College of Nurses of Ontario v. Emilie Richard, 2024 ONCNO 107212 — College of Nurses of Ontario Discipline Committee | minicounsel

PANEL: Michael Hogard, RPN Chairperson

Ramona Dunn, RN Member

Carly Gilchrist, RPN Member

Carly Hourigan Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) GLYNNIS HAWE for

) College of Nurses of Ontario

and - )

EMILIE RICHARD ) GRANT FERGUSON for

Registration No. JE83252 ) Emilie Richard

) PATRICIA HARPER

) Independent Legal Counsel

) Heard: December 5, 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 December 5, 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 publication or broadcasting of the names of the patients, or any information that could disclose the identities of the patients referred to orally or in any documents presented in the Discipline hearing of Emilie Richard.

The Panel considered the submissions of College Counsel and Member’s Counsel and decided that there be an order preventing public disclosure and banning publication or broadcasting of the names of the patients, or any information that could disclose the identities of the patients referred to orally or in any documents presented in the Discipline hearing of Emilie Richard.

The Allegations

The allegations against Emilie Richard (the “Member”) as stated in the Notice of Hearing dated October 24, 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 practicing as a Registered Practical Nurse (“RPN”) in independent practice in Mississauga, Ontario, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession in that:

a) on or about September 2018 to November 2020, you failed to obtain, conduct, and/or document any pre-treatment assessment, treatment planning, patient outcomes, and/or consultation or authorization by a physician or other qualified health care professional to administer neuromodulators, dermal fillers, dermal threads and/or Hyaluronidase to patients, including with respect to the patients listed in Appendix A;

b) on or about April 1, 2019, you made disparaging social media postings directed at Patient [P], in which you discussed your treatment of Patient [P];

c) you failed to obtain the informed consent of Patient [P] prior to administering injections of neuromodulators, dermal fillers, and/or Hyaluronidase, on or about the following dates:

i. December 17, 2018;

ii. January 8, 2019; and/or

iii. January 22, 2019;

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 practicing as a RPN in independent practice in Mississauga, Ontario, you failed to keep records as required, in 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(19) of Ontario Regulation 799/93, in that, while practicing as a RPN in independent practice in Mississauga, Ontario, you contravened a provision of the Act, the Regulated Health Professions Act, 1991 and/or the regulations under either of those Acts, and in particular, section 27 of the Regulated Health Professions Act, 1991, S.O. 1991, c. 18, and/or section 5 of the Nursing Act, 1991, S.O. 1991, c.32, in that:

a) on or about September 2018 to November 2020, you performed the controlled acts of administering injections of neuromodulators, dermal fillers, dermal threads, and/or Hyaluronidase to the patients in Appendix A, without authorization from a physician or other qualified health care professional;

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 practicing as a RPN in independent practice in Mississauga, 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 in that:

b) on or about April 1, 2019, you made disparaging social media postings directed at Patient [P], in which you discussed your treatment of Patient [P]; and/or

c) you failed to obtain the informed consent of Patient [P] prior to administering injections of neuromodulators, dermal fillers, and/or Hyaluronidase, on or about the following dates:

i. December 17, 2018;

ii. January 8, 2019; and/or

iii. January 22, 2019.

APPENDIX A

	Patient	Date (on or about)
1.	[Patient A]	February 13, 2020
2.	[Patient A]	July 14, 2020
3.	[Patient B]	February 19, 2020
4.	[Patient C]	January 24, 2020
5.	[Patient C]	February 18, 2020
6.	[Patient D]	February 19, 2020
7.	[Patient E]	February 7, 2020
8.	[Patient F]	February 19, 2020
9.	[Patient F]	September 1, 2020
10.	[Patient F]	November 9, 2020
11.	[Patient G]	February 14, 2020
12.	[Patient H]	February 14, 2020
13.	[Patient I]	October 4, 2019
14.	[Patient I]	February 13, 2020
15.	[Patient J]	August 22, 2019
16.	[Patient J]	October 30, 2019
17.	[Patient J]	February 13, 2019
18.	[Patient J]	August 6, 2020
19.	[Patient J]	November 17, 2020
20.	[Patient K]	February 18, 2020
21.	[Patient L]	September 5, 2019
22.	[Patient L]	February 14, 2020
23.	[Patient M]	January 7, 2019
24.	[Patient M]	February 18, 2020
25.	[Patient N]	September 21, 2018
26.	[Patient N]	February 7, 2020
27.	[Patient O]	February 27, 2020
28.	[Patient P]	December 17, 2018
29.	[Patient P]	January 8, 2019
30.	[Patient P]	January 22, 2019
31.	[Patient P]	February 6, 2019
32.	[Patient P]	March 7, 2019

Member’s Plea

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

Agreed Statement of Facts

College Counsel and the Member’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited, as follows:

THE MEMBER

Emilie Richard (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on June 9, 2005.
The Member has been self-employed at Ambea Med Spa (the “Spa”) since May 2011.
The Member operates the Spa out of her personal residence in Mississauga, Ontario.
The Member advertises her services across several social media platforms.
The Member offers a variety of cosmetic nursing services, including the administration of hyaluronic acid gel dermal fillers, botulinum toxin (Botox), abobotulinum toxin A (Dysport), Hyaluronidase (dissolvent enzyme), and platelet rich plasma (PRP) injections.

COSMETIC NURSING PRACTICE OVERVIEW

Controlled Acts, Orders and Medical Directives

Administering Botox, Dysport, Hyaluronidase or PRP engages two controlled acts: (i) administering a substance by injection, and (ii) performing a prescribed procedure below the dermis.
Administering substances such as Botox and PRP for cosmetic purposes carries the same risk for patients as administering those substances for medical reasons. If not performed properly, these procedures can result in infection, adverse reactions, and unnecessary pain for patients.
Registered Nurses and RPNs, such as the Member, who administer cosmetic injectables, are legally required to work in collaboration with a prescriber, such as a physician or Nurse Practitioner, to obtain the proper authorization to perform these two controlled acts.
Authorization to perform the controlled act can be granted through either a direct order or medical directive.
Absent a direct order or medical directive, RPNs and Registered Nurses are not authorized to perform either of the controlled acts noted above.
Consequently, the Member was only permitted to perform controlled acts on patients at the Spa providing that she first obtained proper authorization from a physician or Nurse Practitioner.

Medical Directives to Perform Controlled Acts

At the time of the incidents described below, Dr. Shankary Kanaganayakam was the Spa’s sole medical director and, therefore, the only prescriber who could authorize the Member to perform controlled acts at the Spa.
Dr. Kanaganayakam was never on-site for patient consultations or assessments.

Medical Directive

The Member and Dr. Kanaganayakam established a three-part medical directive (“Medical Directive”) setting out how they proposed to operate the Spa with respect to performing controlled acts and obtaining informed patient consent prior to treatment.
The Medical Directive also identified injection dosage amounts and emergency protocols, in addition to the following material components:

The Member was authorized to administer neuromodulators (i.e., Botox Cosmetic, Botox hyperhidrosis, Dysport and Xeomin), PRP and temporary hyaluronic acid fillers by injection only after Dr. Kanaganayakam had completed a patient tele-assessment, informed consent had been obtained, and ‘before’ photographs of the patients’ faces had been taken to compare with the ‘after’ photographs.
The Member was only authorized to perform the controlled act of injecting below the dermis “following consultation with Dr. Kanaganayakam for each client”. [emphasis added]
All treatment was to be documented in the patient’s record and was to include: the patient’s name, Member’s signature, name/lot/expiry of product, date and time, dosage used, treatment location, photographs, patient’s response to procedure, follow-up assessment, and ultimate procedure outcome.

When patients attended the Spa for treatment, the Member was expected to follow four steps.
First, the Member was expected to obtain informed consent, including by walking patients through the risks and benefits of the proposed procedure(s) and explaining what patients could expect post-treatment. This was known as pre-procedure planning. The Member was also required to gather information about patients’ health histories, such as allergies, surgeries, injuries, viruses, skin issues, and previous reactions to cosmetic services to ensure the patient was an appropriate candidate for the requested treatment.
Second, the Member was expected to upload and save patient records on an application software called iRejuvination so Dr. Kanaganayakam could access patient records in real time to discuss procedural risks, informed consent, and expected outcomes with patients. iRejuvination is an application used in cosmetic treatments for recordkeeping. The application allows two practitioners to access a patient record at the same time.
Third, the Member was expected to contact Dr. Kanaganayakam by text or phone so Dr. Kanaganayakam could review the patient’s consent form and address any concerns either noted in the questionnaire or that the patient had about the information in the consent form. Dr. Kanaganayakam was required to speak with patients directly to answer any outstanding questions or concerns about the procedure. Once the patient’s questions were answered, Dr. Kanaganayakam would give a verbal order for the Member to perform the controlled act(s).
Fourth, the Member was expected to forward complete patient records to Dr. Kanaganayakam through iRejuvination within 30 days of the completion of a procedure so Dr. Kanaganayakam could apply her physician’s stamp to the patient’s record for tracking and audit purposes.
The Medical Directive was signed on August 1, 2018 and remained in effect until December 2020, when it was replaced by another directive signed by Dr. Arash Araini, although the content of the directive did not change.

Informed Consent in Independent Practice Settings

In self-employed settings, nurses must collaborate with at least one prescriber, such as a physician, to obtain the proper authorization to perform the procedure.
Once authorization is obtained, nurses must reflect on their practice. They must ask themselves if they have the knowledge, skill, and judgement to perform the procedure. They must also be prepared to manage potential negative reactions to the medication being injected.
Before administering a substance to a patient, nurses must complete an assessment to determine if it is appropriate for the patient. Making sure the patient understands the procedure and is aware of the risks and possible side effects is achieved through a thorough informed consent procedure. Only once a patient has verified that they consent to having the procedure may the nurse perform the two controlled acts.

Consent Form with Patient Questionnaire

The Member used a consent form (“Consent Form”) that posed a series of questions relating to patients’ general health as well as specific queries about patients’ familiarity with cosmetic nursing, past procedures and what products were used during those previous injections (“Patient Questionnaire”). For example, some of the questions include the following:

Have you had previous botulinum toxin treatment?
Did you have any side effects after the injection?
You had any previous dermal filler/fat injections?
Did you have any side effects after the injection?
Do you know the name of the product injected?

The Consent Form also states the following (reproduced as written):

This is an informed consent document that has been prepared by Dr. Kanaganayakam to help inform you concerning Botox/Dysport injections, the potential benefits and risks, and other alternative treatments. During your consultation, Emilie Richard will review potential the benefits and risks and alternatives with you. During the consent discussion process, they will have allowed you to ask questions about the procedure and provided you with answers to these questions to the best of their ability. It is important that you read the information contained in this booklet again carefully and completely. Only when you have do not have any questions or further concerns will we proceed with treatment. By signing the informed consent for the procedure and treatment plan proposed by either Dr. Kanaganayakam or medically directed independent consultant sign you agree to accept the risk and benefits to the procedure and treatment plan.

Although the Member made changes to the Consent Form over the course of her practice, key components – namely, that the Member review the procedure’s risks and benefits with the patient, invite questions, confirm patient consent, and contact Dr. Kanaganayakam prior to performing any controlled acts – were present across all iterations of the Consent Form.
The Member did not consistently present the complete Patient Questionnaire portion of the Consent Form to patients after their initial appointment. The Patient Questionnaire was usually reduced from 23 to four questions. One of the consistent questions was whether patients experienced side effects following the last cosmetic procedure performed by the Member at the Spa.
The unchanged remainder of the Consent Form included information about the injection process, treatment risks and benefits for each type of injection and product, post-treatment expectations and side effects.
If the Member were to testify, she would say that she consulted with Dr. Kanaganayaham on the initial appointment for many, but not all, of her patients. The Member would further say she did consult further with Dr. Kanaganayakam if there was a material change in medical history brought to the Member's attention, but not with every patient, at every appointment.
If Dr. Kanaganayakam were to testify, she would state that it was her understanding and expectation that the Member use the same Consent Form and Patient Questionnaire for each patient at each appointment, not only during the initial consult.
Dr. Kanaganayakam would further testify that it was her expectation, based on the Medical Directive, that she be called to contemporaneously consult on each patient before the Member performed any controlled acts.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

The Member Failed to Provide Appropriate Cosmetic Nursing Care and Keep Records

The 16 patients impacted by the Member’s acts of professional misconduct are set out in Appendix A to the Notice of Hearing. The patients’ interactions with the Member are described below.

Patient [A]

The Member failed to keep adequate records of Patient [A]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on the following dates:

February 13, 2020; and,
July 14, 2020

On February 13, 2020, the Member administered dermal filler to Patient [A].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
The Member documented in Patient [A]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [A] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to either of Patient [A]’s records, as required for tracking and audit purposes.
The Member modified Patient [A]’s record at 15:59 on June 7, 2021.
On July 14, 2020, the Member administered dermal filler to Patient [A].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
The Member documented in Patient [A]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [A] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to either of Patient [A]’s records, as required for tracking and audit purposes.
The Member modified Patient [A]’s record at 14:20 on June 7, 2021.

Patient [B]

The Member failed to keep adequate records of Patient [B]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on February 19, 2020.
On February 19, 2020, the Member administered dermal filler to Patient [B].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member wrote “Treatment went well patient happy with the outcome” in Patient N.A.’s record, without specifics, such as whether any aftercare was required.
The Member documented in Patient [B]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [B] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [B]’s record, as required for tracking and audit purposes.
The Member modified Patient [B]’s record at 15:45 on June 7, 2021.

Patient [C]

The Member failed to keep adequate records of Patient [C]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on the following dates:

January 24, 2020; and,
February 18, 2020.

On January 24, 2020, the Member administered dermal filler to Patient [C].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
Patient [C]’s record was blank except for the dermal filler name, brand, and dosage.
The Member did not consult Dr. Kanaganayakam about Patient [C] with respect to the treatment provided on January 24, 2020, or document having done so.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [D]’s record, as required for tracking and audit purposes.
The Member modified Patient [C]’s record at 10:40 on April 20, 2020.
On February 18, 2020, the Member administered dermal filler to Patient [C].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to Patient [C]’s response to the procedure, such as how the treatment went and if any aftercare was required.
Patient [C]’s record was blank except for the dermal filler name, brand, and dosage.
The Member did not document any contemporaneous consultation or assessment with Dr. Kanaganayakam in Patient [C]’s chart.
However, the Member provided Patient [C]’s chart to Dr. Kanaganayakam on or around April 20, 2020, at which time Dr. Kanaganayakum applied her physician’s stamp.
The Member modified Patient [C]’s record at 10:40 on April 20, 2020.

Patient [D]

The Member failed to keep adequate records of Patient [D]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional on February 19, 2020.
On February 19, 2020, the Member administered Dysport injections to Patient [D].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
The Member documented in Patient [D]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [D] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [D]’s record, as required for tracking and audit purposes.
The Member modified Patient [D]’s record at 15:43 on June 7, 2021.

Patient [E]

The Member failed to keep adequate records of Patient [E]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on February 7, 2020.
On February 7, 2020, the Member administered dermal filler to Patient [E].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to Patient [E]’s response to the procedure aside from noting “Pt very happy with the 5 syringe package looks fantastic no bruising” in Patient [E]’s record, without specifics, such as if any aftercare was required.
The Member did not document any contemporaneous consultation or assessment with Dr. Kanaganayakam in Patient [E]’s chart.
However, the Member provided Patient [E]’s chart to Dr. Kanaganayakam on or around March 11, 2020, at which time Dr. Kanaganayakum applied her physician’s stamp.
The Member modified Patient [E]’s record at 10:46 on April 20, 2020.

Patient [F]

The Member failed to keep adequate records of Patient [F]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on the following dates:

February 19, 2020;
September 1, 2020; and,
November 9, 2020.

On February 19, 2020, the Member administered Dysport injections to Patient [F].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
The Member documented in Patient [F]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [F] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [F]’s record, as required for tracking and audit purposes.
The Member modified Patient [F]’s record at 17:11 on June 18, 2021.
On September 1, 2020, the Member administered dermal filler to Patient [F].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
The Member documented in Patient [F]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [F] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [F]’s record, as required for tracking and audit purposes.
The Member did not modify this record following the procedure.
On November 9, 2020, the Member administered Dysport injections and dermal filler to Patient [F].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
The Member documented in Patient [F]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [F] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [F]’s record, as required for tracking and audit purposes.
The Member modified Patient [F]’s record at 15:46 on June 7, 2021.

Patient [G]

The Member failed to keep adequate records of Patient [G]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on February 14, 2020.
On February 14, 2020, the Member administered dermal filler to Patient [G].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to Patient [G]’s response to the procedure aside from noting “Treatment went well pt happy” in Patient [G]’s record, without specifics, such as if any aftercare was required.
The Member documented in Patient [G]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [G] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [G]’s record, as required for tracking and audit purposes.
The Member modified Patient [G]’s record at 15:51 on June 7, 2021.

Patient [H]

The Member failed to keep adequate records of Patient [H]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on February 14, 2020.
On February 14, 2020, the Member administered dermal filler to Patient [H].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member wrote “Treatment went well Post care given” in Patient [H]’s chart, without any explanation of post-treatment outcomes, context or specifics about the post-procedure care given and if additional aftercare was required.
The Member documented in Patient [H]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [H] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [H]’s record, as required for tracking and audit purposes.
The Member modified Patient [H]’s record at 15:53 on June 7, 2021.

Patient [I]

The Member failed to keep adequate records of Patient [I]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on the following dates:

October 4, 2019; and,
February 13, 2020.

On October 4, 2019, the Member administered dermal filler to Patient [I].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
The Member documented in Patient [I]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [I] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [I]’s record, as required for tracking and audit purposes.
The Member modified Patient [I]’s record at 17:05 on June 18, 2021.
On February 13, 2020, the Member administered Dysport injections to Patient [I].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
The Member documented in Patient [I]’s chart, “Proceded (sic) with treatment Pt consulted with Dr. Kanaganayakam”. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [I] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [I]’s record, as required for tracking and audit purposes.
The Member modified Patient [I]’s record at 13:09 on June 17, 2021.

Patient [J]

The Member failed to keep adequate records of Patient [J]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on the following dates:

August 22, 2019;
October 30, 2019;
February 13, 2019;
August 6, 2020; and,
November 17, 2020.

On August 22, 2019, the Member administered Dysport injections and dermal fillers to Patient [J].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member wrote “Pt well” in Patient [J]’s chart, without any explanation of post-treatment outcomes, context or specifics about the post-procedure care given and if additional aftercare was required.
The Member documented in Patient [J]’s chart, “Consulted with dr Kanaganayakam (sic)”. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [J] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [J]’s record, as required for tracking and audit purposes.
The Member modified Patient [J]’s record at 17:15 on June 18, 2021.
On October 30, 2019, the Member administered Dysport to Patient [J].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member wrote “Pt well” in Patient [J]’s chart, without any explanation of post-treatment outcomes, context or specifics about the post-procedure care given and if additional aftercare was required.
The Member documented in Patient [J]’s chart, “Consulted with dr Kanaganayakam (sic)”. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [J] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [J]’s record, as required for tracking and audit purposes.
The Member modified Patient [J]’s record at 17:13 on June 18, 2021.
On February 13, 2020, the Member administered Dysport injections to Patient [J].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member wrote “Pt well” in Patient [J]’s chart, without any explanation of post-treatment outcomes, context or specifics about the post-procedure care given and if additional aftercare was required.
The Member documented in Patient [J]’s chart, “Consulted with dr Kanaganayakam (sic)”. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [J] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [J]’s record, as required for tracking and audit purposes.
The Member modified Patient [J]’s record at 15:57 on June 7, 2021.
On August 6, 2020, the Member administered Dysport injections to Patient [J].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member wrote “Pt well” in Patient [J]’s chart, without any explanation of post-treatment outcomes, context or specifics about the post-procedure care given and if additional aftercare was required.
The Member documented in Patient [J]’s chart, “Consulted with dr Kanaganayakam (sic)”. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [J] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [J]’s record, as required for tracking and audit purposes.
The Member modified Patient [J]’s record at 12:36 on September 1, 2020.
On November 17, 2020, the Member administered Dysport injections to Patient [J].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member wrote “Pt well” in Patient [J]’s chart, without any explanation of post-treatment outcomes, context or specifics about the post-procedure care given and if additional aftercare was required.
The Member documented in Patient [J]’s chart, “Consulted with dr Kanaganayakam (sic)”. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [J] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [J]’s record, as required for tracking and audit purposes.
The Member did not modify this record following the procedure.

Patient [K]

The Member failed to keep adequate records of Patient [K]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on February 18, 2020.
On February 18, 2020, the Member administered dermal filler to Patient [K].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member wrote “Treatment went well patient happy with the results Post care instructions given with ice” in Patient [K]’s chart, without any explanation of the specific instructions communicated to the patient and if any aftercare was recommended.
The Member documented in Patient [K]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [K] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [K]’s record, as required for tracking and audit purposes.
The Member modified Patient [K]’s record at 15:48 on June 7, 2021.

Patient [L]

The Member failed to keep adequate records of Patient [L]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on the following dates:

September 5, 2019; and,
February 14, 2020.

On September 5, 2019, the Member administered dermal filler to Patient [L].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member wrote “Treatment went well” in Patient [L]’s chart, without any explanation of post-treatment outcomes, context or specifics about the post-procedure care and if additional aftercare was required.
The Member documented in Patient [L]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [L] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [L]’s record, as required for tracking and audit purposes.
The Member modified Patient [L]’s record at 17:20 on June 18, 2021.
On February 14, 2020, the Member administered dermal filler to Patient [L].
The Member did not document any pre-procedure assessment, treatment consent discussion, and/or review of post-procedure outcomes. The Member wrote “Treatment went well” in Patient [L]’s record, without specifics about the post-procedure care and if additional aftercare was required.
The Member documented in Patient [L]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [L] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [L]’s record, as required for tracking and audit purposes.
The Member modified Patient [L]’s record at 17:21 on June 18, 2021.

Patient [M]

The Member failed to keep adequate records of Patient [M]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on the following dates:

January 7, 2019; and,
February 18, 2020.

On January 7, 2019, the Member administered dermal filler to Patient [M].
The Member did not document any pre-procedure assessment, treatment consent discussion, and/or review of post-procedure outcomes. The Member wrote “Treatment went pt happy – Post care instructions given with Ice” in Patient [M]’s record, without specifics about the post-procedure care and if additional aftercare was required.
The Member documented in Patient [M]’s chart that she had consulted with, and therefore obtained authorization from, Dr. Kanaganayakam. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [M] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [L]’s record, as required for tracking and audit purposes.
The Member modified Patient [M]’s record at 15:49 on June 1, 2021.
On February 18, 2020, the Member administered dermal filler to Patient [M].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
The Member documented in Patient [M]’s chart, “Consulted with Dr. Kanaganayakam”. If Dr. Kanaganayakam were to testify, she would state that the Member did not consult with her regarding Patient [M] on that date.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [M]’s record, as required for tracking and audit purposes.
The Member modified Patient [M]’s record at 17:21 on June 7, 2021.

Patient [N]

The Member failed to keep adequate records of Patient [N]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on the following dates:

September 21, 2018; and,
February 7, 2020.

On September 21, 2018, the Member administered dermal filler to Patient [N].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
Patient [N]’s record was blank except for the dermal filler name, brand, and dosage.
The Member did not consult Dr. Kanaganayakam about Patient [C] with respect to the treatment provided on January 24, 2020, or document having done so.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [N]’s record, as required for tracking and audit purposes.
The Member modified Patient [N]’s record at 10:39 on April 20, 2020.
On February 7, 2020, the Member administered dermal filler to Patient [N].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to Patient [N]’s response to the procedure, such as how the treatment went and if any aftercare was required.
Patient [N]’s record was blank except for the dermal filler name, brand, and dosage.
The Member did not document any contemporaneous consultation or assessment with Dr. Kanaganayakam in Patient [N]’s chart.
However, the Member provided Patient [N]’s chart to Dr. Kanaganayakam on or around April 18, 2020, at which time Dr. Kanaganayakum applied her physician’s stamp.
The Member modified Patient [N]’s record at 16:05 on April 18, 2020.

Patient [O]

The Member failed to keep adequate records of Patient [O]’s treatment on February 27, 2020.
On February 27, 2020, the Member administered dermal filler to Patient [O].
The Member did not document any pre-treatment assessment, treatment planning, informed consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to the patient’s response to the procedure, including whether any aftercare was recommended or required.
Patient [O]’s record was blank except for the dermal filler name, brand, and dosage.
The Member did not document any contemporaneous consultation or assessment with Dr. Kanaganayakam in Patient [O]’s chart.
However, the Member provided Patient [O]’s chart to Dr. Kanaganayakam on or around April 20, 2020, at which time Dr. Kanaganayakum applied her physician’s stamp.
The Member modified Patient [O]’s record at 10:45 on April 20, 2020.

Patient [P]

The Member failed to keep adequate records of Patient [P]’s treatment, and performed controlled acts without authorization from a physician or qualified health professional, on the following dates:

December 17, 2018;
January 8, 2019;
January 22, 2019;
February 6, 2019 and,
March 7, 2019.

The Member never consulted Dr. Kanaganayakam about Patient [P] at any time.
The Member’s interactions with Patient [P] are described below.

Failure to Obtain Patient [P]’s Informed Consent Prior to Performing Controlled Act

The Member failed to obtain informed consent from Patient [P] prior to administering injections or neuromodulators, dermal fillers and/or Hyaluronidase on or about the following dates:

December 17, 2018;
January 8, 2019; and,
January 22, 2019.

December 17, 2018

On December 17, 2018, the Member administered dermal filler to Patient [P].
At the beginning of her appointment, the Member’s assistant asked Patient [P] to sign a “waiver” on an iPad. The Member was not present. When the Member’s assistant handed the iPad to Patient [P], the document, which was in fact a Consent Form and Patient Questionnaire, was pre-emptively scrolled to the point of the signature line.
Patient [P] only partially completed the Consent Form and Patient Questionnaire. Places for Patient [P]’s printed name, signature and date were left blank on multiple pages.
If Patient [P] were to testify, she would state that she signed the Consent Form without reading it and that she was not provided a copy after signing. The Member did not review the Consent Form with Patient [P], nor did she ask Patient [P] to complete the Consent Form before continuing with the appointment.
The Member did not inform Patient [P] of the potential risks of the procedure nor discuss her treatment options before Patient [P] signed the Consent Form and Patient Questionnaire, or at any point thereafter. If Patient [P] were to testify, she would state that she assumed that the Member would at some point review these things with her, but she did not.
If Patient [P] were to testify, she would state that her only conversation with the Member involved the Member asking her what she wanted done and if she had received cosmetic injections before. When Patient [P] answered that she wanted undereye filler and that she had received injections before, the Member proceeded to perform the procedure. The Member did not advise Patient [P] or the risks and benefits of the procedure, or her treatment options, nor did she ask Patient [P] any other questions. Patient [P] would also testify that she did not speak to a physician before the Member performed the procedure, or at any time thereafter.
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to Patient [P]’s response to the procedure, such as how the treatment went and if any aftercare was required. While the Member did document asking Patient [P] several assessment questions, if Patient [P] were to testify, she would state that those questions were never discussed.
Patient [P]’s record was blank except for the dermal filler name, brand, and dosage.
The Member did not consult Dr. Kanaganayakam about Patient [P] at any time, or document having done so.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [P]’s record, as required for tracking and audit purposes.
The Member modified Patient [P]’s record at 15:55 on March 10, 2020.

January 8, 2019

Patient [P] returned to the Spa for additional treatment on January 8, 2019 because she wanted the Member to fix what Patient [P] considered to be puffiness under her eyes following the initial procedure.
If Patient [P] were to testify, she would testify that she was not presented with the Consent Form and Patient Questionnaire prior to the procedure or at any time during the appointment. Patient [P] would also testify that the Member did not discuss with her at any time during this appointment the potential risks and benefits of treatment, or her treatment options.
The Member administered Dysport injections and dermal filler to Patient [P].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to Patient [P]’s response to the procedure, such as how the treatment went and if any aftercare was required.
Patient [P]’s record was blank except for the Dysport and dermal filler names, brands, and dosages.
The Member did not consult Dr. Kanaganayakam about Patient [P] at any time, or document having done so.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [P]’s record, as required for tracking and audit purposes.
The Member modified Patient [P]’s record at 15:54 on March 10, 2020.

January 22, 2019

Patient [P] returned to the Spa for additional procedures on January 22, 2019, because she suspected the area under her eyes was overfilled.
The Member recommended injecting Hyaluronidase, which is intended to dissolve fillers used in cosmetic nursing.
If Patient [P] were to testify, she would testify that she was not presented with the Consent Form and Patient Questionnaire prior to the procedure or at any time during the appointment. Patient [P] would also testify that the Member did not discuss with her at any time during this appointment the potential risks and benefits of treatment, or her treatment options.
The Member administered Hyaluronidase to Patient [P], in addition to Dysport injections and dermal fillers.
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to Patient [P]’s response to the procedure, such as how the treatment went and if any aftercare was required.
Patient [P]’s record was blank except for the Dysport, dermal filler and Hyaluronidase names, brands and dosages and, the injection sites for the Hyaluronidase.
The Member did not consult Dr. Kanaganayakam about Patient [P] at any time, or document having done so.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [P]’s record, as required for tracking and audit purposes.
The Member modified Patient [P]’s record at 18:55 on April 1, 2019 and at 11:37 on March 10, 2020.

February 6, 2019

Patient [P] attended the Spa for additional procedures on February 6, 2019.
Patient [P] completed a partial Patient Questionnaire and signed the Consent Form.
The Member administered dermal filler to Patient [P].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to Patient [P]’s response to the procedure, such as how the treatment went and if any aftercare was required.
Patient [P]’s record was blank except for the dermal filler name, brand, and dosage.
The Member did not consult Dr. Kanaganayakam about Patient [P] at any time, or document having done so.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [P]’s record, as required for tracking and audit purposes.
The Member modified Patient [P]’s record at 14:22 on March 7, 2019.

March 7, 2019

Patient [P] returned to the Spa for a final appointment on March 7, 2019 because of a perceived asymmetry under her eyes. Patient [P] asked the Member to correct this through further injections.
Patient [P] completed a partial Patient Questionnaire and signed the Consent Form.
The Member administered Hyaluronidase to Patient [P].
The Member did not document any pre-procedure assessment, treatment consent discussion, or review of post-procedure outcomes. The Member did not document anything relating to Patient [P]’s response to the procedure, such as how the treatment went and if any aftercare was required.
Patient [P]’s record was blank except for the Hyaluronidase name, brand, and dosage. The record did not indicate the injection sites.
The Member did not consult Dr. Kanaganayakam about Patient [P] at any time, or document having done so.
Dr. Kanaganayakam’s physician stamp was not applied to Patient [P]’s record, as required for tracking and audit purposes.
The Member modified Patient [P]’s record at 14:20 on March 7, 2019 and at 15:53 on March 10, 2020.

Inappropriate Social Media Communication with Patient [P]

Following the Member’s appointment with Patient [P] on March 7, 2019, Patient [P] posted on Instagram: “Do not go to #emilie_master_nurse_injector VERY UNPROFESSIONAL DM ME FOR MORE INFO.”
On April 1, 2019, the Member responded to Patient [P]’s social media posts with the following (all messages below reproduce the spelling and capitalization of the original messages):

I’m sorry did you want me to hold your hand for 20 minutes after I bruise you? With that help? I’m snobby? 😂 … Bruising happens … Also your last injector took one hour to do your lips that’s great I’m sure you guys had a blast! Takes me last time because that’s just the way I am. Here a lollipop 🍭 hope you feel better

If I could show you her before and after since she wants to make this public… Anyways thanks for sending me more clients I just had 5 girls book for tear through fillers thanks Felicia ✌

If the Member were to testify, she would admit that the sarcastic, mocking and/or disparaging tone of her social media communications demonstrates a lack of professional judgment. She would also acknowledge that engaging with a patient online as opposed to in person does not change the degree to which the Member should be respectful, and that her posts are contrary to that expectation.

CNO STANDARDS OF PRACTICE

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

Professional Standards

CNO’s Professional Standards provides an overall framework for the practice of nursing and a link with other standards, guidelines, and competencies.
Nurses uphold this standard by doing the following, among other actions:

a. providing, facilitating, advocating and promoting the best possible care for patients;

b. ensuring practice is consistent with CNO’s standards of practice and guidelines as well as legislation;

c. taking responsibility for errors when they occur and taking appropriate action to maintain patient safety;

d. being aware of how practice environments affect professional practice;

e. planning approaches to providing care or service with the patient; and

f. evaluating or describing the outcomes of specific interventions and modifying the plan or approach, as necessary.

Documentation Standard

CNO’s Documentation Standard helps nurses understand the importance of accurate and timely documentation, and how to apply the standards to their individual practice.
CNO’s Documentation Standard provides that nurses are accountable for ensuring their documentation of patient care is “accurate, timely and complete.” The standard further explains that nurses meet expectations by:

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

b. documenting both objective and subjective data;

c. documenting in a timely manner and completing documentation during, or as soon as possible after, the care or event;

d. documenting the date and time that care was provided and when it was recorded;

e. ensuring that the plan of care is clear, current, relevant and individualized to meet the patient’s needs and wishes;

f. documenting informed consent when the nurse initiates a treatment or intervention authorized in legislation; and

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

ADMISSIONS OF PROFESSIONAL MISCONDUCT

The Member admits that she committed the acts of professional misconduct, as described in paragraphs 2-244 above, and as alleged in paragraphs 1(a), (b) and (c)(i)-(iii) 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.
The Member admits that she failed to keep records as required, as described in paragraphs 6-236, 241-244 above, and as alleged in paragraph 2(a) of the Notice of Hearing.
The Member admits that she performed controlled acts without authorization from a physician or other qualified health professional, as described in paragraphs 6-236, 241-244 above, and as alleged in paragraph 3(a) of the Notice of Hearing.
The Member admits that she committed the acts of professional misconduct as described in paragraphs 2-244 above, and as alleged in paragraphs 4(a), 4(b) and 4(c)(i)-(iii) the Notice of Hearing, and, in particular, that her conduct was dishonourable and unprofessional.

College Counsel’s Submissions on Liability

College Counsel asked the Panel to accept the Agreed Statement of Facts, as well as the Member’s admissions to all the allegations as set out in paragraphs 245-248 of the Agreed Statement of Facts and, on the basis of those facts and admissions, make findings of professional misconduct with respect to the allegations in the Notice of Hearing. College Counsel submitted that the Panel has taken the Member’s plea, conducted a verbal plea inquiry, and received a written plea inquiry which confirmed that the plea was voluntary, informed, and made on the advice of experienced Counsel. College Counsel submitted that based on the Agreed Statement of Facts, which specifically describes the facts in relation to the allegations, the Panel has enough evidence to find that the Member committed professional misconduct as set out in all of the allegations in the Notice of Hearing.

College Counsel reviewed allegations #1(a), (b), (c)(i), (ii) and (iii) and #4(a), (b), (c)(i), (ii) and (iii) with the Panel. With regard to allegations #1(a), (b), (c)(i), (ii) and (iii), College Counsel submitted that these allegations are supported by the Agreed Statement of Facts, which contained evidence of the relevant College standards of the profession, as well as the Member’s admissions that those standards were breached.

With regard to allegations #4(a), (b), (c)(i), (ii) and (iii), College Counsel submitted that the parties agreed that the Member’s conduct is relevant to the practice of nursing as it occurred over the course of the Member’s nursing practice.

College Counsel submitted that the Member’s conduct was unprofessional and dishonourable. College Counsel submitted that the Member’s conduct in responding to Patient [P]’s Instagram post and posting about what treatment she provided to Patient [P] was a failure on her part to comply with her obligations of professional communication with her patients. The Member responded to Patient [P] outside the workplace on Instagram. The Member posted comments of a mocking nature directed at the Patient. College Counsel submitted that the Member had an obligation to document the treatment provided to her patients, which she failed to do, and that the completion of documentation is one of the basic obligations of a nurse.

College Counsel submitted that the Member’s conduct was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations. College Counsel submitted that the Member’s conduct was also dishonourable as it involved an element of moral failing. College Counsel submitted that the Member knew or ought to have known that her conduct fell below the standards of the profession and that she engaged in a persistent and systemic failure to meet the requirements of being a nurse when she failed to document and ensure that her procedures had proper authorization from a physician.

The Member’s Counsel’s Submissions on Liability

The Member’s Counsel submitted that the College has met the burden of proof, and that the Agreed Statement of Facts should be accepted as it is the totality of the evidence that is before the Panel. The Member’s Counsel submitted that the allegations set out in the Notice of Hearing have been reviewed and admitted to by the Member. In regard to allegations #4(a), (b), (c)(i), (ii) and (iii), the Member’s Counsel submitted that the Panel does not need to make findings of all three disgraceful, dishonourable and unprofessional, but rather only the elements of dishonourable and unprofessional conduct are met through the terms of the Agreed Statement of Facts, which is sufficient to meet allegation #4 in the Notice of Hearing.

The Member’s Counsel submitted that in reviewing the Agreed Statement of Facts, proper authorization is required for all controlled acts. At the time of these consultations, the treating physician was not on site and was reliant on phone/video consults and review of documentation. While there was a medical directive, it was very clear that it allows for the administration of cosmetic injections after the consultation with a physician and it was not a standing medical directive and was often applied in that manner by the Member. The Member’s Counsel submitted that there was a thorough consent form and there was information provided to a physician, however, it was inconsistently applied to patients. The Member’s Counsel submitted that there were errors in the consistency of the presentation of the consent and consultation of the information provided to the patients. The Member’s Counsel submitted that the physician had different expectations of the Member and they were not met by experience; consultations completed before each and every treatment, and particularly the initial treatment. This was not always completed. The Member’s Counsel submitted that there were modifications made to the patients’ charts which did not reflect the printing of records and are not intended to suggest there was any misuse of the records merely they were accessed well after the fact with missing documentation. The Member’s Counsel submitted that the Member admitted to the allegations and accepted accountability that supports the allegations in the Notice of Hearing.

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), (b), (c)(i), (ii), (iii), 2(a), 3(a) and 4(a), (b), (c)(i), (ii) and (iii) of the Notice of Hearing. As to allegations #4(a), (b), (c)(i), (ii) and (iii), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be unprofessional and dishonourable.

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), (b), (c)(i), (ii) and (iii) in the Notice of Hearing are supported by paragraphs 2-244 and 245 in the Agreed Statement of Facts. While self-employed at Ambea Med Spa, the Member failed to keep adequate records of her patients’ treatments and performed controlled acts without authorization from a physician or qualified health professional. The College’s nursing standards set out the expectations for the practice of nursing. These standards inform nurses of their accountabilities and apply to all nurses regardless of their role, job description or area of practice. The Professional Standards provide that nurses are accountable to the public and responsible for ensuring that their practice and conduct meets legislative requirements and the standards of the profession and that a nurse demonstrates this standard by among other things ensuring that their practice is consistent with the College’s standards of practice and guidelines, as well as legislation. The Member breached this standard when she performed the controlled acts of administering injections to her patients without consulting and receiving the authorization of Dr. Kanaganayakam. The Documentation Standard provides that nurses are accountable for ensuring their documentation of patient care is accurate, timely and complete. The Member breached this standard by failing to ensure that her documentation was a complete record of the nursing care she provided and that it reflected all aspects of her nursing process, including assessment, planning, intervention and evaluation. The Member also failed to consistently document informed consent when she initiated treatment.

Allegation #2(a) in the Notice of Hearing is supported by paragraphs 6-236, 241-244 and 246 in the Agreed Statement of Facts. The Member failed to keep records when she did not document pre-procedure assessments, treatment consent discussions or review of post-procedure outcomes. The Member did not document any consultations with Dr. Kanaganayakam and Dr. Kanaganayakam’s stamp was not applied to the patients’ charts. The Member also modified the patients’ records.

Allegation #3(a) in the Notice of Hearing is supported by paragraphs 6-236, 241-244 and 247 in the Agreed Statement of Facts. The Member performed controlled acts without authorization from Dr. Kanaganayakam and at times, did not consult with Dr. Kanaganayakam prior to administering cosmetic injections.

Allegations #4(a), (b), (c)(i), (ii), (iii) in the Notice of Hearing are supported by paragraphs 2-244 and 248 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in failing to document, failing to maintain records, failing to obtain informed consent and engaging in an inappropriate manner with Patient [P] on a social media platform was clearly relevant to the practice of nursing. It was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations. Even though the Member practiced in an independent manner, it is an expectation that she follows the standards of the profession.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing through her repeated actions over a 2-year period. The Member repeatedly failed to document, obtain informed consent and did not have proper authority to perform a controlled act. The Member also entertained and engaged in a social media post that she knew or ought to have known was inappropriate. A nurse must act with decorum. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional.

Penalty

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

Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
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.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at the Member’s expense within 6 months from the date that this Order becomes final. If the Expert determines that a greater number of sessions are required, the Expert will advise CNO regarding the total number of sessions that are required, and the length of time required to complete the additional sessions. All sessions shall be completed within 12 months from the date that this Order becomes final. To comply, the Member is required to ensure that:

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

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

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
the Panel’s Decision and Reasons, if available;

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

Code of Conduct,
Consent,
Directives,
Documentation,
Independent Practice, and
Scope of Practice;

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:

the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
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:

the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into the Member’s behaviour;

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

b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify each of the Member’s employers of the Panel’s Order. The Member is required to comply with the following:

i. The Member shall provide CNO with the name, business address, telephone number and email address (if applicable) of all employer(s) at least 14 days before commencing or resuming employment in any nursing position;

ii. The Member shall inform all employer(s) of the Panel’s Order at least 14 days before commencing or resuming employment in any nursing position;

iii. The Member shall provide all employer(s) with a copy of:

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
the Panel’s Decision and Reasons, once available;

iv. If the Member is self-employed (which term includes employment by a corporation owned by the Member, either in whole or in part), the Member’s employer(s) for the purposes of interpreting and enforcing the terms of this Order shall include all regulated health professionals with whom the Member is in a professional relationship and who are responsible for authorizing the Member to perform controlled acts (the “Authorizing Professional(s)”) in the course of the Member’s practice;

v. The Authorizing Professional(s) must be pre-approved by CNO prior to the Member’s commencement or resumption of practice in any nursing position where authorization from the Authorizing Professional(s) is required for the Member to perform controlled acts;

vi. The Member shall ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, all employer(s) or, if self-employed in an independent practice environment, each Authorizing Professional(s), send written confirmation to CNO regarding the following:

they received a copy of the Panel’s Order, Notice of Hearing, Agreed Statement of Facts and Joint Submission on Order, in addition to the Panel’s Decision and Reasons, when available;
they agree to notify CNO immediately upon observation or receipt of information that the Member may have breached a standard of practice of the profession, and
they agree to perform 4 random spot audit cycles of the Member’s documentation, authorizing mechanisms and consent practices at the following intervals over a 12-month period, and provide a report to CNO after each audit cycle:

a. the first audit cycle shall take place within 3 months from the date the Member begins or resumes employment with the employer(s) and/or a professional relationship with the Authorizing Professional(s),

b. the second audit cycle shall take place within 6 months from the date the Member begins or resumes employment with the employer(s) and/or a professional relationship with the Authorizing Professional(s),

c. the third audit cycle shall take place within 9 months from the date the Member begins or resumes employment with the employer(s) and/or a professional relationship with the Authorizing Professional(s), and

d. the fourth audit cycle shall take place within 12 months from the date the Member begins or resumes employment with the employer(s) and/or a professional relationship with the Authorizing Professional(s); and,

vii. Each of the 4 random spot audits shall involve the following:

the employer(s) or Authorizing Professional(s) reviewing 5 random patient health records to ensure the Member is meeting CNO standards, including but not limited to ensuring the following:

a. the Member’s documentation represents a complete record of the nursing care provided,

b. the Member obtained authorization from the Authorizing Professional(s) prior to performing controlled act(s), and/or

c. the Member obtained informed patient consent prior to performing controlled act(s);

the employer(s) or Authorizing Professional(s) discussing the care provided by the Member to 3 patients, selected at random, who received procedures for which both informed consent and authorization from the Authorizing Professional(s) were required prior to the performance of the controlled act(s).
If self-employed in an independent practice environment, the Member shall post the following notice regarding practice restrictions in a visible location at all locations at which she practices nursing, as well as on any websites, social media, and/or platforms through which appointment booking is available, for a period of 12 months from the date the Member commences or resumes employment in any nursing position:

ENTITLED TO PRACTISE NURSING WITH RESTRICTIONS

Emilie Richard, RPN, is permitted to practise nursing subject to terms, conditions and limitations. Further information regarding restrictions may be found on the public register: https://registry.cno.org/Search/Details/e1d8fd41-03b8-4087-ab81-47538e622646

If the Member chooses to practise nursing in any language other than English, the Member shall also be required to post a certified translation(s) of the notice referred to in paragraph 4 in a visible location at all locations at which she practices nursing, as well as on any websites, social media, and/or platforms through which appointment booking is available, for a period of 12 months from the date the Member commences or resumes employment in any nursing position.
The Member shall provide CNO with copies of the certified translation(s) referred to in paragraph 5.
The Member shall provide CNO with active links to the websites, social media, and/or platforms on which the notice referred to in paragraph 4 shall be posted, for a period of 12 months from the date the Member commences or resumes employment in any nursing position.
All documents delivered by the Member to CNO, the Expert, the employer(s), and/or the Authorizing Professional(s), shall be delivered by verifiable method, the proof of which the Member will retain.

Penalty Submissions

College Counsel’s Submissions on Penalty

College Counsel submitted that the penalty proposed includes an oral reprimand, a 4-month suspension of the Member’s certificate of registration and terms, conditions and limitations on the Member’s certificate of registration including a minimum of 2 meetings with a Regulatory Expert and 12 months of employer notification. In regard to the Member being self-employed, College Counsel reviewed with the Panel how the Joint Submission on Order would supervise this element by including all regulated health professionals with whom the Member is in a professional relationship with and who are responsible for authorizing the Member to perform controlled acts. College Counsel submitted that if the Member was employed in a traditional nursing environment where she was being supervised by other healthcare professionals then the terms would apply as 12 months of employer notification. However, the Member is currently employed in an independent practice and engages the service of an authorizing professional in order to conduct her practise. Accordingly, the terms in the Joint Submission on Order are slightly modified and the effect is that the authorizing physician or other authorizing healthcare professionals with whom the Member has the professional relationship will perform the supervision that is normally required to be done by an employer. College Counsel submitted that in paragraph 3(b)(v) of the Joint Submission on Order the College must pre-approve the authorizing professional provided that the Member is still performing controlled acts. In paragraph 3(b)(vi) the Member must ensure that the authorizing professional has received a copy of the Panel's Order, Notice of Hearing, Agreed Statement of Facts and Joint Submission on Order, in addition to the Panel's Decision and Reasons, when available. The authorizing professional must agree to notify the College immediately upon observation or receipt of information that the Member may have breached a standard of practice of the profession, and they agree to perform 4 random spot audit cycles of the Member's documentation, authorizing mechanisms and consent practices at specified intervals over a 12-month period, and provide a report to the College. College Counsel submitted that if the Member continues to be self-employed in an independent practice environment, the Member shall post a notice regarding practice restrictions in a visible location at all locations at which she practices nursing, as well as on any websites, social media, and/or platforms through which appointment booking is available, for a period of 12 months from the date the Member commences or resumes employment in any position. College Counsel submitted that in regard to paragraph #5 of the Joint Submission on Order, if the Member chooses to practise nursing in any language other than English, the Member shall also be required to post a certified translation(s) of the notice referred to in paragraph 4 in a visible location at all locations at which she practices nursing, as well as on any websites, social media, and/or platforms through which appointment booking is available, for a period of 12 months from the date the Member commences or resumes employment in any nursing position.

College Counsel submitted that the Panel ought to accept the proposed penalty because it meets the overarching goals of penalty in a regulatory proceeding. College Counsel submitted that it is an appropriate penalty taking into consideration the circumstances in this case. College Counsel submitted that the penalty is consistent with prior decisions of this Discipline Committee with similar conduct.

College Counsel submitted that the overriding concern from the College with any penalty is the protection of the public interest in addition to meeting 3 specific objectives: specific deterrence, general deterrence and remediation and rehabilitation of the Member.

Specific deterrence specifically focuses on deterring the Member from engaging in this or similar misconduct again. The proposed penalty provides for specific deterrence through the oral reprimand, which will signal to the Member that the Panel and members of the profession disapprove of this type of conduct. The 4-month suspension of the Member’s certificate of registration is also a specific deterrence as the suspension is significant in length which will remind the Member that she should not engage in this type of conduct in the future.

General deterrence focuses on deterring other members of the profession from engaging in similar conduct. The proposed penalty provides for general deterrence through the 4-month suspension of the Member’s certificate of registration, as well as the public nature of the findings in this case including the public posting requirements which signals to the profession that the College is capable of self-regulation and takes this type of misconduct very seriously.

The proposed penalty provides for remediation and rehabilitation through a minimum of 2 meetings with a Regulatory Expert and the review of the College’s publications.

Overall, the public is protected through the 12 months of employer or authorized professional notification and the 4 random spot audits of the Member’s practice and documentation, which will provide additional mentorship and supervision to guide the Member and improve her practice in the future.

The aggravating factors of this case were:

The potential for harm to the Member’s patients; and
The repeated nature of the Member’s conduct over an extended period of time (2018-2020).

The mitigating factors of this case were:

There have been no previous discipline findings against the Member;
The Member has expressed remorse for her misconduct; and
The Member has cooperated with the College by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College.

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. Besada (Discipline Committee, 2023): The Panel was provided with a copy of the Order as the Decision and Reasons had not yet been published. This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The allegations in this case were very similar to those in the case before this Panel. The member worked independently and specialized in cosmetic injections, dermal fillers and had an authorizing professional who was a physician. There were 16 different patient charts collected. There were allegations of inadequate documentation, failing to keep records as required and the member used a name, in order to provide professional services as a nurse, that was different than what was set out in the College’s register. While the member on numerous occasions failed to document consultations with the physician, there was proper authorization that followed. There was some deficiency in documenting informed consent, but that informed consent was obtained. The member’s conduct was found to be unprofessional. The penalty included an oral reprimand, a 2-month suspension of the member’s certificate of registration, 2 meetings with a Regulatory Expert, 12 months of employer notification and 4 random spot audits of the member’s practice and documentation.

CNO v. Russon (Discipline Committee, 2018): This hearing was a contested hearing in the absence of the member. In this case, there were no mitigating factors of cooperation with the College as in the case before this Panel and the allegations were very similar. The member practiced independently, performing cosmetic nursing injections and the allegations involved two separate patients, on two separate dates. The member’s conduct was found to be disgraceful, dishonourable and unprofessional. The penalty included an oral reprimand, a four-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and 24 months of employer notification.

CNO v. Ozueh (Discipline Committee, 2017): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The allegations in this case were very similar to those in the case before this Panel. The member practiced independently, performing cosmetic nursing injections. The member failed to obtain appropriate authorization to administer injections of fillers to a patient, failed to adequately document in an appropriate manner and misused the title of Registered Nurse. The member’s conduct was found to be dishonourable and unprofessional. The penalty included an oral reprimand, a three-month suspension of the member’s certificate of registration, two meetings with a Nursing Expert, 18 months of mentor notification and 12 months of ten random chart audits by the Mentor.

The Member’s Counsel’s Submissions on Penalty

The Member's Counsel submitted that the penalty is a negotiated resolution. The Member’s Counsel submitted that the penalty meets the needs of the Member, the College, the profession and the public. The Member’s Counsel submitted that the Joint Submission on Order meets the goals and factors of penalty and is consistent with the aggravating and mitigating factors of this case. Finally, the penalty is consistent with prior cases from this Discipline Committee. The Member’s Counsel submitted that unless the Joint Submission on Order brings the administration of justice into disrepute there is an obligation under the law for the Panel to accept the Joint Submission on Order. The Member’s Counsel submitted that any deciding party should not depart from the Joint Submission on Order unless that proposed order is so impossible to accept that it would cause members of the public to doubt the administration of justice at 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 3 months of the date that this Order becomes final.
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.
The Executive Director is directed to impose the following terms, conditions and limitations on the Member’s certificate of registration:

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 the following documents:

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
the Panel’s Decision and Reasons, if available;

Code of Conduct,
Consent,
Directives,
Documentation,
Independent Practice, and
Scope of Practice;

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:

the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
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:

the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into the Member’s behaviour;

ii. The Member shall inform all employer(s) of the Panel’s Order at least 14 days before commencing or resuming employment in any nursing position;

iii. The Member shall provide all employer(s) with a copy of:

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
the Panel’s Decision and Reasons, once available;

they received a copy of the Panel’s Order, Notice of Hearing, Agreed Statement of Facts and Joint Submission on Order, in addition to the Panel’s Decision and Reasons, when available;
they agree to notify CNO immediately upon observation or receipt of information that the Member may have breached a standard of practice of the profession, and
they agree to perform 4 random spot audit cycles of the Member’s documentation, authorizing mechanisms and consent practices at the following intervals over a 12-month period, and provide a report to CNO after each audit cycle:

vii. Each of the 4 random spot audits shall involve the following:

the employer(s) or Authorizing Professional(s) reviewing 5 random patient health records to ensure the Member is meeting CNO standards, including but not limited to ensuring the following:

a. the Member’s documentation represents a complete record of the nursing care provided,

b. the Member obtained authorization from the Authorizing Professional(s) prior to performing controlled act(s), and/or

c. the Member obtained informed patient consent prior to performing controlled act(s);

the employer(s) or Authorizing Professional(s) discussing the care provided by the Member to 3 patients, selected at random, who received procedures for which both informed consent and authorization from the Authorizing Professional(s) were required prior to the performance of the controlled act(s).
If self-employed in an independent practice environment, the Member shall post the following notice regarding practice restrictions in a visible location at all locations at which she practices nursing, as well as on any websites, social media, and/or platforms through which appointment booking is available, for a period of 12 months from the date the Member commences or resumes employment in any nursing position:

ENTITLED TO PRACTISE NURSING WITH RESTRICTIONS

If the Member chooses to practise nursing in any language other than English, the Member shall also be required to post a certified translation(s) of the notice referred to in paragraph 4 in a visible location at all locations at which she practices nursing, as well as on any websites, social media, and/or platforms through which appointment booking is available, for a period of 12 months from the date the Member commences or resumes employment in any nursing position.
The Member shall provide CNO with copies of the certified translation(s) referred to in paragraph 5.
The Member shall provide CNO with active links to the websites, social media, and/or platforms on which the notice referred to in paragraph 4 shall be posted, for a period of 12 months from the date the Member commences or resumes employment in any nursing position.
All documents delivered by the Member to CNO, the Expert, the employer(s), and/or the Authorizing Professional(s), shall 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 Panel recognized that there has been a rise in nurses practicing independently and the type of misconduct demonstrated by the Member has become more frequent and an increase in the suspension period is warranted to send a strong message to the profession. 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.

The penalty provides for general deterrence through the 4-month suspension of the Member’s certificate of registration. This will send a strong message to the profession that this type of misconduct will not be tolerated.

The penalty provides for specific deterrence through the oral reprimand and the 4-month suspension of the Member’s certificate of registration, as well as the post in regard to her restrictions on her social media platforms and practice environment. This will remind the Member of her misconduct, and that there will be close monitoring from her patients and an authorizing professional.

The penalty provides for remediation and rehabilitation through a minimum of 2 meetings with a Regulatory Expert and the review of the College’s publications. This will allow the Member to gain further insight into her misconduct and return to practice with the knowledge that is expected of the nursing profession.

Overall, the public is protected through the 12 months of employer or authorized professional notification and the 4 random spot audits of the Member’s practice and documentation, which will allow for greater oversight upon her return to nursing practice.

The penalty sends a strong message to the Member, and the membership as a whole, that engaging in controlled acts without proper authorization and failing to maintain the standards of practice for assessment and documentation will not be tolerated. Confidence in the nursing profession and protection of public safety will be strengthened by this message.

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

I, 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.