DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Tyler Hands, RN Chairperson
Tina Colarossi, NP Member Samuel Jennings, RPN Member
Sandra Larmour Public Member
Lalitha Poonasamy Public Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) JOSEPH BERGER for
) College of Nurses of Ontario
- and - )
ANGELENE RICHARDSON ) MARIA KOTSOPOULOS for
Registration No. IH08593 ) Angelene Richardson
) KIMBERLEY ISHMAEL
) Independent Legal Counsel
) Heard: March 11, 2024
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 March 11, 2024, via videoconference.
Publication Ban
College Counsel brought a motion pursuant to s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, for an order preventing public disclosure and banning the publication or broadcasting of the names of the patients, or any information that could disclose their identities, referred to orally or in any documents presented at the Discipline hearing of Angelene Richardson. The Member’s Counsel did not dispute the order.
The Panel considered the submissions of College Counsel and the Member’s Counsel and decided that there be an order preventing public disclosure and banning the publication or broadcasting of the names of the patients, or any information that could disclose their identities, referred to orally or in any documents presented at the Discipline hearing of Angelene Richardson.
The Allegations
The allegations against Angelene Richardson (the “Member”) as stated in the Notice of Hearing dated January 30, 2024 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 employed as a Registered Practical Nurse at Holland Christian Homes – Grace Manor, in Brampton, Ontario, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession in that:
(a) you failed to administer medications to the patients listed in Appendix “A”;
(b) you documented that you had administered medications to the patients listed in Appendix “A” when you had not;
(c) you failed to document that you had not administered medications to the patients listed in Appendix “A”;
(d) you failed to consult and/or follow-up with the prescriber with respect to your failure to administer medications to the patients listed in Appendix “A”; and/or
(e) you failed to appropriately dispose of medications listed in Appendix “A”.
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 subsection 1(7) of Ontario Regulation 799/93 in that, while employed as a Registered Practical Nurse at Holland Christian Homes – Grace Manor, in Brampton, Ontario, you abused a patient, verbally, physically and/or emotionally in that you neglected the patients listed in Appendix “A” when you failed to administer medications.
You have committed an act of professional misconduct, as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(13) of Ontario Regulation 799/93, in that, while employed as a Registered Practical Nurse at Holland Christian Homes – Grace Manor, in Brampton, Ontario, you failed to keep records as required, and in particular you failed to document that you had not administered medications to the patients listed in Appendix “A”.
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(14) of Ontario Regulation 799/93, in that, while employed as a Registered Practical Nurse at Holland Christian Homes – Grace Manor, in Brampton, Ontario, you falsified a record relating to your practice in that you documented that you had administered medications to the patients listed in Appendix “A” when you had not.
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93 in that while employed as a Registered Practical Nurse at Holland Christian Homes – Grace Manor, in Brampton, 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, and in particular:
(a) you failed to administer medications to the patients listed in Appendix “A”;
(b) you documented that you had administered medications to the patients listed in Appendix “A” when you had not;
(c) you failed to document that you had not administered medications to the patients listed in Appendix “A”;
(d) you failed to consult and/or follow-up with the prescriber with respect to your failure to administer medications to the patients listed in Appendix “A”; and/or
(e) you failed to appropriately dispose of medications listed in Appendix “A”.
APPENDIX “A”
Patient
No.
Medication and time
Date
[Patient A]
Acetaminophen 500mg x 2 tabs at 1400
2/22/2021
Acetaminophen 500mg x 2 tabs at 1400
04/27/2021
Acetaminophen 500mg x 2 tabs at 1400
05/26/2021
Acetaminophen 500mg x 2 tabs at 1400
05/28/2021
Acetaminophen 500mg x 2 tabs at 1400
06/01/2021
Acetaminophen 500mg x 2 tabs at 1400
06/03/2021
Acetaminophen 500mg x 2 tabs at 1400
06/05/2021
[Patient B]
Acetaminophen 500mg x 2 tabs at 1400
03/28/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
03/28/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
03/28/2021
Acetaminophen 500mg x 2 tabs at 1400
04/17/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
04/17/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
04/17/2021
Acetaminophen 500mg x 2 tabs at 1400
04/22/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
04/22/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
04/22/2021
Acetaminophen 500mg x 2 tabs at 1400
04/25/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
04/25/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
04/25/2021
Acetaminophen 500 mg x 2 tabs at 1400
04/26/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
04/26/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
04/26/2021
Acetaminophen 500 mg x 2 tabs at 1400
04/27/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
04/27/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
04/27/2021
Acetaminophen 500 mg x 2 tabs at 1400
04/28/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
04/28/2021
Patient
No.
Medication and time
Date
Quetiapine Fumarate 25mg x ½ tab at 1400
04/28/2021
Acetaminophen 500 mg x 2 tabs at 1400
04/29/2021
Levodopa/carbidopa 100/25mg x 3 tabs at
1400
04/29/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
04/29/2021
Acetaminophen 500 mg x 2 tabs at 1400
04/30/2021
Levodopa/carbidopa 100/25mg x 3 tabs at
1400
04/30/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
04/30/2021
Acetaminophen 500 mg x 2 tabs at 1400
05/01/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
05/01/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
05/01/2021
Acetaminophen 500 mg x 2 tabs at 1400
05/09/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
05/09/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
05/09/2021
Acetaminophen 500 mg x 2 tabs at 1400
05/26/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
05/26/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
05/26/2021
Acetaminophen 500 mg x 2 tabs at 1400
05/27/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
05/27/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
05/27/2021
Acetaminophen 500 mg x 2 tabs at 1400
05/28/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
05/28/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
05/28/2021
Acetaminophen 500 mg x 2 tabs at 1400
06/01/2021
Levodopa/carbidopa 100/25mg x 3 tabs at 1400
06/01/2021
Quetiapine Fumarate 25mg x ½ tab at 1400
06/01/2021
[Patient C]
Acetaminophen 500mg x 1 tab at 1200
04/26/2021
Acetaminophen 500mg x 1 tab at 1200
04/27/2021
Acetaminophen 500mg x 1 tab at 1200
05/31/2021
Patient
No.
Medication and time
Date
Acetaminophen 500mg x 1 tab at 1200
06/02/2021
Acetaminophen 500mg x 1 tab at 1200
06/06/2021
[Patient D]
Olanzapine 5 mg x 1 tab at 1200
04/26/2021
Acetaminophen 500mg x 2 tab at 1230
04/26/2021
Acetaminophen 500mg x 2 tab at 1230
05/27/2021
Acetaminophen 500mg x 2 tab at 1230
05/31/2021
Acetaminophen 500mg x 2 tab at 1230
06/02/2021
Acetaminophen 500mg x 2 tab at 1230
06/06/2021
[Patient E]
Metformin 500mg x ½ tab at 1200
04/26/2021
Acetaminophen 500mg x 1 tab at 1200
04/26/2021
Metformin 500mg x ½ tab at 1200
05/09/2021
Acetaminophen 500mg x 1 tab at 1200
05/09/2021
Metformin 500mg x ½ tab at 1200
05/28/2021
Acetaminophen 500mg x 1 tab at 1200
05/28/2021
Metformin 500mg x ½ tab at 1200
06/02/2021
Acetaminophen 500mg x 1 tab at 1200
06/02/2021
Metformin 500mg x ½ tab at 1200
06/03/2021
Acetaminophen 500mg x 1 tab at 1200
06/03/2021
Metformin 500mg x ½ tab at 1200
06/06/2021
Acetaminophen 500mg x 1 tab at 1200
06/06/2021
[Patient F]
Haloperidol 0.5mg x 1 tab at 1300
04/26/2021
Vitamin D 1000 units x 1 tab at 1300
04/26/2021
Haloperidol 0.5mg x 1 tab at 1300
04/29/2021
Vitamin D 1000 units x 1 tab at 1300
04/29/2021
Haloperidol 0.5mg x 1 tab at 1300
05/09/2021
Vitamin D 1000 units x 1 tab at 1300
05/09/2021
[Patient G]
Levodopa/Carbidopa 100/25mg X 1.5 tab at
1130
04/21/2021
Acetaminophen 500 mg X 2 tabs at 1200
04/21/2021
Acetaminophen 500 mg X 2 tabs at 1700
04/21/2021
Levodopa/Carbidopa 100/25mg X 1.5 tab at 1130
04/30/2021
Acetaminophen 500 mg X 2 tabs at 1200
04/30/2021
Trazadone 50mg x ½ tab at 1400
05/08/2021
Acetaminophen 500 mg X 2 tabs at 1200
05/09/2021
Patient
No.
Medication and time
Date
Trazadone 50mg x ½ tab at 1400
05/18/2021
Levodopa/Carbidopa 100/25mg ½ tabs at 1130
05/27/2021
Levodopa/Carbidopa 100/25mg ½ tabs at 1130
05/28/2021
Levodopa/Carbidopa 100/25mg 1.5 tabs at 1130
05/31/2021
[Patient H]
Acetaminophen 500mg X 2 tabs at 1200
04/30/2021
Gabapentin 100mg x 1 tab at 1200
04/30/2021
[Patient I]
Acetaminophen 500mg x 1 tab at 0800
04/12/2021
ASA Delayed Release 81 mg x 1 tab at 0800
04/12/2021
Tamsulosin Hydrochloride 0.4mg x 1 tab at 0800
04/12/2021
Vitamin B12 1000 mcg X 1 tab at 0800
04/12/2021
Vitamin D 1000 units X 1 tab at 0800
04/12/2021
Galantamine Hydrobromide 16mg x 1 tab at 0830
04/12/2021
[Patient J]
Calcium with Vit-D 650 mg/400IU x 2 tab at
1230
05/01/2021
[Patient K]
Acetaminophen Arthritis Pain Extend 650 mg x
1 tab at 1200
05/05/2021
Acetaminophen Arthritis Pain Extend 650 mg x 1 tab at 1200
05/09/2021
Acetaminophen Arthritis Pain Extend 650 mg x
1 tab at 1200
05/22/2021
Acetaminophen Arthritis Pain Extend 650 mg x 1 tab at 1230
06/02/2021
Acetaminophen Arthritis Pain Extend 650 mg x
1 tab at 1230
06/03/2021
Acetaminophen Arthritis Pain Extend 650 mg x 1 tab at 1230
06/06/2021
[Patient L]
Dilantin 100mg x 3 capsules at 0800
06/06/2021
Member’s Plea
The Member admitted the allegations set out in paragraphs 1(a), (b), (c), (d), (e), 2, 3, 4 and 5(a), (b), (c), (d) and (e) 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 as amended reads, unedited without Appendix “A”, as follows:
THE MEMBER
- Angelene Richardson (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on March 18, 1998. The Member’s certificate of registration expired in March 2022.
PRIOR HISTORY
- The Member has no prior disciplinary findings with CNO.
THE FACILITY
The Member was employed at Holland Christian Homes – Grace Manor, in Brampton, Ontario (the “Facility”) from September 28, 2004 to June 10, 2021, at which time her employment was terminated.
At the relevant time, the Member was a full-time RPN in the Facility’s “1 South” home area. As an RPN, the Member was in charge of the 1 South area, a locked dementia unit with cognitively impaired and frail seniors.
The Facility has a policy titled “Holland Christian Homes Policy and Procedure, Medication Administration, Drug Wastage and Drug Destruction”. The Policy provides that if a resident refuses a medication, the refusal is noted in the electronic Medication Administration Record (“eMAR”). It is also best practice to document a resident’s refusal of medication in the progress notes.
If a nurse withholds a medication, the medication is to be checked with another staff member, the medication is put in the destruction bin, and a Medication Destruction Record is completed and signed.
On 1 South, a sharps container is attached to the medication cart. There is also a separate sharps container located in the locked medication room for discarding non-controlled substances. The sharps containers are a one-way only punch resistant container.
At the material time, discarding non-controlled substances involved the registered staff and another staff designated by the Director of Resident Care (“DORC”) (not necessarily a registered staff member) witnessing disposal of the item into a bin in the medication room. The bin is referred to as the non-controlled substances discontinued medications bin. Medications are discarded in this bin when they are discontinued, or orders are changed. There was no requirement to record in writing what was being disposed of in this bin.
Approximately one year prior to the incidents in question, the Facility conducted mandatory education on medication management with staff. The Member participated in this training on March 19, 2020.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
On June 5, 2021, two RPNs working in 1 South observed a strip of medications sticking out of a sharps container. They pulled on the strip and realized the medications had not been given, because the strip was intact. They also noticed other strips of medications in the sharps container. They were able to remove all the strips they could see and discovered a total of eight strips of medications belonging to six residents. All eight strips were intact meaning they had not been administered.
The RPNs alerted the charge nurse who then informed the Director of Care. The Director of Care instructed the RPNs to secure the sharps container and make a list of all the medications that had been removed.
The following Monday, the Director of Care and two other staff members examined three additional sharps containers on 1 South. They found medication strips in all three containers.
An audit was conducted involving a review of each of the medication strips found, and the records of the patients at issue. The Facility found a total of 62 unopened medication pouches that contained 106 medications that were not administered. All of these had been signed as administered to 12 patients over a 5-month time frame by the Member.
Attached at Appendix “A” is a list of the 12 patients, a summary of the contents of the medication strip retrieved, along with the administration date on the mediation strip. For each medication strip retrieved and reviewed by the Facility’s pharmacy provider, the Member documented that the medication had been administered, when it had not.
When the Facility’s administration asked the Member to explain what had happened, the Member admitted that she had not given medications and falsely recorded that she had. The Member noted that patients would refuse medications and indicated that she was “burnt out.” She felt embarrassed and admitted it was selfish of her. The events took place during the Covid pandemic, the Facility was short-staffed, and the Member was required to work long shifts.
When a patient refuses medication, the Facility protocol is for the nurse to return to the patient later and try to give the medication a second time. If the patient continued to refuse the medication, the nurse was to: (i) place the unused medications in a designated box in the nurses’ room where they could be returned to the pharmacy; and (ii) document the refusal in the electronic medical system, so that the doctor was aware and could assess, diagnose and treat the patient accordingly.
Without this important information, patients were at an increased risk of harm as all staff at the home rely on internal electronic records when assessing and treating patients. Failure to record the medication not given risked the long-term health and wellbeing of the patient.
Ultimately, all patients were determined to be clinically stable with no obvious adverse effects from the omission of medication, except for one, who fell twice as a result of not receiving multiple medications on consecutive days, however the falls did not lead to any permanent injuries.
On June 11, 2021, the Member was arrested and charged with 11 counts of failing to provide the necessaries of life, contrary to s. 215(2)(a)(ii) of the Criminal Code (the “Charges”). The Member subsequently pled guilty and was sentenced to a 1 year conditional sentence to be followed by 1 year probation order. As a term of the Member’s probation, she is not to attend the Facility or contact any employees of the Facility; and, she will not be employed in any healthcare setting or anywhere with vulnerable members of the community, except for immediate family members.
CNO STANDARDS
CNO’s Professional Standards provides that each nurse is accountable to the public and responsible for ensuring her or his practice and conduct meets legislative requirements and the standards of practice of the profession. A nurse demonstrates this standard by providing, facilitating, advocating and promoting the best possible care for patients.
CNO’s Professional Standards further provides, in relation to the Accountability standard, that each nurse demonstrates accountability by taking action in situations in which client safety and well-being are compromised; advocating on behalf of clients; and seeking assistance appropriately and in a timely manner.
Each nurse is expected to understand, uphold and promote the values and beliefs described in CNO’s Ethics Standard. The Ethics Standard defines truthfulness as speaking or acting without intending to deceive.
Nurses promote safe care and contribute to a culture of safety within their practice environment, when involved in medication practices. As set out in the Medication standard, nurses are required to promote and/or implement strategies to minimize the risk of misuse of medication and to take appropriate action to resolve or minimize the risk of harm to a client.
The Therapeutic Nurse-Client Relationship Standard describes five components of the nurse-client relationship: trust, respect, professional intimacy, empathy and power. The nurse-client relationship is one of unequal power. The nurse has more power than the client. The nurse has more authority and influence in the health care system, specialized knowledge, access to privileged information and the ability to advocate for the client and the client’s significant others.
Abuse means the misuse of the power imbalance intrinsic in the nurse-client relationship. It can take the form of neglect, which includes but is not limited to: denying care and withholding medication.
CNO’s Documentation Standard requires that documentation reflect all aspects of the nursing process including, assessment, planning, intervention (independent and collaborative) and evaluation.
In accordance with the Documentation Standard, nurses are accountable for ensuring their documentation of client care is accurate, timely and complete. A nurse meets the standard by demonstrating compliance with various indicators, including, inter alia: documenting the date and time that care was provided and when it was recorded; and indicating when an entry is late as defined by organizational policies; and correcting errors while ensuring that the original information remains visible/retrievable.
CNO’s Decisions About Procedures and Authority Standard mandates nurses to ensure that they have the appropriate authority before performing procedures. The standard defines an order as a prescription for a procedure, drug or intervention.
Nurses are expected to have sufficient knowledge, skill and judgment to determine the appropriateness of performing a particular procedure at a given time for a particular client considering the client’s overall condition, risks and benefits, and available resources to support the performance of the procedure and manage outcomes. The standard further stipulates that nurses meet the standard by obtaining direct client orders or implementing directives appropriately; and ensuring that client records reflect the procedures.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1 (a)(b)(c)(d) and (e) of the Notice of Hearing, in that she contravened a standard of practice of the profession or failed to meet the standard of practice of the profession, as described in paragraphs 10 –29 above.
The Member admits that she committed the act of professional misconduct as alleged in paragraph 2 of the Notice of Hearing, in that she abused a patient verbally, physically, and/or emotionally, when she neglected the patients listed in Appendix “A” and failed to administer medications, as described in paragraphs 10 – 29 above.
The Member admits that she committed the act of professional misconduct as alleged in paragraph 3 of the Notice of Hearing, in that she failed to keep records as required, and in particular, failed to document that she had not administered medications to the patients listed in Appendix “A” as described in paragraphs 10 – 29 above.
The Member admits that she committed the act of professional misconduct as alleged in paragraph 4 of the Notice of Hearing, in that she falsified a record relating to her practice in that she documented that she had administered medications to the patients listed in Appendix “A” when she had not, as described in paragraphs 10 – 29 above.
The Member admits that she committed the act of professional misconduct as alleged in paragraph 5, in that, she engaged in conduct relevant to the practice of nursing that, having regard to all the circumstances, would reasonably be regarded by members as dishonourable and unprofessional, as described in paragraphs 10 – 29 above.
Submissions on Liability by College Counsel
College Counsel asked the Panel to accept the Agreed Statement of Facts, as well as the Member's admissions to all the allegations as set out in paragraphs 30-34 of the Agreed Statement of Facts and, on the basis of those facts and admissions, make findings of professional misconduct with respect to all the allegations in the Notice of Hearing.
With regard to allegations #1(a), (b), (c), (d) and (e), 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. The standards breached were the College’s Professional Standards, the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”), the Documentation Standard and the Decisions About Procedures and Authority Standard. The Member breached all these standards by repeatedly failing to administer medications and then documented that they were administered.
With regard to allegation #2, College Counsel submitted that the Member failed to provide patients with multiple medications over a significant amount of time and that the Member's conduct amounted to neglect which was patient abuse.
With regard to allegation #3, College Counsel submitted that the Member failed to keep records as required, and in particular failed to document that she had not administered medications to patients.
With regard to allegation #4, College Counsel submitted that the Agreed Statement of Facts demonstrates that the Member documented that the medications had been administered when the medications were not administered to multiple patients over many dates. It would be professional misconduct not to administer medications but there is another layer because the Member documented that they were administered. By covering this up by falsely documenting that the medications were administrated, it makes it difficult for another staff to catch this and intervene.
With regard to allegations #5(a), (b), (c), (d) and (e), College Counsel submitted that as the Member’s conduct occurred in her capacity as a nurse fulfilling her duty it was relevant to the practice of nursing and that the nursing profession would find the Member’s conduct to be dishonourable and unprofessional. The Member admitted that her conduct was dishonourable and unprofessional. Unprofessional is the least severe and the Member’s conduct displays a serious and persistent disregard for her professional obligations. The Member’s conduct meets the criteria of dishonourable in that she falsified documentation, and she ought to have known that her conduct fell below the expectations for a nurse. The evidence in the Agreed Statement of Facts shows the Member’s intentional action of failing to administer medication and then covering it up which demonstrates an element of moral failing.
College Counsel submitted the following cases to the Panel to demonstrate prior findings with similar allegations from this Discipline Committee:
CNO v. Parker (Discipline Committee, 2022): This case proceeded by way of an Agreed Statement of Facts. The member worked in long term care. The member failed to administer medications for 5 days and documented that the medications were administered, which is similar misconduct as in the case before this Panel. The panel found that the member had committed professional misconduct by breaching the standards, failing to keep records as required and engaging in dishonourable and unprofessional conduct. There were no allegations of falsifying records. In the case before this Panel there are facts to make the findings of falsifying records.
CNO v. Jackson (Discipline Committee, 2021): The member did not attend the hearing and was deemed to deny the allegations in this case. There were many differences from the case before this Panel, but there were also similarities. The member was a Registered Nurse responsible for two group homes. The member failed to administer medications and to keep records. The panel found that the member had committed professional misconduct by breaching the standards, failing to keep records as required, abusing patients by not administering medications and engaging in conduct which was found to be disgraceful, dishonourable and unprofessional conduct.
CNO v. Labrosse (Discipline Committee, 2019): The member did not attend the hearing and was deemed to deny the allegations in this case. The member worked on a medical surgical unit. The member documented that she had administered the medications when she had not. The findings of the Discipline Committee were that the member falsified documentation as this was not an error based on the number of times the falsifying of records was found. College Counsel asked the Panel to make the same findings in the case before this Panel as made in the Labrosse case.
College Counsel asked that the Panel make the findings of professional misconduct as set out in the Notice of Hearing on all the allegations and as admitted by the Member.
The Member’s Counsel made no submissions on liability.
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), (d), (e), 2, 3, 4 and 5(a), (b), (c), (d) and (e) of the Notice of Hearing. With respect to allegation #2, the Panel finds that the Member physically abused patients. As to allegations #5(a), (b), (c), (d) and (e), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonourable and unprofessional.
Reasons for Decision
The Panel considered the Agreed Statement of Facts and the Member’s plea and finds that this evidence supports findings of professional misconduct as alleged in the Notice of Hearing.
Allegations #1(a), (b), (c), (d) and (e) in the Notice of Hearing are supported by paragraphs 10-29 and 30 in the Agreed Statement of Facts. While employed as a Registered Practical Nurse (“RPN”) at Holland Christian Homes – Grace Manor (the “Facility”), the Member contravened a standard of practice of the profession by failing to administer medications to multiple patients on numerous occasions and documenting that the medications were administered. The standards breached were the College’s Professional Standards, the TNCR Standard, the Documentation Standard and the Decisions About Procedures and Authority Standard.
Allegation #2 in the Notice of Hearing is supported by paragraphs 10-29 and 31 in the Agreed Statement of Facts. The Member committed an act of professional misconduct and physically abused patients by failing to administer medications.
Allegation #3 in the Notice of Hearing is supported by paragraphs 10-29 and 32 in the Agreed Statement of Facts. The Member committed an act of professional misconduct by failing to keep records as required. An audit conducted by the Facility found a total of 62 unopened medication pouches that contained 106 medications that were not administered. All of these had been signed as administered to 12 patients over a 5-month time frame by the Member.
Allegation #4 in the Notice of Hearing is supported by paragraphs 10-29 and 33 in the Agreed Statement of Facts. The Member committed an act of professional misconduct by falsifying records. The Member documented that the medications had been administered when the medications were not administered to multiple patients over many dates.
Allegations #5(a), (b), (c), (d) and (e) in the Notice of Hearing are supported by paragraphs 10-29 and 34 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct of not administering prescribed medications and then documenting that the medications had been administered to multiple patients over many dates was clearly relevant to the practice of nursing and a disregard for her professional obligations in breaching the College’s Professional Standards, the TNCR Standard, the Documentation Standard and the Decisions About Procedures and Authority Standard.
The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of dishonesty and deceit by documenting that the medications were given when they were not and trying to cover it up. 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 three months of the date that this Order becomes final.
Penalty Submissions
College Counsel’s Submissions
College Counsel submitted that the Joint Submission on Order also provides in Appendix “A” an undertaking and agreement by the Member for the Member’s permanent resignation as a member of the College effective March 11, 2024 (the “Undertaking”). Pursuant to this Undertaking, the Member undertakes, acknowledges and agrees to:
a) Permanently resign as a member of the College, effective from the date that the Order made by the Discipline Committee in accordance with the Joint Submission on Order becomes final;
b) Not apply for membership with the College as a Registered Nurse or Registered Practical Nurse at any time in the future;
c) Agree that the public portion of the College’s Register will indefinitely reflect that the Member entered into an Undertaking with the Executive Director to permanently resign as a member of the College as part of an agreed resolution of allegations of professional misconduct;
d) No longer have a right to the issuance or reinstatement of a Certificate of Registration from the College;
e) No longer have a right to use the title “Nurse”, “Registered Nurse”, “Registered Practical Nurse”, “RN”, “RPN” or a variation, an abbreviation or an equivalent in another language;
f) No longer have a right to hold herself out as a Nurse, Registered Nurse, Registered Practical Nurse or as a person who is qualified to practise in Ontario as a Nurse, Registered Nurse or Registered Practical Nurse;
g) No longer have a right to engage in the practice of nursing in any capacity; and
h) Agree the College is authorized to and may, in its sole discretion, provide a copy of the Undertaking and/or its terms to a governing body that regulates nursing in Canada or elsewhere in response to an inquiry or otherwise.
College Counsel submitted that the Member has agreed to resign her certificate of registration. The penalty requires the Member to appear before the Panel to be reprimanded within three months of the date that the Order becomes final. Given that the Member has agreed to permanently resign her certificate of registration, the only penalty necessary is the oral reprimand. She will not reapply to the College as an RN or RPN. Also, the terms of the Undertaking can be provided to another nursing body in Canada. The penalty ordered was a product of negotiations between the College and the Member. The Member was represented by experienced counsel.
The penalty is in the public’s best interest and is appropriate for three reasons: (1) it meets the goals of penalty; (2) it appropriately addresses the mitigating and aggravating factors; and (3) it is consistent with prior decisions of the Discipline Committee.
The goal of penalty is to protect the public and the public's interest. The Member has agreed to resign her certificate of registration with the College and to not reapply in the future. The College can notify other regulators in other jurisdictions if she tries to gain registration in another jurisdiction. This is the ultimate public protection because she will not be practicing nursing any longer. The Member has admitted to professional misconduct, and this will be on the registry. The Member has agreed to the penalty and agreed not to practice nursing any longer. The Member has participated in the hearing and agreed to an oral reprimand.
The aggravating factors in this case were:
The Member’s conduct was serious and persistent neglect and by falsifying records she was dishonest and deceitful; and
The Member’s conduct was repeated for a length of time with multiple patients and the Member knew or ought to have known that her conduct was unprofessional.
The mitigating factors in this case were:
The Member co-operated in the discipline process and entered into an Agreed Statement of Facts and a Joint Submission on Order with the College;
The Member had no prior discipline history with the College; and
The Member took responsibility and admitted guilt in the criminal hearing.
Specific deterrence is not essential in this case because the Member has already undertaken to permanently resign from the practice of nursing. In such circumstances, the penalty of an oral reprimand is sufficient.
General deterrence is achieved through the oral reprimand and the fact that the findings will be publicly posted indefinitely and sends a clear message to other members of the profession that there are serious consequences for similar misconduct.
Rehabilitation and remediation are not essential components of the penalty in this case given the Member’s permanent resignation. There is no public interest served in including remedial terms in the penalty.
Overall, the public is protected by the resignation of the Member’s certificate of registration and the ability of the College to communicate this to any governing body that regulates nursing in Canada or elsewhere. Accordingly, the Panel does not need to impose further conditions in order to achieve protection of the public.
College Counsel submitted the following cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee:
CNO v. Smith (Discipline Committee, 2017): In this case, the hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member was represented by experienced counsel just like in the case before this Panel. The member was found to have breached the standards, to have physically abused the patient and to have engaged in disgraceful, dishonourable and unprofessional conduct. The member signed an undertaking to permanently resign as a member of the College. The penalty included an oral reprimand, which is the same penalty as in the case before this Panel.
CNO v. Walker (Discipline Committee, 2019): In this case, the hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member was represented by experienced counsel just like in the case before this Panel. The member was found to have breached the standards and to have engaged in dishonourable and unprofessional conduct. The member signed an undertaking to permanently resign as a member of the College. The penalty included an oral reprimand, which was the same penalty as in the case before this Panel.
College Counsel submitted that the Panel should give significant weight to the fact that both parties have negotiated this Joint Submission on Order and therefore, should accept it.
The Member’s Counsel made no submissions on penalty.
Penalty Decision
The Panel accepts the Joint Submission on Order and accordingly orders:
- The Member is required to appear before the Panel to be reprimanded within three months of the date that this Order becomes final.
Reasons for Penalty Decision
The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. In the normal course, this is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The Panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly.
The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility.
In this case, because the Member has undertaken to permanently resign, the oral reprimand is a sufficient penalty, and no other specific deterrence is required.
Furthermore, because of the Member’s resignation, it is not necessary to consider remediation and rehabilitation in determining the appropriate penalty.
General deterrence is also addressed as the Panel concluded had the Member’s situation been different and no Undertaking given, the Panel would have ordered a suspension, and terms, conditions and limitations on the Member’s certificate of registration which would have been in line with previous penalties.
Finally, the penalty of a reprimand is appropriate because the public is already protected through the permanent resignation and the Undertaking to never apply for registration as a nurse in Ontario or engage in the practice of nursing in any capacity.
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, Tyler Hands, RN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.
Chairperson