DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Michael Hogard, RPN Chairperson
Tim Crowder Public Member Grace Fox, NP Member
Ahamad Mohammed, RPN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) GLYNNIS HAWE for
) College of Nurses of Ontario
- and - )
BUKKY OYEDELE ) VICTORIA TREMBLETT for
Registration No. 0312223 ) Bukky Oyedele
) CHRISTOPHER WIRTH
) Independent Legal Counsel
) Heard: February 14, 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 February 14, 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 Bukky Oyedele.
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 Bukky Oyedele.
The Allegations
College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraph 3 in the Notice of Hearing dated December 18, 2023. The Panel granted this request. The remaining allegations against Bukky Oyedele (the “Member”) 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 working as a Registered Nurse in the PICU/Step Down Unit at Markham Stouffville Hospital in Markham, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, and in particular:
a) on or about September 22 to 23, 2018:
i) you failed to monitor and/or observe Patients A, B, C, D, E, and F with the appropriate frequency;
ii) you documented inaccurate and/or false entries in the health records of Patients A, B, C, D, E, and F with respect to monitoring and/or observation that you did not complete; and/or
iii) you failed to complete and/or document post-fall assessments of Patient D with the appropriate frequency; and/or
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(13) of Ontario Regulation 799/93, in that, while working as a Registered Nurse in the PICU/Step Down Unit at Markham Stouffville Hospital in Markham, Ontario, you failed to keep records as required, and in particular:
(a) on or about September 22 to 23, 2018, you documented inaccurate and/or false entries in the health records of Patients A, B, C, D, E, and F with respect to monitoring and/or observation that you did not complete; and/or
(b) you failed to document post-fall assessments of Patient D with the appropriate frequency; and/or
[Withdrawn]; and/or
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that, while working as a Registered Nurse in the PICU/Step Down Unit at Markham Stouffville Hospital in Markham, 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) on or about September 22 to 23, 2018:
i) you failed to monitor and/or observe Patients A, B, C, D, E, and F with the appropriate frequency;
ii) you documented inaccurate and/or false entries in the health records of Patients A, B, C, D, E, and F with respect to monitoring and/or observation that you did not complete; and/or
iii) you failed to complete and/or document post-fall assessments of Patient D with the appropriate frequency.
Member’s Plea
The Member admitted the allegations set out in paragraphs 1(a)(i), (ii), (iii), 2(a), (b) and 4(a)(i), (ii) and (iii) in the Notice of Hearing. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admissions were voluntary, informed and unequivocal.
Agreed Statement of Facts
College Counsel and the Member’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited without exhibits, as follows:
THE MEMBER
Bukky Oyedele (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on July 23, 2003.
The Member was employed on a casual basis as a nurse at Markham Stouffville Hospital (the “Facility”), working approximately one shift every six weeks. The Member worked on the Psychiatric Intensive Care Unit (the “PICU”) and the Stepdown Unit.
THE PICU
The PICU is a designated area in the Inpatient Mental Health Unit (the “IPMH”) at the Facility for acutely ill patients who require a level of intensive observation by a designated staff member.
Observation levels may vary throughout the IPMH depending on the patient’s mental/physical status. The Facility’s Observation and Privilege Levels in Inpatient Mental Health policy in force at the time of the incidents (the “Observation Policy”) specifies that observation of a patient includes the assessment of that person’s location, mental status, and physical wellbeing.
The Observation Policy also outlines the observation levels that may be required including:
Routine – Direct monitoring and observation of a patient by a designated staff member every 1 hour;
Close (C15) – Direct monitoring and observation of a patient by a designated staff member every 15 minutes (“q15 checks”);
Intensive – Assessment of a patient more frequently than q15min, with the continuous physical presence of a staff member in the same environmental vicinity as the patient; and
One to One – Continuous sight contact and within reach of patient at all times.
The q15 checks can be done by way of video monitors located at the nursing station, or by going to the patient rooms and either observing the patients through the door or entering the room if the nurse cannot properly visualize the patient’s condition by observing through the door. The q15 checks are to be documented on the Close Observation sheet, with the nurse identifying the patient’s location and/or behaviour every 15 minutes and signing each entry.
The Routine check is a physical check in each patient’s room which is to be done each hour. It can be done by visualizing the patient through the doors to their room or actually entering the room. This check is to be documented on the Hourly Rounds Sheet.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
The Member worked the night shift on the PICU from September 22 to 23, 2018. There were six patients in the PICU at the time: Patient A, Patient B, Patient C, Patient D, Patient E and Patient F. Three of the six patients required q15 checks.
Two other nurses were working the night shift with the Member including Colleague A, RN, and Colleague B, Registered Practical Nurse. Colleague A was in charge of the PICU. Colleague A was employed full-time at the Facility and worked on the PICU. Colleague B was employed part-time at the Facility and worked on the PICU.
During the night shift, Colleague A began her break around midnight. At approximately 0200 hours, Colleague B began her break, when Colleague A had not yet returned. As such, the Member was caring for all PICU patients by herself between 0200 and 0320 hours when both Colleague A and Colleague B returned to the PICU in response to a Code Blue.
Observation and Documentation
Throughout the shift, the Member failed to monitor and observe the PICU patients at the required frequency. In particular, video surveillance footage from the Facility shows the Member did not leave the nursing station between 0100 and 0315 hours and thus did not conduct the hourly checks during that time, which required personally visualizing the patients, either through the doors to their rooms or actually entering the rooms. Notwithstanding that the Member did not conduct hourly checks, the Member completed documentation for the patients as though she had.
The Member also documented observing the patients in the PICU every 15 minutes between 0100 hours and 0315 hours. In particular, during the period from 0100 hours to 0245 hours, the Member documented the following on the Close Observation sheets:
Patient A: q15 checks from 0100-0300;
Patient B: q15 checks from 0100-0300;
Patient C: q15 checks from 0100-0300;
Patient D: q15 checks from 0100-0230;
Patient E: q15 checks from 0100-0300; and
Patient F: q15 checks from 0100-0300.
If the Member were to testify, she would say that she performed q15 checks via video monitoring at the nursing station, although not with the frequency required by the Observation Policy.
The Member was assigned to provide care to Patient D who required q15 checks. Between approximately 0100 hours to 0315 hours, Patient D fell approximately 26 times, hitting his face and head. Patient D sustained injuries including a laceration to the nose and inner lip, hematomas to his forehead and the back of his head, and abrasions.
Had the Member been conducting q15 checks using the nursing station’s video monitors, the Member would have been able to see that Patient D was on the floor at times and visibly injured. She failed to do so.
If the Member were to testify, she would say that she was specifically advised not to enter Patient D’s room without another staff member and/or security guards as Patient D was known to be aggressive and had assaulted a staff member on the previous shift. However, the Member admits and acknowledges that she did not request assistance from other staff in order to conduct the hourly checks, nor was she prevented by this security protocol from conducting q15 checks on Patient D using the nursing station’s video monitors, which she was obligated to conduct in any event.
At approximately 0315 hours Patient D entered the hallway, at which time the Member observed his injuries and immediately called for assistance.
Patient D subsequently underwent a CT scan and x-ray which did not identify any serious injuries. Patient D was discharged from the Hospital the following day, September 24, 2018.
Post Fall Assessment
Once the incident involving Patient D was discovered, the Member failed to follow the Hospital’s Falls Risk Reduction and Injury Prevention Program in force at the time of the incidents (the “Falls Policy”).
According to the Falls Policy, after an unwitnessed or witnessed fall with a head injury, neurological assessments, vital signs, pain score, and skin assessments, must be performed on the following schedule:
Q 15 minutes x 4, then;
Q 1 hour x 4, then;
Q 4 hours x 8, then; and
As ordered.
- Under the Falls Policy, nurses must also:
assess the fall-related injury as serious, moderate or minor;
communicate their findings to the appropriate physician;
notify attending/on-call physician, substitute decision-maker/family, and manager/director immediately if a serious or moderate injury;
conduct a post-fall debrief as soon as possible after the fall (in the same shift) and once the patient has been fully assessed and treated; and
document the fall, post-fall monitoring and post-fall debrief.
The Member took Patient D’s vitals only once, at 0627 hours. Staff other than the Member took Patient D’s vitals at 0325, 0339, 0427, and 0457 hours. Patient D’s pulse and blood pressure were also documented at 0330, 0400, 0430, 0500, 0601, 0630, and 0740 hours. Patient D’s chart does not indicate who documented taking these vital signs.
The only vital signs assessments evident on the video surveillance footage are those conducted by another nurse at approximately 0322 and 0335 hours.
Patient D left the floor for a CT scan from approximately 0352 to 0420 hours accompanied by the Member, another registered staff, and two security guards.
The video surveillance footage demonstrates that between the time the Member called the Code Blue and Patient D leaving the PICU at around 0352 hours, the Member was actively engaged with the care of the patient, including by doing the following:
the Member spoke with the responding physician who arrived on the PICU in response to the Member’s call for assistance;
the Member inspected Patient D’s face, eyes, head, and arms;
the Member held a towel to an abrasion on Patient D’s head and cleaned blood off of Patient D’s face; and
the Member spoke with Patient D while another nurse took Patient D’s vital signs.
While three additional post-fall assessments were documented by Colleague A, the video surveillance footage from the Facility demonstrates that neither the Member nor Colleague A conducted a complete post-falls assessment of Patient D during that time, or at all.
The other assessments required by the Falls Policy were either not conducted at all or, if they were, it is not evident on the video surveillance footage from the Facility, and they were not documented.
CNO STANDARDS
Professional Standards
CNO’s Professional Standards provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by CNO. It includes seven broad standard statements pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership and relationships.
CNO’s Professional Standards provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring their practice and conduct meets the legislative requirements and the standard 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 the 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.
- Attached as Exhibit “A” is a copy of CNO’s Professional Standards which was in force at the time of the incidents and has since been retired.
Documentation
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.
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; and
documenting both objective and subjective data.
- 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; and
clearly identifying the individual performing the assessment and/or intervention when documenting.
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.
Attached as Exhibit “B” is a copy of CNO’s Documentation Standard which was in force at the time of the incidents.
The Member admits and acknowledges that she contravened CNO’s Professional Standards and Documentation Standard when she:
failed to monitor and observe Patients A, B, C, D, E, and F with the appropriate frequency;
documented inaccurate entries in the health records of Patients A, B, C, D, E, and F with respect to monitoring and observation that she did not complete; and
failed to complete and/or document post-fall assessments of Patient D with the appropriate frequency.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a)(i), 1(a)(ii) in that she documented inaccurate entries, and 1(a)(iii) of the Notice of Hearing in that she contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 8 to 35 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2(a) in that she documented inaccurate entries, and 2(b) of the Notice of Hearing in that she failed to keep records as required, as described in paragraphs 8 to 26 and 30 to 35 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 4(a)(i), 4(a)(ii) in that she documented inaccurate entries, and 4(a)(iii) of the Notice of Hearing, and in particular that she 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 dishonourable and unprofessional, as described in paragraphs 8 to 35 above.
OTHER
- With the leave of the Panel of the Discipline Committee, CNO withdraws the remaining allegations in the Notice of Hearing, which are as follows: paragraph 3 of the Notice of Hearing.
College Counsel’s Submissions on Liability
College Counsel asked the Panel to accept the Agreed Statement of Facts, as well as the Member’s admissions to the allegations in the Notice of Hearing except for allegation #3 as it was withdrawn. The Member’s admissions in paragraphs 36 to 38 of the Agreed Statement of Facts were voluntary and informed and make references to the appropriate paragraphs within the document. The resolution was fair and protects the public interest.
As to allegations #1(a)(i), (ii) and (iii), the breach of the standards of practice, the particular standards breached have been included in the Agreed Statement of Facts along with the Member’s admission that these standards were contravened.
As to allegations #2(a) and (b), the facts within the Agreed Statement of Facts demonstrate that the Member’s documentation was inaccurate.
As to allegations #4(a)(i), (ii) and (iii), the Member’s conduct was relevant to the practice of nursing as it was during direct care to the patients. Members of the profession would find that the Member’s conduct was unprofessional as she disregarded her professional obligations, as well as dishonourable as it had an element of moral failing and fell below the standards expected of and by nurses. The Member’s admissions to these allegations are set out in paragraph 38 of the Agreed Statement of Facts.
The Member’s Counsel’s Submissions on Liability
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)(i), (ii), (iii), 2(a), (b) and 4(a)(i), (ii) and (iii) of the Notice of Hearing. As to allegations #4(a)(i), (ii) and (iii), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be 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 (excluding Allegation #3).
Allegations #1(a)(i), (ii) and (iii) in the Notice of Hearing are supported by paragraphs 8 to 36 in the Agreed Statement of Facts. While working as a Registered Nurse (“RN”) at the Markham Stouffville Hospital (the “Facility”), the Member breached the College’s Professional Standards in relation to the accountability standard when she failed to monitor the patients in the Psychiatric Intensive Care Unit (“PICU”) at the required frequency. She documented the appropriate frequency, but did not perform the monitoring according to the Facility’s Observation and Privilege Levels in Inpatient Mental Health policy (the “Observation Policy”). The Member also failed to complete and/or document post-fall assessments on Patient D according to the required frequency. The Member did not provide the best possible care to her patients. She did not seek assistance initially or act in this situation where the patients’ safety and well-being were compromised.
The Member breached the College’s Documentation Standard in failing to follow and document the post-fall assessment and ongoing observations of Patient D. She also failed to ensure that her documentation was accurate in her patient checks.
Allegations #2(a) and (b) in the Notice of Hearing are supported by paragraphs 8 to 26, 30 to 35 and 37 in the Agreed Statement of Facts. The Member documented inaccurate and/or false entries regarding monitoring and observing the patients she was assigned and covering during breaks. She also failed to document post-fall assessments on Patient D as required by the Facility’s Falls Risk Reduction and Injury Prevention Program (the “Falls Policy”).
Allegations # 4(a)(i), (ii) and (iii) in the Notice of Hearing are supported by paragraphs 8 to 35 and 38 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct, in failing to monitor and observe PICU patients at appropriate intervals, as required by the Facility’s Observation Policy, and documenting as if she had completed the monitoring when she had not and not following post-fall assessments as required by the Facility’s Fall Policy, was relevant to the practice of nursing. It was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations in breaching the Professional Standards and the Documentation Standard. It put those vulnerable patients at increased risk of injury, which did occur in the case of Patient D.
The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of dishonesty and deceit when she did not follow the Facility’s Observation Policy and Falls Policy, but charted that she had completed the monitoring at the appropriate frequency. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional.
Penalty
College Counsel and the Member’s Counsel advised the Panel that a Joint Submission on Order had been agreed upon. The Joint Submission on Order requests that this Panel make an order as follows:
Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for 3 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) The Member will attend 2 meetings with a Regulatory Expert (the “Expert”), at the Member’s own expense and within 6 months from the date that this Order becomes final. To comply, the Member is required to ensure that:
i. The Expert has expertise in nursing regulation and has been approved by CNO in advance of the meetings;
ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
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):
Code of Conduct, and
Documentation;
iv. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires;
v. The subject of the sessions with the Expert will include:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards their report to CNO, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into the Member’s behaviour;
vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on the Member’s certificate of registration;
b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify 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:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
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:
that they received a copy of the required documents, and
that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession.
All documents delivered by the Member to CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.
Penalty Submissions
College Counsel’s Submissions
College Counsel asked that the Panel accept the Joint Submission on Order as it meets the goals of penalty, reflects the aggravating and mitigating factors, is consistent with previous decisions, and protects the public.
The aggravating factors in this case were:
The Member failed to monitor the PICU patients which posed a risk of serious harm to those patients. In other cases there have been deaths, but not in this case; and
The patients were vulnerable patients in a mental health unit.
The mitigating factors in this case were:
The Member has no disciplinary history with the College; and
The Member has taken full responsibility for her actions and cooperated with the College throughout the process by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College.
The goal of specific deterrence is met through the oral reprimand and the 3-month suspension of the Member’s certificate of registration, which is a significant amount of time and will deter the Member from this type of conduct when she returns to nursing practice.
General deterrence is met through the 3-month suspension of the Member’s certificate of registration, which will send a signal to members of the profession that this is serious conduct that leads to a significant suspension.
Remediation and rehabilitation are met through the 2 meetings with a Regulatory Expert and review of the College’s Code of Conduct and Documentation Standard.
Overall, the public is protected through the 12 months of employer notification, which will allow for the Member’s employer to have greater oversight over her practice upon her return to nursing.
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. Bose (Discipline Committee, 2022): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. This case is similar as the member worked night shifts in a seniors Mental Health Unit. The member did not monitor patients but documented that he did. He did not enter any patients’ rooms over an 8 hour period. A patient was found unresponsive and later died. The member admitted to falsifying records and to dishonourable and unprofessional conduct. The penalty included an oral reprimand, a 3-month suspension of the member’s certificate of registration, 2 meetings with a Regulatory Expert and 8 months of employer notification. The member had taken steps prior to the discipline process to educate himself.
CNO v. Nkwelle (Discipline Committee, 2018): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. This case is similar as the member worked in mental health within the ER. He failed to perform checks. One of the patients he was assigned to committed suicide. The member admitted to falsifying records and to dishonourable and unprofessional conduct. The member showed deep regret, did take courses and took responsibility. The penalty included an oral reprimand, a three-month suspension of the member’s certificate of registration, two meetings with a Nursing Expert and 12 months of employer notification.
CNO v. Beerschoten (Discipline Committee, 2020): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member was a unit leader and failed to assign or ensure patient checks were completed. Staff found a patient unresponsive, and the patient died of suicide. The member signed a document with misleading statements. The aggravating and mitigating factors were similar and prior to disciplinary action she met with a nursing expert twice. There was also extreme acuity in the unit at the time of the incident. The penalty included an oral reprimand, a two-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and 12 months of employer notification.
The Member’s Counsel’s Submissions
The Member’s Counsel submitted that the Member has engaged in continuing education since the incident and has completed her Master’s in Forensic Nursing and taken courses in Ethics and Advanced Nursing Assessment.
Penalty Decision
The Panel accepts the Joint Submission on Order and accordingly orders:
The Member is required to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
The Executive Director is directed to suspend the Member’s certificate of registration for 3 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.
The Executive Director is directed to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) The Member will attend 2 meetings with a Regulatory Expert (the “Expert”), at the Member’s own expense and within 6 months from the date that this Order becomes final. To comply, the Member is required to ensure that:
i. The Expert has expertise in nursing regulation and has been approved by CNO in advance of the meetings;
ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
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):
Code of Conduct, and
Documentation;
iv. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires;
v. The subject of the sessions with the Expert will include:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards their report to CNO, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into the Member’s behaviour;
vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on the Member’s certificate of registration;
b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify 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:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
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:
that they received a copy of the required documents, and
that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession.
All documents delivered by the Member to CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.
Reasons for Penalty Decision
The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The Panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly.
The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility. The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection.
The proposed penalty provides for general deterrence through the 3-month suspension of the Member’s certificate of registration, which will deter the membership from engaging in such conduct.
The proposed penalty provides for specific deterrence through the oral reprimand and the 3-month suspension of the Member’s certificate of registration. The Member will gain an understanding of how members of the profession and the public feel about her conduct through the reprimand. The suspension will give the Member time to reflect on her conduct.
The proposed penalty provides for remediation and rehabilitation through the review of the standards and the 2 meetings with a Regulatory Expert. This will support her in her return to ethical and professional practice and protect the public.
Overall, the public is protected through the 12 months of employer notification and because the goals of penalty are met, and the Member will return to practice with support and supervision.
The penalty is also in line with what has been ordered in previous cases in similar circumstances as demonstrated by the cases submitted and referred to by College Counsel.
I, Michael Hogard, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.