College of Nurses of Ontario v. Camp, 2023 CanLII 69929

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Karen Laforet, RN Chairperson Tyler Hands, RN Member Carly Hourigan Public Member Mary MacNeil, RN Member Lalitha Poonasamy Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO GLYNNIS HAWE for College of Nurses of Ontario

• and -

ELIZABETH IRENE CAMP Registration No. HC06391 NO REPRESENTATION for Elizabeth Irene Camp

KIMBERLEY ISHMAEL Independent Legal Counsel

Heard: February 28, 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 February 28, 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 names of the patient(s), or any information that could disclose the identity(ies) of the patient(s), referred to orally or in any documents presented at the Discipline hearing of Elizabeth Irene Camp.

The Panel considered the submissions of the College and decided that there be an order preventing public disclosure and banning the publication or broadcasting of the names of the patient(s), or any information that could disclose the identity(ies) of the patient(s), referred to orally or in any documents presented at the Discipline hearing of Elizabeth Irene Camp.

The Allegations

The allegations against Elizabeth Irene Camp (the “Member”) as stated in the amended Notice of Hearing dated December 14, 2022 are as follows:

IT IS ALLEGED THAT:

1. You have committed an act of professional misconduct as provided by subsection 51(1)(a) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, in that you were found guilty of an offence relevant to your suitability to practise, as follows:

a) on January 30, 2020, you were found guilty of failing to obey Community Health Protection Order No. 563, dated October 30, 2019, contrary to s. 100(1) of the Health Protection and Promotion Act, R.S.O. 1990, c. H.7; and/or

b) on January 30, 2020, you were found guilty of failing to obey Community Health Protection Order No. 564, dated November 25, 2019, contrary to s. 100(1) of the Health Protection and Promotion Act, R.S.O. 1990, c. H.7;

2. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that while working as a Registered Practical Nurse for Community Care for South Hastings, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession in that:

a) in or around October 2019, including but not limited to October 24, 2019, you provided foot care without adequate infection prevention and control measures, including but not limited to:

i. access to point-of-care handwashing station(s) and/or alternative hand hygiene measures;

ii. the use of personal protective equipment;

iii. adequate sterilization of reusable foot care equipment and/or the foot care environment; and/or

iv. written infection prevention and control policies and procedures;

b) on November 18, 2019, you provided foot care to [the Patient], in contravention of Community Health Protection Order No. 563, issued by Hastings Prince Edward Public Health on October 30, 2019; and/or

c) you contravened Community Health Protection Order No. 564, issued by Hastings Prince Edward Public Health on November 25, 2019, when you failed to provide all past and present patient names, telephone numbers, home addresses, and/or appointment dates and times to Hastings Prince Edward Public Health by December 6, 2019;

3. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that while working as a Registered Practical Nurse, 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 in that:

a) in or around October 2019, including but not limited to October 24, 2019, you provided foot care without adequate infection prevention and control measures, including but not limited to:

i. access to point-of-care handwashing station(s) and/or alternative hand hygiene measures;

ii. the use of personal protective equipment;

iii. adequate sterilization of reusable foot care equipment and/or the foot care environment; and/or

iv. written infection prevention and control policies and procedures;

b) on November 18, 2019, you provided foot care to [the Patient], in contravention of Community Health Protection Order No. 563, issued by Hastings Prince Edward Public Health on October 30, 2019; and/or

c) you contravened Community Health Protection Order No. 564, issued by Hastings Prince Edward Public Health on November 25, 2019, when you failed to provide all past and present patient names, telephone numbers, home addresses, and/or appointment dates and times to Hastings Prince Edward Public Health by December 6, 2019.

Member’s Plea

The Member admitted the allegations set out in paragraphs #1(a), 1(b), #2(a)(i), 2(a)(ii), 2(a)(iii), 2(a)(iv), 2(b), 2(c), #3(a)(i), 3(a)(ii), 3(a)(iii), 3(a)(iv), 3(b) and 3(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 advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited, as follows:

THE MEMBER

1. Elizabeth Irene Camp (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on January 1, 1983.

2. The Member worked as a contract nurse for Community Care for South Hastings in Deseronto, Ontario (“CCSH”).

3. The Member provided foot care nursing services at the CCSH Foot Care Clinic held regularly at the Deseronto Community Recreation Centre, or in home. The services included foot maintenance, and basic and advanced foot care in a clinical setting to seniors, the chronically ill, and other vulnerable populations. On November 20, 2019, CCSH terminated its contract relationship with the Member as a result of the incidents described below.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

October 24, 2019 Incident

4. On October 24, 2019, the Member was working in the CCSH Foot Care Clinic. During her shift, she was observed by an environmental inspector for Hastings Prince Edward Public Health (“Public Health”) providing foot care to a patient in a conference room of the Deseronto Community Recreation Centre. The conference room did not have a sink or handwashing station and was more than 100 metres away from the closest washroom.

5. The inspector notified Public Health regarding the lack of point-of-care handwashing access, which initiated an investigation to assess public health risk to the Member’s patients.

6. On October 29, 2019, the Member was interviewed by a Public Health inspector, who questioned the Member about her instrument cleaning and sterilization practices. The Member informed the inspector that she conducted her own instrument reprocessing by cleaning her foot care instruments with soap and water and then soaking them in liquid disinfectant. The Member did not sterilize her instruments.

7. Public Health Ontario defines foot care equipment as “critical” equipment. The minimum standard for reprocessing of foot care equipment between patients requires that they be first cleaned and then sterilized, typically by autoclave.

8. Infection Prevention and Control Canada and Public Health Ontario standards also require the following in clinical foot care settings:

a. Access to dedicated handwashing stations and use of alcohol-based hand rub (hand sanitizer);

b. The availability and use of personal protective equipment including, gloves, gowns, masks, visors, goggles, as appropriate, as well as a current, fit-tested N95 respirator during electronic filing; and

c. Written infection prevention and control policies and procedures.

October 30, 2019 Community Health Protection Order

9. As a result of the Member’s failure to sterilize her foot care instruments, the inspector issued an order against the Member, pursuant to s. 13 of the Health Protection and Promotion Act, R.S.O. 1990, c H.7 (the “First Order”). The First Order noted that items/instruments were not meeting the minimum level of reprocessing by way of cleaning followed by sterilization and ordered the Member to cease all foot care operations until a public health inspector verified that the operation may be resumed. The First Order advised the Member that a failure to comply was itself an offence.

10. On November 5, 2019, the Member attended a meeting with Public Health at which she received education on sterilization requirements, the risks of not sterilizing, and options for use of reprocessed or single-use equipment to mitigate health risks for her patients. During this meeting, Public Health had a number of concerns with the Member’s description of her practice, including:

a. A lack of written policies and procedures for infection prevention and control, environmental cleaning, hand hygiene, and equipment reprocessing;

b. The Member was cleaning her foot care instruments at her home and had failed to sterilize her instruments;

c. The Member was laundering towels used by patients at her home and/or requiring patients to bring their own;

d. The Member was providing foot care to patients on porous, carpeted surfaces that were not cleaned;

e. No handwashing sink was immediately available, and the hand sanitizer available was out-of-date and rarely used by the Member; and

f. Other than gloves, the Member rarely used available personal protective equipment such as gowns, masks and goggles while providing foot care services;

g. The Member did not use a fit-tested N95 respirator when conducting electronic foot filing with a Dremel.

11. On November 12, 2019, Public Health wrote to the Member about these additional concerns and outlined the corrective action she was required to take.

November 18, 2019 Incident

12. On November 18, 2019, in contravention of the First Order, the Member provided foot care to [the Patient] in his home.

13. If [the Patient] were to testify, he would state that he had no knowledge of the First Order when the Member provided foot care to him. Following his appointment with the Member, [the Patient] expressed concerns to Public Health regarding the sanitation of the Member’s equipment used during the treatment, including that the Member’s clean foot care instruments were wrapped in an “off colour” face cloth, not sterilized packaging.

November 25, 2019 Community Health Protection Order

14. On November 25, 2019, Public Health Ontario issued a second order pursuant to s. 13 of the Health Protection and Promotion Act R.S.O. 1990, c H.7 (the “Second Order”). The Second Order required the Member to provide all past and present patient names, including telephone numbers, home addresses, appointment dates and times, by December 6, 2019. The Second Order also indicated that non-compliance was an offence for which the Member may be liable, on conviction, for a fine.

15. The Member refused to comply with the Second Order.

Findings of Guilt

16. On December 16, 2019, the Member was summonsed under the Provincial Offences Act, R.S.O. 1990, c P.33 for her failure to comply with the First and Second Orders.

17. On January 30, 2020, the Member pleaded guilty to failing to obey Community Health Protection Order Number 563 (the First Order) made under Section 13, dated October 30, 2019, and failing to obey Community Health Protection Order number 564 (the Second Order) made under Section 13, dated November 25, 2019, contrary to the Health Protection and Promotion Act, R.S.O. 1990, s. 100(1).

18. The Member was sentenced to six months’ probation and payment of a $750 fine.

CNO STANDARDS

Code of Conduct

19. CNO’s Code of Conduct is a standard of practice describing the accountabilities all Ontario nurses have to the public. The Code of Conduct consists of six principles, one of which is that nurses maintain patients’ trust by providing safe and competent care. Specifically, CNO’s Code of Conduct provides that:

• Nurses maintain and continually improve their competence. They reflect on their practice and set learning goals annually by participating in CNO’s Quality Assurance Program; and

• Nurses are accountable to, and practice under, relevant laws and CNO’s standards of practice.

20. With respect to the principle requiring nurses to maintain public confidence in the nursing profession, CNO’s Code of Conduct provides that nurses are accountable for their own actions and decisions.

Professional Standards

21. 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.

22. 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 actions such as:

• Ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation; and

• Maintaining competence and refraining from performing activities that they are not competent in.

23. CNO’s Professional Standards further provides, in relation to the continuing competence standard, that competence is the nurse’s ability to their knowledge, skill, judgment, attitudes, values and beliefs to perform in a given role, situation and practice setting. Nurses demonstrate this standard by:

• Assuming responsibility for their own professional development and for sharing knowledge with others;

• Investing time and effort and other resources to improve their knowledge, skills, and judgment; and

• Engaging in a learning process to enhance their practice.

24. In addition, CNO’s Professional Standards provides, in relation to the knowledge standard, that all nurses add to their basic education and foundational knowledge by pursing ongoing learning throughout their careers. Nurses demonstrate this standard by:

• Understanding the legislation and standards relevant to nursing and the practice area; and

• Knowing where/how to access learning resources, when necessary.

Ethics

25. CNO’s Ethics Standard describes ethical values that are important to the nursing profession in Ontario including patient well-being, patient choice, privacy and confidentiality, respect for life, maintaining commitments, truthfulness and fairness.

26. CNO’s Ethics Standard provides, in relation to maintaining commitments, that nurses have a commitment to the nursing profession and being a member of the profession brings with it the respect and trust of the public. To continue to deserve this respect, nurses have a duty to uphold the standards of the profession, conduct themselves in a manner that reflects well on the profession, and to participate in and promote the growth of the profession.

27. The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards and Ethics Standard when she provided foot care without adequate infection prevention and control measures, provided footcare to [the Patient] in contravention of the First Order, and failed to provide all past and present patient names, telephone numbers, home addresses, and appointment dates and times to Public Health in contravention of the Second Order.

28. If the Member were to testify, she would state that she deeply regrets her actions. The Member would further testify that she regrets and acknowledges that she did not know of the prevailing standards for foot care at the time of these incidents and acknowledges that it is her responsibility as a nurse to continually educate herself on the standards of the profession and legislative requirements. The Member would also testify that she regrets not complying with the Public Health orders and state that in November 2019, she was experiencing a great deal of personal stress because of her husband’s health crisis.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

29. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a) and 1(b) of the Notice of Hearing, in that she was found guilty of an offence relevant to her suitability to practise, and in particular, she was found guilty of failing to obey Community Health Protection Orders No. 563, dated October 30, 2019, and Community Health Protection Order No. 564, dated November 25, 2019, contrary to s. 100(1) of the Health Protection and Promotion Act, R.S.O. 1990, c. H.7, as described in paragraphs 4 to 18 above.

30. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2(a)(i), 2(a)(ii), 2(a)(iii), 2(a)(iv), 2(b) and 2(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 4 to 28 above.

31. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3(a)(i), 3(a)(ii), 3(a)(iii), 3(a)(iv), 3(b), and 3(c) of the Notice of Hearing, and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 4 to 28 above.

Submissions on liability were made by College Counsel.

College Counsel asked the Panel to accept the Agreed Statement of Facts, as well as the Member’s admissions to all the allegations and, on the basis of those facts and admissions, to make findings of professional misconduct with respect to the allegations in the Notice of Hearing. The Member admitted to the allegations in paragraphs 29, 30 and 31 of the Agreed Statement of Facts with a plea that was voluntary and informed. The Member admitted to allegations #1(a), 1(b), #2(a)(i), 2(a)(ii), 2(a)(iii), 2(a)(iv), 2(b) and 2(c), in paragraph 29 and 30 respectively in the Agreed Statement of Facts and the College standards are provided to help the Panel make findings. To make a finding for allegations #3(a)(i), 3(a)(ii), 3(a)(iii), 3(a)(iv), 3(b) and 3(c), the Panel needs to be satisfied that the Member’s conduct was relevant to the practice of nursing. College Counsel submitted that the allegations are related to direct patient care as the Member was employed as a nurse at the time of the allegations. In the Agreed Statement of Facts, the Member also admitted that her conduct was unprofessional and dishonourable. The Member’s conduct was unprofessional as she breached standards of the profession that she was obligated to follow. The Member's conduct was dishonourable as she showed an element of moral failing by exposing [the Patient] to a risk of harm. The Member was also given orders from Public Health to stop providing care which she disregarded.

Submissions on liability were made by the Member.

The Member submitted that she deeply regretted the incidents from 2019 and is deeply upset by the allegations of professional misconduct. The Member submitted that she was extremely regretful of her dishonourable and unprofessional behaviour. The Member submitted that she had a great deal of respect for the College over the last 40 years since graduating as a Registered Practical Nurse (“RPN”). The Member submitted that 2019 was a difficult time in her life. Since 2016, she was the main caregiver for her spouse who had dementia. She worked at a nursing home in the county for 26 years and worked on the floor where most of the residents had dementia. When she realized her husband had dementia, she was gravely upset as dementia was now in her house. On November 10, 2019, two weeks after the first findings from the local Public Health inspection, the Member’s husband had a major heart attack. He was in the hospital for five days and then came home. Following the hospitalization, he did well but had other issues. The Member submitted that at that time, her stress level skyrocketed, and she developed high blood pressure. The Member submitted that she was not offering an excuse for her behaviour but wanted the Panel to know the stress she was under in her personal life. In March 2021, the Member’s spouse died from chronic obstructive pulmonary disease. The Member was dealing with her grief, sold her home and had to sell her pot belly pigs. It was one loss after another. In March 2021, the Member found someone to autoclave her instruments and was then given approval from Community Care for South Hastings (“CCSH”) to resume her practice. The Member submitted that after her suspension, should she return to practice, the errors in practice from 2019 would not happen again. The Member submitted that she was deeply sorry for what occurred.

Decision

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

Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs #1(a), 1(b), #2(a)(i), 2(a)(ii), 2(a)(iii), 2(a)(iv), 2(b), 2(c), #3(a)(i), 3(a)(ii), 3(a)(iii), 3(a)(iv), 3(b) and 3(c) of the Notice of Hearing. As to allegations #3(a)(i), 3(a)(ii), 3(a)(iii), 3(a)(iv), 3(b) and 3(c), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonourable and unprofessional.

Reasons for Decision

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

Allegations #1(a) and 1(b) in the Notice of Hearing are supported by paragraphs 4-18 and 29 in the Agreed Statement of Facts. On October 30, 2019, the Member was issued a Community Health Protection Order (the “First Order”). The First Order noted that items/instruments were not meeting the minimum level of reprocessing required and ordered the Member to cease all foot care operations. The Member ignored this First Order and on November 18, 2019, in contravention of the First Order, provided foot care to [the Patient] in his home. On November 25, 2019 a second Community Health Protection Order (the “Second Order”) was issued requiring the Member to provide all past and present patient names, telephone numbers, home addresses, appointment dates and times to Hastings Prince Edward Public Health by December 6, 2019. The Member did not comply. On January 30, 2020, the Member pled guilty to failing to obey both Community Health Protection Orders and as such, committed acts of professional misconduct by being found guilty of offences which were clearly relevant to her suitability to practice.

Allegations #2(a)(i), 2(a)(ii), 2(a)(iii), 2(a)(iv), 2(b) and 2(c) in the Notice of Hearing are supported by paragraphs 4-28 and 30 in the Agreed Statement of Facts. In failing to comply with the Community Health Protection Orders, the Member breached her professional standards by failing to provide safe and competent care. She was accountable to be knowledgeable and incorporate into her practice, appropriate instrument reprocessing procedures as well as proper infection prevention and control procedures. The Member failed to do this. The Member also breached the trust of [the Patient] who relied on the Member to meet professional nursing standards, including public health requirements for instrument cleaning, sterilization and proper infection prevention and control practices. The Member’s responsibility to maintain these standards and public health requirements as they relate to her practice are covered in the College’s Code of Conduct, the Professional Standards and the Ethics Standard. The Member’s failure to meet these standards constituted acts of professional misconduct.

Allegations #3(a)(i), 3(a)(ii), 3(a)(iii), 3(a)(iv), 3(b) and 3(c) in the Notice of Hearing are supported by paragraphs 4-28 and 31 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct was clearly relevant to the practice of nursing as it involved the application of her professional nursing knowledge and nursing standards while employed to provide nursing care to patients. It was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations as set out in the College’s Code of Conduct, the Professional Standards and the Ethics Standard. The Member failed to stay current on foot care requirements to ensure the ongoing safety of her patient population.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing, particularly by failing to comply with two Community Health Protection Orders. Additionally, in providing care to [the Patient] on November 18, 2019, the Member knew or ought to have known that her practice fell below the standards of a professional as well as failed to meet the Public Health requirements. By ignoring the Community Health Protection Orders and providing care to [the Patient], she carelessly put [the Patient] at risk.

Penalty

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

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

2. Directing the Executive Director to suspend the Member’s certificate of registration for 4 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.

3. Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend 2 meetings with a Regulatory Expert (the “Expert”), at the Member’s own expense and within 6 months from the date that this Order becomes final. To comply, the Member is required to ensure that:

i. The Expert has expertise in nursing regulation and has been approved by CNO in advance of the meetings;

ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. if available, a copy of the Panel’s Decision and Reasons;

iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules and decision tools (where applicable):

1. Code of Conduct, and

2. Professional Standards;

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

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

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

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

3. strategies for preventing the misconduct from recurring,

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

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

vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards their report to CNO, in which the Expert will confirm:

1. the dates the Member attended the sessions,

2. that the Expert received the required documents from the Member,

3. that the Expert reviewed the required documents and subjects with the Member, and

4. the Expert’s assessment of the Member’s insight into the Member’s behaviour;

vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on the Member’s certificate of registration;

b) Within 12 months from the date that this Order becomes final, or a longer time period as approved by CNO, the Member shall successfully complete at the Member’s own expense a course that has received prior approval from CNO regarding: Infection Prevention and Control. The Member must achieve a minimum passing grade of 65%, or otherwise complete the course as agreed in advance to the satisfaction of CNO. The Member must provide CNO with proof of enrolment, successful completion of the course and the specific grade received (if applicable).

c) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify the Member’s employers of the decision. To comply, the Member is required to:

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

ii. Ensure that CNO is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;

iii. Provide the Member’s employer(s) with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. a copy of the Panel’s Decision and Reasons, once available;

iv. Only practice nursing for an employer who agrees to, and does, forward a report to CNO within 14 days of the commencement or resumption of the Member’s employment in any nursing position, confirming:

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

2. that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession, and

3. that they agree to perform 4 random spot audits of the Member’s practice at the following intervals and provide a report to CNO regarding the Member’s practice after each audit:

a. the first audit shall take place within 3 months from the date the Member begins or resumes employment with the employer,

b. the second audit shall take place within 6 months from the date the Member begins or resumes employment with the employer,

c. the third audit shall take place within 9 months from the date the Member begins or resumes employment with the employer, and

d. the fourth audit shall take place within 12 months from the date the Member begins or resumes employment with the employer;

v. The audits shall, on each occasion, involve the following:

1. reviewing a random selection of the Member’s charts to ensure they meet both CNO and employer standards, and

2. discussing (by telephone or in person), with at least 3 of the Member’s patients, the care provided by the Member to ensure that the Member’s practice is consistent with both CNO and employer standards;

d) The Member shall not practice independently in the community for a period of 12 months from the date the Member returns to the practice of nursing.

4. All documents delivered by the Member to CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.

Penalty Submissions

Submissions were made by College Counsel.

The aggravating factors in this case were:

• The Member’s conduct exposed [the Patient] to a risk of harm;

• The patients in the Member’s care were medically vulnerable as they required foot care and an infection could have serious repercussions for their health;

• The Member intentionally disregarded and disobeyed Community Health Protection Orders from Public Health which were intended to protect patients; and

• The Member’s conduct displayed a level of ungovernability.

The mitigating factors in this case were:

• The Member worked for 40 years as an RPN and did not have a disciplinary history with the College;

• The Member accepted responsibility and cooperated by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College; and

• In many conversations with the College, the Member expressed very sincere regret and that her misconduct would not be repeated in the future.

The proposed penalty provides for general deterrence through the 4-month suspension of the Member’s certificate of registration, which sends a strong message to members of the profession that this type of conduct will not be tolerated.

The proposed penalty provides for specific deterrence through the oral reprimand and the 4-month suspension of the Member’s certificate of registration, which signals to the Member the disapproval of her conduct and that the profession takes this type of misconduct seriously.

The proposed penalty provides for remediation and rehabilitation through the 2 meetings with a Regulatory Expert and review of the College’s publications, which will give the Member an opportunity to learn and understand what led to her misconduct. The Member will also have to successfully complete a College approved Infection Prevention and Control course, which will allow her the opportunity to bring her practice up to standard thereby protecting the public in the future.

Overall, the public is protected through the 12 months of employer notification, the 4 random spot audits of the Member’s practice and the restriction on independent practice in the community for 12 months, which will ensure there is oversight of the Member on her return to practice.

College Counsel submitted the following case to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee:

College of Chiropodists of Ontario v. Im (2015): College Counsel submitted that chiropodists are specialty foot doctors who are regulated professionals under the Regulated Health Professions Act with similar statutory requirements as nurses. This case involved very similar misconduct and a similar approach to address the misconduct compared to the case before this Panel. In this case, the member provided chiropody care in their home and elsewhere. An investigation by the College of Chiropodists found that the member failed to use sterile exam gloves or masks and had multiple failures related to cleaning, sterilizing, storing, documenting and labelling equipment and instruments. This case did not include a failure to obey a Public Health order but nonetheless, the member was found to have committed professional misconduct that was unprofessional, disgraceful and dishonourable. The member admitted to the allegations. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration with conditions for a remittance of suspension, the member was required to receive mentorship at least 3 times during the first two months of his suspension and to submit a report to the College of Chiropodists of Ontario about changes made to his practice relating to infection control, safety and the practice environment. The member was also required to have his practice supervised for 2 years including supervised practice visits every 4 months for a total of 6 supervisory sessions and to pay costs in the amount of $5,000.00. The penalty imposed was similar to the terms, conditions and limitations being sought in the case before this Panel although costs are not being sought.

College Counsel submitted that there are no previous Discipline Committee decisions from this College with facts similar to this case, but submitted the following cases where members disregarded orders from the College:

CNO v. Prevost (Discipline Committee, 2020): In this case, the member failed to comply with the terms of a Resolution Agreement that was adopted by the Inquiries, Complaints and Reports Committee (“ICRC”). The terms of the Resolution Agreement stated that the member agreed to review one of the College standards, meet with the Manager of Complaints, Professional Conduct to engage in a practice reflection and also complete a Complaint Reflection Worksheet. The member entered into the Resolution Agreement, but then failed to comply with it. The member did not schedule meetings as required and failed to respond to many emails. The College proceeded on allegations of professional misconduct. The member did not attend the hearing. The panel accepted the allegations of professional misconduct and found the member’s conduct to be unprofessional. The aggravating factors were similar to the case before this Panel. The member was intentional in ignoring the Resolution Agreement and decided to not participate in the hearing. She showed a disregard for the regulatory processes. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration and a minimum of 2 meetings with a Regulatory Expert. College Counsel submitted that this case is comparable to the case before this Panel. The aggravating circumstances demonstrate similar concerns and the need for protection of the public through regulatory functions.

CNO v. Cecilioni (Discipline Committee, 2013): In this case, this was the second time the member was before the Discipline Committee. In 2008, the member was found guilty of acts of professional misconduct where she participated in an undertaking, agreeing to only practice nursing within the controlled acts authorized to nursing and only perform a procedure within these controlled acts if permitted by regulation or if the procedure was ordered by a member of a specific profession. The member failed to comply with the undertaking and was before the Discipline Committee again in 2013 in which the panel found the member committed professional misconduct, which was disgraceful, dishonourable and unprofessional. Aggravating factors included that the member had a previous discipline history with the College. Her misconduct was also serious and posed a risk to patients. The mitigating factors were similar to the case before this Panel in that, the member had a 40-year career and had no prior discipline history with the College until the end of her career. Despite her pattern of ungovernability, the member cooperated with the College. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration, 2 meetings with a Nursing Expert, review of the College’s publications, 12 months of employer notification and restriction on independent practice in the community for 12 months.

College Counsel submitted that the Joint Submission on Order is reasonable and serves the goals and objectives of penalty, protects the public, is relevant to the circumstances and falls within the range of penalties for this type of misconduct.

The Member agreed with the submissions made by the College.

Penalty Decision

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

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

2. The Executive Director is directed to suspend the Member’s certificate of registration for 4 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.

3. The Executive Director is directed to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend 2 meetings with a Regulatory Expert (the “Expert”), at the Member’s own expense and within 6 months from the date that this Order becomes final. To comply, the Member is required to ensure that:

i. The Expert has expertise in nursing regulation and has been approved by CNO in advance of the meetings;

ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. if available, a copy of the Panel’s Decision and Reasons;

iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules and decision tools (where applicable):

1. Code of Conduct, and

2. Professional Standards;

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

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

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

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

3. strategies for preventing the misconduct from recurring,

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

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

vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards their report to CNO, in which the Expert will confirm:

1. the dates the Member attended the sessions,

2. that the Expert received the required documents from the Member,

3. that the Expert reviewed the required documents and subjects with the Member, and

4. the Expert’s assessment of the Member’s insight into the Member’s behaviour;

vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on the Member’s certificate of registration;

b) Within 12 months from the date that this Order becomes final, or a longer time period as approved by CNO, the Member shall successfully complete at the Member’s own expense a course that has received prior approval from CNO regarding: Infection Prevention and Control. The Member must achieve a minimum passing grade of 65%, or otherwise complete the course as agreed in advance to the satisfaction of CNO. The Member must provide CNO with proof of enrolment, successful completion of the course and the specific grade received (if applicable).

c) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify the Member’s employers of the decision. To comply, the Member is required to:

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

ii. Ensure that CNO is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;

iii. Provide the Member’s employer(s) with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. a copy of the Panel’s Decision and Reasons, once available;

iv. Only practice nursing for an employer who agrees to, and does, forward a report to CNO within 14 days of the commencement or resumption of the Member’s employment in any nursing position, confirming:

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

2. that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession, and

3. that they agree to perform 4 random spot audits of the Member’s practice at the following intervals and provide a report to CNO regarding the Member’s practice after each audit:

a. the first audit shall take place within 3 months from the date the Member begins or resumes employment with the employer,

b. the second audit shall take place within 6 months from the date the Member begins or resumes employment with the employer,

c. the third audit shall take place within 9 months from the date the Member begins or resumes employment with the employer, and

d. the fourth audit shall take place within 12 months from the date the Member begins or resumes employment with the employer;

v. The audits shall, on each occasion, involve the following:

1. reviewing a random selection of the Member’s charts to ensure they meet both CNO and employer standards, and

2. discussing (by telephone or in person), with at least 3 of the Member’s patients, the care provided by the Member to ensure that the Member’s practice is consistent with both CNO and employer standards;

d) The Member shall not practice independently in the community for a period of 12 months from the date the Member returns to the practice of nursing.

4. All documents delivered by the Member to CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.

Reasons for Penalty Decision

The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The Panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly.

The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility.

The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection. Specific deterrence is achieved through the oral reprimand and the 4-month suspension of the Member's certificate of registration. General deterrence is achieved through the 4-month suspension of the Member’s certificate of registration. Rehabilitation and remediation are achieved through the 2 meetings with a Regulatory Expert, review of the College’s publications and successful completion of a College approved Infection Prevention and Control course. The public is protected through the 12 months of employer notification, 4 random spot audits of the Member’s practice and the restriction on independent practice in the community for 12 months once she returns to practice.

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

I, Karen Laforet, RN, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel.