College of Nurses of Ontario v. Ubredi, 2024 ONCNO 125215

Discipline Committee of the College of Nurses of Ontario

PANEL: Grace Fox, NP Chairperson Sherry Szucsko-Bedard, RN Member Emilija Stojsavljevic, RPN Member Lalitha Poonasamy Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO HAILEY BRUCKNER for College of Nurses of Ontario

• and -

OCHUKO JUDITH UBREDI Registration No. 11447366 MICHAEL ALEXANDER for Ochuko Judith Ubredi

KIMBERLEY ISHMAEL Independent Legal Counsel

Heard: June 7, 2024, via videoconference

DECISION AND REASONS

Publication Ban

By Order of the Discipline Panel dated June 7, 2024, pursuant to subsection s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, no one shall publish or broadcast the names of the patients, or any information that could disclose the identities of the patients, referred to orally or in any documents presented at the Discipline hearing of Ochuko Judith Ubredi.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on June 7, 2024.

The Allegations

The allegations against Ochuko Judith Ubredi (the “Member”) as stated in the Notice of Hearing dated January 8, 2024 are as follows:

IT IS ALLEGED THAT:

1. 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 practising as a Registered Nurse at Niagara Health System - Greater Niagara General Site (“Niagara Health”) in Niagara, Ontario and/or Sunnybrook Health Sciences Centre (“Sunnybrook”) in Toronto, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession as follows:

(a) On January 15 and/or 16, 2019, at Niagara Health, you failed to adequately document administering or wasting 2 mg of midazolam you withdrew for Patient [A];

(b) On January 15 and/or 16, 2019, at Niagara Health, you failed to intervene as ordered when Patient [A]’s potassium level dropped;

(c) On January 16, 2019, at Niagara Health, you failed to intervene appropriately when Patient [A]’s arterial line came out;

(d) On January 16, 2019, at Niagara Health, you failed to adequately document your nursing intervention(s) when Patient [A]’s arterial line came out;

(e) On January 16, 2019, at Niagara Health, you failed to follow the Heparin Standard Dose Anticoagulation Order Set when Patient [A] received a critical aPTT result;

(f) On October 11 and/or 12, 2019, at Sunnybrook, you administered 1.6 mg of hydromorphone to Patient [B] without authorization;

(g) On October 11 and/or 12, 2019, at Sunnybrook, you failed to adequately document administering or wasting 1.6 mg of hydromorphone you withdrew for Patient [B];

(h) On October 20, 2019, at Sunnybrook, you failed to apply pacer pads to Patient [C] when the patient required emergent intervention, despite multiple directions to do so from a physician;

(i) On October 20 and/or 21, 2019, at Sunnybrook, you failed to adequately document the nursing care you provided to Patient [D];

(j) On October 20 and/or 21, 2019, at Sunnybrook, you failed to adequately document the nursing care you provided to Patient [E];

(k) On October 20 and/or 21, 2019, at Sunnybrook, you failed to adequately document the nursing care you provided to Patient [F];

(l) On October 20 and/or 21, 2019, at Sunnybrook, you failed to place a c-collar on Patient [D], who had an order for full spinal precautions;

(m) On October 22 and/or 23, 2019, at Sunnybrook, you failed to adequately document your administration of insulin to Patient [G]; and/or

(n) On October 22 and/or 23, 2019, at Sunnybrook, you administered a double dose of insulin to Patient [G] without authorization; and/or

2. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the 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 practising as a Registered Nurse at Niagara Health System - Greater Niagara General Site (“Niagara Health”) in Niagara, Ontario and/or Sunnybrook Health Sciences Centre (“Sunnybrook”) in Toronto, Ontario, you failed to keep records as required, as follows:

(o) On January 15 and/or 16, 2019, at Niagara Health, you failed to adequately document administering or wasting 2 mg of midazolam you withdrew for Patient [A];

(p) On January 16, 2019, at Niagara Health, you failed to adequately document your nursing intervention(s) when Patient [A]’s arterial line came out;

(q) On October 11 and/or 12, 2019, at Sunnybrook, you failed to adequately document administering or wasting 1.6 mg of hydromorphone you withdrew for Patient [B];

(r) On October 20 and/or 21, 2019, at Sunnybrook, you failed to adequately document the nursing care you provided to Patient [D];

(s) On October 20 and/or 21, 2019, at Sunnybrook, you failed to adequately document the nursing care you provided to Patient [E];

(t) On October 20 and/or 21, 2019, at Sunnybrook, you failed to adequately document the nursing care you provided to Patient [F]; and/or

(a) On October 22 and/or 23, 2019, at Sunnybrook, you failed to adequately document your administration of insulin to Patient [G]; and/or

3. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that, in that, while practising as a Registered Nurse at Niagara Health System - Greater Niagara General Site (“Niagara Health”) in Niagara, Ontario and/or Sunnybrook Health Sciences Centre (“Sunnybrook”) in Toronto, 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 of the profession as disgraceful, dishonourable or unprofessional, as follows:

(b) On January 15 and/or 16, 2019, at Niagara Health, you failed to adequately document administering or wasting 2 mg of midazolam you withdrew for Patient [A];

(c) On January 15 and/or 16, 2019, at Niagara Health, you failed to intervene as ordered when Patient [A]’s potassium level dropped;

(d) On January 16, 2019, at Niagara Health, you failed to intervene appropriately when Patient [A]’s arterial line came out;

(e) On January 16, 2019, at Niagara Health, you failed to adequately document your nursing intervention(s) when Patient [A]’s arterial line came out;

(f) On January 16, 2019, at Niagara Health, you failed to follow the Heparin Standard Dose Anticoagulation Order Set when Patient [A] received a critical aPTT result;

(g) On October 11 and/or 12, 2019, at Sunnybrook, you administered 1.6 mg of hydromorphone to Patient [B] without authorization;

(h) On October 11 and/or 12, 2019, at Sunnybrook, you failed to adequately document administering or wasting 1.6 mg of hydromorphone you withdrew for Patient [B];

(i) On October 20, 2019, at Sunnybrook, you failed to apply pacer pads to Patient [C] when the patient required emergent intervention, despite multiple directions to do so from a physician;

(j) On October 20 and/or 21, 2019, at Sunnybrook, you failed to adequately document the nursing care you provided to Patient [D];

(k) On October 20 and/or 21, 2019, at Sunnybrook, you failed to adequately document the nursing care you provided to Patient [E];

(l) On October 20 and/or 21, 2019, at Sunnybrook, you failed to adequately document the nursing care you provided to Patient [F];

(m) On October 20 and/or 21, 2019, at Sunnybrook, you failed to place a c-collar on Patient [D], who had an order for full spinal precautions;

(n) On October 22 and/or 23, 2019, at Sunnybrook, you failed to adequately document your administration of insulin to Patient [G]; and/or

(a) On October 22 and/or 23, 2019, at Sunnybrook, you administered a double dose of insulin to Patient [G] without authorization.

Member’s Plea

The Member admitted the allegations set out in paragraphs #1(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m), (n), #2(a), (b), (c), (d), (e), (f), (g) and #3(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m) and (n) 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 and without exhibits mentioned therein, as follows:

THE MEMBER

1. Ochuko Judith Ubredi (“the Member”) first registered as a Registered Nurse (“RN”) with the College of Nurses of Ontario (“CNO”) on March 28, 2011.

2. The Member worked part-time in the Intensive Care Unit at Niagara Health System - Greater Niagara General Site (“Niagara Health”) in Niagara, Ontario from August 20, 2018 until January 23, 2019. The Member opted to resign from Niagara Health in lieu of termination in January 2019.

3. The Member also worked for an agency called Helping Hands Healthcare (“Helping Hands”) in Mississauga, Ontario. Helping Hands assigned the Member to assist in the emergency department at Sunnybrook Health Sciences Centre (“Sunnybrook”) in Toronto, Ontario. Sunnybrook permanently restricted the Member from returning to Sunnybrook in October 2019.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Incidents at Niagara Health

The Member failed to adequately document the administration or waste of medication to Patient [A]

4. On January 15 and/or 16, 2019, at Niagara Health, the Member failed to adequately document administering or wasting 2 mg of midazolam she withdrew for Patient [A].

5. The Member worked the night shift at Niagara Health from January 15 to 16, 2019. While working this shift she had a 10 mg/10 ml vial of midazolam dispensed for the patient at 9:22 pm on January 15, 2019. She documented administering 8 mg of midazolam to Patient [A] over the course of her shift on the patient’s Medication Administration Record (“MAR”), but she did not document wasting or administering the remaining 2 mg of midazolam.

6. If the Member wasted the midazolam, she was required both to document it in Niagara Health’s medication management software (Pyxis) and to have a colleague witness her disposal of the drug in the appropriate waste container. If she administered it, she should have recorded this action in the patient’s MAR. The Member took neither course of action, and the remaining 2 mg of midazolam was never accounted for.

The Member failed to intervene as ordered when Patient [A]’s potassium level dropped

7. On January 15 and/or 16, 2019, at Niagara Health, the Member failed to intervene as ordered when Patient [A]’s potassium level dropped.

8. The patient’s potassium level was 3.0 mmol/l at 10:27 pm on January 15, 2019. The Member documented this potassium level in the patient’s MAR at 11:25 pm on January 15, 2019.

9. The potassium order for the patient stipulated that if the patient’s potassium level was between 3-3.4 mmol/l, the patient should receive 20 mmol of potassium in a 100 ml IV over one hour, and then another 20 mmol potassium in a 100 ml IV over 1 hour. Potassium levels should be repeated in 24 hours.

10. The Member did not follow this order when the patient’s potassium level dropped to 3.0 mmol/l on January 15, 2019. The Member did not document administering a 20 mmol bolus to the patient until 12:25 am on January 16, 2019. And contrary to the potassium order, she did not administer the second bolus of potassium to the patient.

The Member failed to intervene and document appropriately when Patient [A]’s arterial line came out

11. On January 16, 2019, at Niagara Health, the Member failed to intervene appropriately when Patient [A]’s arterial line came out.

12. The patient’s arterial line came out while the patient was under the Member’s care on January 16, 2019. At 6 am on January 16, 2019, the Member made an entry on the patient’s Interdisciplinary Clinical Notes: “Art. Line came out; Site cleaned and covered w. dry gauze.”

13. In this situation, the Member should have notified the Charge Nurse that the patient’s arterial line had come out, so that the Charge Nurse could consult with the patient’s physician and determine whether to replace the line. The Member also should have documented her discussion with the Charge Nurse, as well as any steps she took to provide care to the patient while the issue was being escalated to the physician.

14. However, the Member did not notify the Charge Nurse that the patient’s arterial line had come out or ensure that this matter was escalated to a physician. If the Member were to testify she would say that she reported the arterial line had come out to a respiratory therapist. The Member did not document this action as required.

The Member failed to intervene appropriately when Patient [A] received a critical aPTT result

15. On January 16, 2019, at Niagara Health, the Member failed to follow the Heparin Standard Dose Anticoagulation Order Set when Patient [A] received a critical aPTT result.

16. A Lab Inquiry Report from approximately 6:03 am on January 16, 2019 recorded the patient’s aPTT at 104 seconds. The lab report states explicitly that an aPTT of 104 seconds is a critical result.

17. The Heparin Standard Dose Anticoagulation Order Set for the patient stipulated that the heparin infusion should be held for 60 minutes and then decreased by 4 ml/h if the patient had an aPTT between 101 and 110 seconds. However, the Member took no steps to address the critical aPTT result of 104 seconds during her shift.

18. The patient continued to receive heparin until approximately 8:03 am on January 16, 2019. At that time, the oncoming nurse held the heparin for 60 minutes as required, and then started decreasing the dose by 4 ml/h.

Incidents at Sunnybrook

The Member administered 1.6 mg of hydromorphone without authorization and failed to document administering or wasting the medication

19. On October 11 and/or 12, 2019, at Sunnybrook, the Member administered 1.6 mg of hydromorphone to Patient [B] without authorization and failed to adequately document administering or wasting 1.6 mg of hydromorphone she withdrew for the patient.

20. At 6:00 am on October 12, 2019, the Member spoke to a physician who authorized 0.2 mg hydromorphone q15m to max 0.6 mg for the patient by phone. The Member withdrew a 2 mg ampoule of hydromorphone for the patient at 6:12 am on October 12, 2019. She documented wasting 0.4 mg hydromorphone at 6:13 am on October 12, 2019. One of the Member’s colleagues witnessed this waste.

21. The Member’s documentation does not account for the remaining 1.6 mg of hydromorphone. The Member did not document wasting this hydromorphone. However, she later told Sunnybrook that she did not administer hydromorphone to the patient because the patient was sleeping and she thought it was unnecessary.

22. The patient showed signs of a narcotics overdose on October 12, 2019, which suggests that the Member administered the full 1.6 mg of hydromorphone to the patient. At 9:30 am on October 12, another nurse at the Facility discovered that the patient was not responding to voice or touch. The patient responded to a sternal rub by moving their right arm to their chest. The nurse called for a physician and noted that she could not locate the documentation in which the night nurse (the Member) recorded administering hydromorphone to the patient. Staff at Sunnybrook gave the patient Narcan (0.4 mg/ml over a few minutes). The patient responded verbally after the second 0.2 mg IV push of Narcan.

The Member failed to document adequately in the charts of Patient [D], Patient [E], and Patient [F]

23. On October 20 and 21, 2019, at Sunnybrook, the Member failed to adequately document the nursing care she provided to Patient [D], Patient [E], and Patient [F].

24. The Member worked a 12-hour night shift from October 20, 2019 to October 21, 2019 at Sunnybrook (the “October 20th Night Shift”). She was responsible for four patients, including Patient [D], Patient [E], and Patient [F].

25. Sunnybrook expects nurses to document a transfer of accountability, an initial assessment, and notes throughout the shift. If a nurse is dealing with more acute and critically ill patients, Sunnybrook’s expectation is that the nurse will document more frequently.

26. However, the Member’s documentation for Patient [D], Patient [E], and Patient [F] did not meet these requirements:

a) The Member did not make any nursing notes for Patient [D] until after 3:40 am on October 21, 2019. Sometime after 3:40 am on October 21, the Member made two late entry notes for 10 pm and 11:55 pm on October 20, 2019. However, neither of these notes includes details about the transfer of accountability or the Member’s initial assessment of the patient. The Member also failed to document an initial assessment of the patient’s vital signs as part of the transfer of accountability for the patient;

b) The Member made her first nursing note for Patient A.S.C at 4:30 am on October 21, 2019. She did not document details about the transfer of accountability or her initial assessment of the patient. The Member also failed to document any vitals for the patient between 1:30 am and 7:30 am on October 21, 2019; and

c) The Member only made one nursing note for Patient [F]. She made this note at 4:30 am on October 21, 2019. She did not document details about the transfer of accountability or her initial assessment of the patient.

The Member failed to place a required c-collar on a patient on full spinal precautions

27. On October 20 and 21, 2019, at Sunnybrook, the Member failed to place a c-collar on Patient [D], who had an order for full spinal precautions.

28. As set out above, the Member was responsible for Patient [D]’s care during the October 20th Night Shift. The patient’s Spine Service Consult Orders stipulated that he had to wear a c-collar. These orders were issued during the Member’s shift, at 11:30 pm on October 20, 2019.

29. The Member took her break from 2 am to 4 am on October 21, 2019. During this time, staff from the neurosurgery department came to assess the patient. They asked the two nurses working with the Member why the c-collar had not been placed on the patient. The Member had not made any documentation in the patient’s chart before leaving for her break, so the two nurses did not know why the c-collar had not been placed on the patient as ordered.

30. The two nurses placed the c-collar on the patient themselves, and one nurse recorded this action in the patient’s chart. At 2:50 am on October 21, 2019, the same nurse made a progress note stating: “Covering RN – initial pt contact – pt on full spine precautions, without c-collar on pt. Aspen collar obtained from C5 – applied w/ 2 RNs maintaining cervical precautions…”

31. When the Member returned from her break, she made a late entry progress note for the patient, which said that the patient was taken off c-spine precautions by plastics, but that ortho placed the patient back on c-spine precautions at 11:55 pm on October 20, 2019. The Member did not make a progress note or otherwise explain why she did not place a c-collar on the patient between 11:55 pm on October 20, 2019 and 2:00 am on October 21, 2019 when she went on her break.

The Member failed to apply pacer pads to a patient requiring emergent intervention, despite multiple directions to do so from a physician

32. On October 20, 2019, at Sunnybrook, the Member failed to apply pacer pads to Patient S.C. when the patient required emergent intervention, despite multiple directions to do so from a physician.

33. The patient had third degree heart block, and was under the Member’s care on the October 20th Night Shift. The patient needed pads applied for emergent intervention. However, the Member ignored the cardiologist – who asked the Member to apply pads multiple times – and instead continued to chart. Another nurse applied the pads and brought the crash cart to the cardiologist in the Member’s place.

The Member administered a double dose of insulin and failed to adequately document insulin administration

34. On October 22 and/or 23, 2019, at Sunnybrook, the Member failed to adequately document administering insulin to Patient [G] and administered a double dose of insulin to the patient without authorization.

35. The Member was the primary nurse for the patient on a 12-hour shift at Sunnybrook from October 22, 2019 to October 23, 2019 (the “October 22nd Night Shift”).

36. The patient was receiving insulin according to orders set out in the Critical Care Insulin Infusion Nomogram. The Member made notes about adjusting and administering insulin to the patient in the nursing documentation/notes throughout her shift. However, she did not document her insulin administration on the Medication Dose/Route chart, as required.

37. The Member asked another nurse at Sunnybrook to check the patient’s glucose levels during the Member’s break on the October 22nd Night Shift. This nurse checked the patient’s blood glucose and on finding that it was 12.7 mmol/l, she administered 2 units of insulin. She documented that she had administered insulin to the patient in the patient’s chart. The patient was not authorized to receive further insulin until 90 minutes after this dose of insulin was administered.

38. Less than 90 minutes later, after the Member returned from her break, the same nurse went to assist the Member with wound care for the patient and found the Member administering an additional, unauthorized dose of insulin to the patient. This nurse reported the medication error – that the patient received double the authorized insulin dose – to her supervisors and filled out an Incident Report.

CNO STANDARDS

Code of Conduct

39. CNO’s Code of Conduct is a standard of practice describing the accountabilities all Ontario nurses have to the public. The Code of Conduct consists of six principles including:

• Nurses respect the dignity of patients and treat them as individuals;

• Nurses work together to promote patient well-being;

• Nurses maintain patients’ trust by providing safe and competent care;

• Nurses work respectfully with colleagues to best meet patients’ needs;

• Nurses act with integrity to maintain patients’ trust; and

• Nurses maintain public confidence in the nursing profession.

40. With respect to the principle requiring nurses to respect the dignity of patients and treat them as individuals, CNO’s Code of Conduct provides that nurses treat patients with care and compassion.

41. With respect to the principle requiring nurses to work together to promote patient well-being, CNO’s Code of Conduct provides that nurses advocate for patients and help them access appropriate health care and that nursing care is timely, and when this is not possible, nurses explain reasons for this delay to patients.

42. With respect to the principle requiring nurses to maintain patients’ trust by providing safe and competent care, CNO’s Code of Conduct provides that nurses: use appropriate knowledge, skill and judgment when assessing the health needs of patients; respond and are available to patients when working; seek advice and collaborate with the health care team to uphold safe patient care; maintain complete, accurate and timely documentation in their practice; and are accountable to, and practice under, relevant laws and CNO’s standards of practice.

43. With respect to the principle requiring nurses to work respectfully with colleagues to best meet patients’ needs, CNO’s Code of Conduct provides that nurses are professional with colleagues and treat them with respect and that nurses collaborate and communicate with colleagues in a clear, effective, professional and timely way.

44. With respect to the principle requiring nurses to act with integrity to maintain patients’ trust, CNO’s Code of Conduct provides that nurses take prompt action to prevent and protect patients from harm.

45. With respect to the principle requiring nurses to maintain public confidence in the nursing profession, CNO’s Code of Conduct provides that nurses are accountable for their own actions and decisions and have a duty to report any error or conduct that affects patient safety.

46. Attached as Exhibit “A” is a copy of CNO’s Code of Conduct that was in force at the time of the incidents described herein.

Professional Standards

47. CNO’s Professional Standards provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by CNO. It includes seven broad standard statements and indicators that illustrate how the standard may be demonstrated pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership and relationships.

48. CNO’s Professional Standards provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring their practice and conduct meets the legislative requirements and the standards of the profession. Nurses are responsible for their actions and the consequences of those actions as well as for conducting themselves in ways that promote respect for the profession. Nurses demonstrate this standard by:

• providing, facilitating, advocating and promoting the best possible care for [patients];

• advocating on behalf of [patients];

• seeking assistance appropriately and in a timely manner;

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

• taking action in situations in which [patient] safety and well-being are compromised; and

• taking responsibility for errors when they occur and taking appropriate action to maintain [patient] safety.

49. CNO’s Professional Standards provides, in relation to the knowledge standard, that each nurse possesses, through basic education and continuing learning, knowledge relevant to their professional practice. Nurses demonstrate this standard by understanding the knowledge required to meet the needs of complex patients.

50. CNO’s Professional Standards further provides, in relation to the knowledge application standard, that each nurse continually improves the application of professional knowledge. Nurses demonstrate this standard by:

• identifying/recognizing abnormal or unexpected [patient] responses and taking action appropriately;

• recognizing limits of practice and consulting appropriately; and

• identifying and addressing practice-related issues.

51. In addition, CNO’s Professional Standards provides, in relation to the leadership standard, that leadership requires self-knowledge (understanding one’s beliefs and values and being aware of how one’s behaviour affects others), respect, trust, integrity, shared vision, learning, participation, good communication techniques and the ability to be a change facilitator. Nurses demonstrate their leadership by providing, facilitating and promoting the best possible care/service to the public. Nurses also demonstrate this standard by:

• role-modelling professional values, beliefs and attributes; and

• collaborating with [patients] and the health care team to provide professional practice that respects the rights of [patients].

52. Attached as Exhibit “B” is a copy of CNO’s Professional Standards that was in force at the time of the incidents described herein.

Documentation

53. CNO’s Documentation Standard explains the regulatory and legislative requirements for nursing documentation. It includes three standard statements and indicators pertaining to communication, accountability and security which describe a nurse’s accountabilities when documenting.

54. CNO’s Documentation standard provides, in relation to communication, that nurses ensure that documentation presents an accurate, clear and comprehensive picture of the patient’s needs, the nurse’s interventions and the patient’s outcomes. Nurses meet the standard by:

• 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;

• documenting both objective and subjective data.

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

• documenting significant communication with family members/significant others, substitute decision-makers and other care providers.

55. CNO’s Documentation standard further provides, in relation to accountability, that nurses are accountable for ensuring their documentation of patient care is accurate, timely and complete. Nurses meet the standards by:

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

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

• documenting in chronological order;

• ensuring that documentation is completed by the individual who performed the action or observed the event, except when there is a designated recorder, who must sign and indicate the circumstances; and

• clearly identifying the individual performing the assessment and/or intervention when documenting.

56. CNO’s Documentation standard also provides, in relation to security, that nurses safeguard patient health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures that are consistent with the standard(s) and legislation. Nurses meet the standard by ensuring that relevant patient care information is captured in a permanent record.

57. Attached as Exhibit “C” is a copy of CNO’s Documentation Standard that was in force at the time of the incidents described herein.

Medication

58. CNO’s Medication standard provides that administering, recommending and/or prescribing medication requires knowledge, technical skills and judgment. With respect to competence, nurses need the competence to assess the appropriateness of medication for a patient, manage adverse reactions, understand issues related to consent and make ethical decisions about medications.

59. The Medication standard also provides that safe medication practice includes reporting all errors and near misses using formal practice-setting communication mechanisms.

60. The Medication standard further provides that a nurse meets the standard by:

• Taking appropriate action to prevent, resolve or minimize the risk of harm to a patient from a medication error or adverse reaction;

• Reporting medication errors, near misses or adverse reactions in a timely manner;

• Preparing and administering the medication according to an evidence-informed rationale; and

• Documenting, during and/or after medication administration, in the patient’s record according to documentation standards.

61. Attached as Exhibit “D” is a copy of CNO’s Medication Standard that was in force at the time of the incidents described herein.

62. The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards, Documentation, and Medication Standard, as described above.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

63. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a)-(n) of the Notice of Hearing in that she contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 4 to 62 above.

64. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2(a)-(g) of the Notice of Hearing in that she failed to keep records as required, as described in paragraphs 4 to 6, 11 to 14, 19 to 26, and 34 to 38 above.

65. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3(a)-(n) of the Notice of Hearing, and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 4 to 38 above.

The Panel questioned allegation #1(d) and sought further submissions from College Counsel and the Member’s Counsel for clarification. The Member, the Member’s Counsel and College Counsel returned from their discussions and informed the Panel that paragraph 14 in the Agreed Statement of Facts was to be revised to state: “However, the Member did not notify the Charge Nurse that the patient’s arterial line had come out or ensure that this matter was escalated to a physician. If the Member were to testify, she would say that she reported the arterial line had come out to a respiratory therapist. The Member did not document this action as required.” The Panel accepted this amendment to the Agreed Statement of Facts.

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), (f), (g), (h), (i), (j), (k), (l), (m), (n), #2(a), (b), (c), (d), (e), (f), (g) and #3(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m) and (n) of the Notice of Hearing. As to allegations #3(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m) and (n), 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.

Allegation #1(a) in the Notice of Hearing is supported by paragraphs 4-6, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while working as a Registered Nurse (“RN”) at Niagara Health System – Greater Niagara General Site (“Niagara Health”) she committed professional misconduct when she failed to adequately document administering or wasting 2 mg of midazolam after she had drawn it up for Patient [A]. The College’s Medication Standard provides that a nurse must document during and/or after medication administration, in the patient’s record according to documentation standards.

Allegation #1(b) in the Notice of Hearing is supported by paragraphs 7-10, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while at Niagara Health she committed professional misconduct when she failed to intervene when Patient [A]’s potassium level dropped to 3.0 mmol/L even though there was an order for intravenous potassium to be given if the patient’s potassium level was between 3-3.4 mmol/L. The Member failed to meet the College's Professional Standards when she failed to take action when Patient [A]’s potassium level was low. Nurses are expected to take action in situations in which a patient’s wellbeing is compromised.

Allegation #1(c) in the Notice of Hearing is supported by paragraphs 11-14, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while at Niagara Health she committed professional misconduct when she failed to intervene appropriately when Patient [A]’s arterial line came out. The Member failed to meet the College’s Professional Standards when she failed to respond to a situation in which a patient’s safety was compromised. Nurses are to provide their patients with the best possible care, as well they are to ensure their practice is consistent with the College’s standards of practice.

Allegation #1(d) in the Notice of Hearing is supported by paragraphs 14, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while at Niagara Health she committed professional misconduct when she failed to document her nursing interventions when Patient [A]’s arterial line came out. The College’s Documentation Standard sets out that nurses are responsible for ensuring their documentation is complete, which includes a record of all care provided including assessment, planning, intervention and evaluation.

Allegation #1(e) in the Notice of Hearing is supported by paragraphs 15-18, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while at Niagara Health she committed professional misconduct when she failed to meet the College’s Code of Conduct by not following the Heparin Standard Dose Anticoagulation Order Set. The Code of Conduct requires nurses to maintain patients’ trust by providing safe and competent care. By failing to adhere to the Heparin Standard Dose Anticoagulation Order Set when Patient [A] had a critical aPTT blood result, the Member potentially put the patient at risk, thereby not providing safe and competent care.

Allegation #1(f) in the Notice of Hearing is supported by paragraphs 19, 20, 22, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while working as an RN at Sunnybrook Health Sciences Centre (“Sunnybrook”) she committed professional misconduct when she failed to meet the College’s Medication Standard when she administered 1.6 mg of hydromorphone to Patient [B] without authorization.

Allegation #1(g) in the Notice of Hearing is supported by paragraphs 19, 21, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while at Sunnybrook she committed professional misconduct when she failed to meet the College’s Medication Standard and Documentation Standard when she failed to document administering or wasting 1.6 mg of hydromorphone she had withdrew for Patient [B]. The Medication Standard outlines that nurses are expected to document during and/or after medication administration.

Allegation #1(h) in the Notice of Hearing is supported by paragraphs 32, 33, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while at Sunnybrook she committed professional misconduct when she failed to apply pacer pads to Patient [C] despite multiple directives from a physician. According to the College’s Professional Standards, a nurse demonstrates these standards by providing, facilitating, advocating, and promoting the best possible care for patients. By failing to apply pacer pads to a patient in third-degree heart block as requested by a cardiologist, the Member contravened the Professional Standards and put Patient [C] at risk.

Allegations #1(i), (j) and (k) in the Notice of Hearing are supported by paragraphs 23-26, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while at Sunnybrook she committed professional misconduct when she failed to document the nursing care she provided to Patient [D], Patient [E] and Patient [F]. The Member worked a 12-hour night shift from October 20-21, 2019, at Sunnybrook when she failed to document transfer of accountability, an initial assessment, and notes throughout the shift including vital signs for three patients. The Member admitted to not completing the expected documentation. Nurses meet the Documentation Standard by ensuring documentation is a compete record of nursing care provided and includes assessment, planning, intervention and evaluation.

Allegation #1(l) in the Notice of Hearing is supported by paragraphs 27-31, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while at Sunnybrook she committed professional misconduct when she failed to meet the College’s Professional Standards by not placing a c-collar on Patient [D], despite an order for full spinal precautions. Nurses demonstrate these standards by providing, facilitating, advocating, and promoting the best possible care for patients. By failing to apply a c-collar to a patient with specified orders during her shift, the Member contravened the Professional Standards and put Patient [D] at risk.

Allegation #1(m) and (n) in the Notice of Hearing are supported by paragraphs 34-38, 62 and 63 in the Agreed Statement of Facts. The Member admitted that while at Sunnybrook she committed professional misconduct when she failed to meet the College’s Documentation Standard and Medication Standard when she administered a double dose of insulin to Patient [G] without authorization and failed to document the administration on the Medication Dose/Route chart, as required by Sunnybrook. These standards expect nurses to document during and/or after administration and to take appropriate action to prevent risk of harm to patients. The evidence clearly shows that the Member failed to meet either of these standards while caring for Patient [G].

Allegations #2(a), (b), (c), (d), (e), (f) and (g) in the Notice of Hearing are supported by paragraphs 4-6, 11-14, 19-26, 34-38 and 64 in the Agreed Statement of Facts. The Member admitted that she committed professional misconduct when she failed to document and/or keep records on several occasions, with several patients between the dates of January 15, 2019 - October 23, 2019. Specifically, the Member admitted to lapses in documentation such as not recording the administration or wastage of 2 mg of midazolam and 1.6 mg of hydromorphone, neglecting to document nursing interventions following the dislodgement of Patient [A]’s arterial line, inadequately documenting care provided to three patients during a specific 12-hour shift on October 20-21, 2019, and failing to sufficiently document the administration of insulin to Patient [G]. These omissions were found to contravene the Documentation Standard set by the College, as the evidence showed inadequate record-keeping, encompassing both routine and narcotic-related documentation.

Allegations #3(a), (b), (c), (d), (e), (f), (g), (h), (i), (j), (k), (l), (m) and (n) in the Notice of Hearing are supported by paragraphs 4-38 and 65 in the Agreed Statement of Facts. The Panel finds that the Member's conduct in administering medication without proper authorization, failing to intervene in critical patient situations when required, and maintaining incomplete and substandard documentation was relevant to the practice of nursing. The Member’s conduct was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations by breaching the Code of Conduct, the Professional Standards, the Documentation Standard and the Medication Standard.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing when she failed to document administering or wasting of medications and nursing interventions, failed to intervene appropriately or as ordered, failed to follow physician orders and administered medication without authorization. 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 that a Joint Submission on Order had been agreed upon and requested that the Panel make the following order:

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

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

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

a) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at the Member’s own expense and within 6 months from the date 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, but in any event, all sessions shall be completed within 12 months from the date this Order becomes final. To comply, the Member is required to ensure that:

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

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

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

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

1. Code of Conduct,

2. Medication,

3. Documentation, and

4. 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:

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

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

3. strategies for preventing the misconduct from recurring,

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

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

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

1. the dates the Member attended the sessions,

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

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

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

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

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

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

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

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

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

iv. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to CNO, in which it will confirm:

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

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

c) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will meet with a nurse registered with CNO, who is employed in a supervisory or leadership role at the same employer as the Member, and who is pre-approved by CNO (“Mentor”), at her expense. At the meetings, the Member and the Mentor will discuss the Member’s reflections and efforts to ensure the Member’s patient care, medication administration and documentation practices are meeting the standards of practice of the profession. The Member will meet with the Mentor at such frequency as determined by the Mentor, but at least monthly. In order for the Mentor to be pre-approved by CNO, the Member must:

i. Provide the proposed mentor with a copy of:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

ii. Provide consent in writing to CNO and to the Member’s proposed mentor allowing the proposed mentor and CNO to communicate about the meetings;

iii. Provide CNO with the résumé of the proposed mentor and a report from the proposed mentor confirming the following:

1. that the proposed mentor has received a copy of the documents identified in paragraph 3(c)(i) above, and

2. that the proposed mentor agrees to notify CNO and the Member’s employer immediately upon receipt of any information that the Member has breached the standards of practice of the profession;

3. that the proposed mentor will conduct audits of the Member’s practice at the following intervals:

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

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

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

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

4. that for each audit, the proposed mentor will review a random selection of 10 of the Member’s charts to ensure they meet both CNO and employer standards, and provide a report to CNO regarding the Member’s practice after each audit;

iv. After the 12-month period identified in 3(c) above, the Mentor will determine whether further meetings are required and will arrange those meetings with the Member as necessary. When the Mentor determines that no further meetings are required, the Mentor will advise CNO in writing when the meetings have ended and explain why they are no longer required; and

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

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

College Submissions on Penalty

College Counsel made submissions which included the following.

The aggravating factors in this case were:

• The Member admitted to serious conduct; and

• The Member repeated this conduct and errors involving multiple patients on multiple occasions at two different facilities.

The mitigating factors in this case were:

• The Member has taken responsibility for her conduct and cooperated with the College by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College; and

• The Member has no prior disciplinary history with the College.

The proposed penalty provides for specific and general deterrence through:

• The oral reprimand; and

• The 4-month suspension of the Member’s certificate of registration;

The proposed penalty provides for remediation and rehabilitation through:

• A minimum of two meetings with a Regulatory Expert, which will allow the Member to review the College’s publications and requirements;

• The terms, conditions and limitations placed on the Member’s certificate of registration; and

• The 12 months of mentorship on return to nursing will assist the Member in reflecting on her practice and to ensure her practice is meeting expected standards.

Overall, the public is protected because this process will assist the Member in gaining additional insight and knowledge into her practice. The 12 months of employer notification and the 12 months of no independent practice in the community will ensure the Member is monitored for a significant amount of time after she returns from the suspension.

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. Fernandez (Discipline Committee, 2021): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member failed to meet the standard of practice when she made several medication errors, failed to keep records as required and failed to attend to a patient in respiratory distress. This case involved multiple patients. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration, a minimum of 2 meetings with a Regulatory Expert, mandatory completion of nursing courses at her own expense, 12 months of employer notification, 8–12 months of mentorship and 12 months of no independent practice in the community upon her return to practice.

CNO v. Tanguay (Discipline Committee, 2021): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member failed to meet the standard of practice when she did not administer sliding scale insulin on 82 dates between December 2017-August 2018. The member improperly delegated nursing tasks to non-registered staff, requested personal health information of a patient from a non-registered staff member in public, left medications unattended and made inappropriate statements in front of patients. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration, a minimum of 2 meetings with a Regulatory Expert, 18 months of employer notification and 18 months of no independent practice in the community upon her return to practice.

College Counsel submitted that the penalty documented in the Joint Submission on Order fits within the penalties for previous similar cases as well as meets all the goals of penalty.

Member’s Submissions on Penalty

The Member’s Counsel indicated that he had no submissions to make but did communicate to the Panel that the Member has been practicing nursing for many years with a spotless record and requested the Panel take this into account during the deliberations.

Penalty Decision

The Panel accepted the Joint Submission on Order and made the order requested.

Reasons for Penalty Decision

There is a high threshold for departing from a Joint Submission on Order established by the Supreme Court of Canada in R. v. Anthony-Cook, 2016 SCC 43. Departing from a joint submission would require a finding that the proposed penalty would bring the administration of justice into disrepute or is otherwise contrary to the public interest.

The Panel concluded that the proposed penalty is not contrary to the public interest and does not bring the administration of justice into disrepute.

The Panel concluded that the proposed penalty is reasonable and in the public interest. It promotes public confidence in the ability of the College to regulate nurses.

The Panel finds that the proposed penalty satisfies the penalty goals of specific and general deterrence, rehabilitation and remediation, and public protection.

The proposed penalty provides for specific deterrence through the oral reprimand and the 4-month suspension of the Member’s certificate of registration.

The proposed penalty provides for general deterrence through the 4-month suspension of the Member’s certificate of registration, which sends a strong message to members of the profession that there are serious consequences for such conduct.

The proposed penalty provides for remediation and rehabilitation through a minimum of 2 meetings with a Regulatory Expert, completion of the review of the standards and completion of Reflective Questionnaires.

Overall, the public is protected through the 12 months of employer notification, the 12 months of mentorship with audits, where the Member will be monitored closely, and the 12 months of no independent practice in the community upon her return to practice. These serve as precautionary measures to ensure the Member operates under supervision once she re-enters nursing practice.

The Panel acknowledges that the Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility, which is a mitigating factor.

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

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