (iii), #1(d)(i), (iii), #2(a), #2(c), #3, #4(a) insofar as it relates to the use of inappropriate language, #4(b)(i), (ii), #4(c)(i), (ii), (iii), #4(d)(i) and (iii) of the Notice of Hearing. With respect to allegations #2(a) and #2(c), the Panel finds that the Member verbally and emotionally abused a patient. As to allegations #4(a) insofar as it relates to the use of inappropriate language, #4(b)(i), (ii), #4(c)(i), (ii), (iii), #4(d)(i) and (iii), the Panel finds the Member engaged in conduct that would reasonably be regarded by members of the profession to be unprofessional, dishonourable and disgraceful.
The Member did not admit to allegation #1(a) as it pertained to shaking the computer screen at the nursing station, #1(d)(ii), #2(b), #4(a) as it pertained to the shaking of the computer screen at the nursing station, or #4(d)(ii). The Agreed Statement of Facts did not contain any evidence in support of these allegations. Accordingly, they are dismissed.
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.
Allegations #1(a) insofar as it relates to the use of inappropriate language, #1(b)(i), (ii), #1(c)(i), (ii), (iii), #1(d)(i) and (iii) in the Notice of Hearing are supported by paragraphs 9 to 72 in the Agreed Statement of Facts. The Member admitted that while employed as a Registered Practical Nurse (“RPN”) at Fiddicks Nursing Home Ltd. (the “Facility”), he used inappropriate language when receiving a shift report from Colleague M.H. on August 12, 2019, which made her feel uncomfortable and anxious. On August 15, 2019, when Patient [A] fell, the Member failed to adequately assess her, respond to her injuries, complete the necessary documentation and helped a Personal Support Worker ("PSW") move Patient [A] from the floor to her bed after being told by the charge nurse not to move her. On August 15-16, 2019, when Patient [B] had an allergic reaction to a condom catheter, the Member failed to complete a set of vitals and did not attempt to insert an in/out catheter or administer PRN Benadryl to offset the allergic reaction. In November 2019, the Member made inappropriate comments to Patient [C] and refused to provide further care to her when she pinched and dug her nails into his hand and again made inappropriate comments to her when she grabbed at him on two other occasions. The member contravened the Professional Standard which has the expectation of nurses with respect to professional relationships and specifies the need to use a wide range of communication and interpersonal skills to effectively establish and maintain collegial relationships. The Member contravened the Documentation Standard, which establishes that nurses are accountable for ensuring their documentation of client care is accurate, timely and complete. The Member contravened the Therapeutic Nurse-Client Relationship Standard which lists examples of abusive behaviours and expressly states that verbal and emotional abuse includes, but is not limited to: sarcasm; intimidation, including threatening gestures/actions; teasing or taunting; swearing; inappropriate tone of voice, such as one expressing impatience.
Allegations #2(a) and #2(c) in the Notice of Hearing are supported by paragraphs 54 to 61, 69 to 71 and 73 in the Agreed Statement of Facts. The Member admitted that he abused Patient [C] verbally and emotionally when he made inappropriate comments to Patient [C] after she pinched and dug her nails into his hand. The PSW who was in the room with the Member and Patient [C] heard the Member respond very aggressively, close to Patient [C]'s face, with a raised voice, he stated "you fucking bitch ... do you even know what I could do to you? I could drop you on the floor". The Member then left the room, leaving Patient [C] with the bed raised and bed rail up.
Allegation #3 in the Notice of Hearing is supported by paragraphs 28 to 42, 62 to 68 and 74 in the Agreed Statement of Facts. The Member admitted that he failed to keep records as required when he failed to complete the necessary documentation after Patient [A] fell. The Facility requires a number of documents be completed when a patient falls. Nurses are expected to assess the patient, which includes writing up an incident report, a diagram indicating injuries, vital signs, falls assessment, a risk assessment and documentation in the patient’s progress notes. The Member started to fill in the Incident Report/Risk Management documents with respect to Patient [A]’s fall but did not complete them.
Allegations #4(a) insofar as it relates to the use of inappropriate language, #4(b)(i), (ii), #4(c)(i), (ii), (iii), #4(d)(i) and (iii) in the Notice of Hearing are supported by paragraphs 9 to 71 and 75 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct was clearly relevant to the practice of nursing and was unprofessional as it demonstrated a serious and persistent disregard for his professional obligations in breaching the College’s Professional Standards, the Documentation Standard, and the Therapeutic Nurse-Client Relationship Standard.
The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing and was a marked departure from the standards expected of a nurse. The Member knew or ought to have known that his conduct was unacceptable and fell well below the standards of a professional. The Member’s conduct demonstrated moral failing in that he abused Patient [C] verbally and/or emotionally.
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 his moral fitness and inherent ability to discharge the higher obligations the public expects professionals to meet.
Penalty
College 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 three months of the date that this Order becomes final.
Penalty Submissions
Submissions were made by College Counsel.
College Counsel submitted that the Joint Submission on Order also provides in Appendix “A” an undertaking and agreement by the Member for the Member’s permanent resignation as a member of the College effective March 16, 2023 (the “Undertaking”). Pursuant to this Undertaking, the Member undertakes, acknowledges and agrees to:
a) Permanently resign as a member of the College, effective from the date that the order made by the Discipline Committee in accordance with the Joint Submission on Order becomes final;
b) Not apply for membership with the College as a Registered Nurse or Registered Practical Nurse at any time in the future;
c) Agree that the public portion of the College’s Register will indefinitely reflect that the Member entered into an Undertaking with the Executive Director to permanently resign as a member of the College as part of an agreed resolution of allegations of professional misconduct;
d) No longer have a right to the issuance or reinstatement of a Certificate of Registration from the College;
e) No longer have a right to use the title “Nurse”, “Registered Nurse”, “Registered Practical Nurse”, “RN”, “RPN” or a variation, an abbreviation or an equivalent in another language;
f) No longer have a right to hold himself out as a Nurse, Registered Nurse, Registered Practical Nurse or as a person who is qualified to practise in Ontario as a Nurse, Registered Nurse or Registered Practical Nurse;
g) No longer have a right to engage in the practice of nursing in any capacity; and
h) Agree the College is authorized to and may, in its sole discretion, provide a copy of the Undertaking and/or its terms to a governing body that regulates nursing in Canada or elsewhere in response to an inquiry or otherwise.
The aggravating factors in this case were:
The seriousness of the Member’s conduct in not performing adequate assessments of Patient [A] and Patient [B] who were vulnerable patients could have led to more serious consequences;
The Member made inappropriate comments to Patient [C] which were disrespectful and did not promote Patient [C]’s dignity; and
The Member used inappropriate language with Colleague M.H. which left her feeling uncomfortable and anxious.
The mitigating factors in this case were:
The Member has no prior discipline history with the College;
The Member accepted full responsibility for his conduct by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College;
The Member regrets not being more proactive, acknowledged that he is responsible for managing his own triggers and reactions, is deeply regretful for his conduct, understands that his reaction was inappropriate and is deeply remorseful; and
The Member has permanently resigned from the College and will no longer be entitled to the College and will no longer have a right to the issuance or reinstatement of a Certificate of Registration from the College.
Specific deterrence is not essential in this case because the Member has already undertaken to permanently resign from the practice of nursing. In such circumstances, the penalty of an oral reprimand is sufficient.
General deterrence is achieved through the oral reprimand and the fact that the findings will be publicly posted indefinitely and sends a clear message to other members of the profession that there are serious consequences for this type of conduct.
Overall, the public is protected by the resignation of the Member’s certificate of registration and the ability of the College to communicate this to any governing body that regulates nursing in Canada. Accordingly, the Panel does not need to impose further conditions in order to achieve protection of the public.
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. Walker (Discipline Committee, 2019): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member committed acts of professional misconduct when she failed to implement the facility's bowel protocol. The penalty included an oral reprimand, and the member signed an undertaking to permanently resign as a member of the College.
CNO v. Doane (Discipline Committee, 2020): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member committed acts of professional misconduct and was found to have physically and emotionally abused a patient. The penalty included an oral reprimand, and the member signed an undertaking to permanently resign as a member of the College.
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 three months of the date that this Order becomes final.
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. In the normal course, 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.
In this case, because the Member has undertaken to permanently resign, the oral reprimand is a sufficient penalty and no other specific deterrence is required.
Furthermore, because of the Member’s resignation, it is not necessary to consider remediation and rehabilitation in determining the appropriate penalty.
General deterrence is also addressed as the Panel concluded had the Member’s situation been different and no Undertaking given, the Panel would have ordered a suspension, and terms, conditions and limitations on the Member’s certificate of registration which would have been in line with previous penalties.
Finally, the penalty of reprimand is appropriate because the public is already protected through the permanent resignation and the Undertaking to never apply for registration as a nurse in Ontario or in any other jurisdiction again in the future.
The penalty is also in line with what has been ordered in previous cases in similar circumstances.
I, Michael Hogard, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel.