College of Nurses of Ontario v. Sarah Skinner, 2024 ONCNO 131472

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Lalitha Poonasamy, Public Member Chairperson Sylvia Douglas, Public Member Ramona Dunn, RN Member Lynn Hall, RN Member Andrew Sharpe, NP Member

BETWEEN:

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

• and -

SARAH SKINNER Registration No. AI194818 (NO REPRESENTATION for Sarah Skinner)

CHRISTOPHER WIRTH Independent Legal Counsel

Heard: April 4, 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 April 4, 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 publication or broadcasting of the names of the patients and complainants, or any information that could disclose the identities of the patients or complainants referred to orally or in any documents presented in the Discipline hearing of Sarah Skinner.

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

The Allegations

The allegations against Sarah Skinner (the “Member”) as stated in the Notice of Hearing dated February 27, 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 employed as a Registered Practical Nurse at Chatham Kent Health Alliance in Chatham, Ontario (the “Facility”), you contravened a standard of practice of the profession, or failed to meet the standards of practice of the profession, in that:

   a. On or about April 23, 2021, you made inappropriate and/or unprofessional comments about and/or directed at Patient [A], including but not limited to:

i. You told Patient [A] to “shut up”, “shut it”, or words to that effect;

ii. When Patient [A] called for her mother, you told Patient [A] that her mother was dead, or words to that effect; and/or

iii. You told colleagues, in front of Patient [A], that “I tell [Patient [A]] stuff like that all the time because she has dementia and will forget about it”, or words to that effect;

b. On or about August 14, 2021, you made inappropriate and/or unprofessional comments about and/or directed at Patient [B], including but not limited to:

i. You told Patient [B], “You don’t do this! You don’t cover yourself in shit when your husband is here”, or words to that effect; and/or

ii. You told Patient [B] to “eat shit” or words to that effect.

c. On or about August 14, 2021, you provided inadequate care to Patient [B], including but not limited to:

i. You tried to force Patient [B]’s hands, which had fecal matter on them, towards the patient’s mouth; and/or

ii. You used unnecessary force and were rough in the care you provided to Patient [B]; and/or

d. On or about August 21, 2021, you made inappropriate and/or unprofessional comments about and/or directed at Patient [C], including but not limited to:

i. You told Patient [C], “You shit all over me again”, or words to that effect; and/or

ii. You stated that Patient [C] had “deliberately shit on [you] 3 times”, or words to that effect.

2. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(7) of Ontario Regulation 799/93, in that while employed as a Registered Practical Nurse at the Facility, you abused a client verbally, physically, and/or emotionally in that:

   a. On or about April 23, 2021, you made inappropriate and/or unprofessional comments about and/or directed at Patient [A], including but not limited to:

i. You told Patient [A] to “shut up”, “shut it”, or words to that effect;

ii. When Patient [A] called for her mother, you told Patient [A] that her mother was dead, or words to that effect; and/or

iii. You told colleagues, in front of Patient [A], that “I tell [Patient [A]] stuff like that all the time because she has dementia and will forget about it”, or words to that effect;

b. On or about August 14, 2021, you made inappropriate and/or unprofessional comments about and/or directed at Patient [B], including but not limited to:

i. You told Patient [B], “You don’t do this! You don’t cover yourself in shit when your husband is here”, or words to that effect; and/or

ii. You told Patient [B] to “eat shit” or words to that effect.

c. On or about August 14, 2021:

i. You tried to force Patient [B]’s hands, which had fecal matter on them, towards the patient’s mouth; and/or

ii. You used unnecessary force and were rough in the care you provided to Patient [B]; and/or

d. On or about August 21, 2021, you made inappropriate and/or unprofessional comments about and/or directed at Patient [C], including but not limited to:

i. You told Patient [C], “You shit all over me again”, or words to that effect; and/or

ii. You stated that Patient [C] had “deliberately shit on [you] 3 times”, or words to that effect.

3. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that while employed as a Registered Practical Nurse at the Facility, you engaged in conduct that would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional with respect to the following incidents:

   a. On or about April 23, 2021, you made inappropriate and/or unprofessional comments about and/or directed at Patient [A], including but not limited to:

i. You told Patient [A] to “shut up”, “shut it”, or words to that effect;

ii. When Patient [A] called for her mother, you told Patient [A] that her mother was dead, or words to that effect; and/or

iii. You told colleagues, in front of Patient [A], that “I tell [Patient [A]] stuff like that all the time because she has dementia and will forget about it”, or words to that effect;

b. On or about August 14, 2021, you made inappropriate and/or unprofessional comments about and/or directed at Patient [B], including but not limited to:

i. You told Patient [B], “You don’t do this! You don’t cover yourself in shit when your husband is here”, or words to that effect; and/or

ii. You told Patient [B] to “eat shit” or words to that effect.

c. On or about August 14, 2021, you provided inadequate care to Patient [B], including but not limited to:

i. You tried to force Patient [B]’s hands, which had fecal matter on them, the patient’s mouth; and/or

ii. You used unnecessary force and were rough in the care you provided to Patient [B]; and/or

d. On or about August 21, 2021, you made inappropriate and/or unprofessional comments about and/or directed at Patient [C], including but not limited to:

i. You told Patient [C], “You shit all over me again”, or words to that effect; and/or

ii. You stated that Patient [C] had “deliberately shit on [you] 3 times”, or words to that effect.

Member’s Plea

The Member admitted the allegations set out in paragraphs #1(a)(i), (ii), (iii), (b)(i), (ii), (c)(i), (ii), (d)(i), (ii), #2(a)(i), (ii), (iii), (b)(i), (ii), (c)(i), (ii), (d)(i), (ii), #3(a)(i), (ii), (iii), (b)(i), (ii), (c)(i), (ii) and (d)(i) and (ii) 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 advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited, and without the exhibits referenced therein, as follows:

THE MEMBER

1. Sarah Skinner (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on August 7, 2019 in the Temporary Class and on October 22, 2019 in the General Class. The Member moved into the Non-Practising Class on December 24, 2021.

2. The Member was employed as a part-time RPN at Chatham Kent Health Alliance in Chatham, Ontario (the “Facility”) from January 6, 2020 until September 8, 2021. The Member worked on the Facility’s Complex Continuing Care unit (the “Unit”). The Facility terminated the Member’s employment in connection with the incidents described below, but later allowed the Member to resign in lieu of termination.

PRIOR HISTORY

3. In April 2021, following receipt of a report regarding concerns about the Member’s practice, including but not limited to, the Member’s inappropriate communication patients, the Inquiries, Complaints and Reports Committee (“ICRC”) directed the Member to attend before the ICRC to be cautioned with respect to the following standards: Professional Standards, Medication, Documentation, Therapeutic Nurse-Client Relationship and Code of Conduct.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

The Member made inappropriate and unprofessional comments to and about Patient A

4. On or about April 23, 2021, the Member made inappropriate and unprofessional comments about and directed at [ ] (“Patient A”), as outlined below.

5. Patient A was a patient at the Facility. Patient A was 99 years old at the time of the incident. Patient A was diagnosed with comorbidities, including, but not limited to, dementia.

6. At approximately 19:00 hours on April 23, 2021, Patient A started yelling near the nursing station where the Member was sitting. It was typical for Patient A to yell and call out in this manner.

7. In response to Patient A yelling and calling out, the Member told Patient A to “shut up”, “shut it” and/or words to that effect.

8. After the Member told Patient A to “shut up”, “shut it”, and/or words to that effect, Patient A began calling for her mother. The Member responded by telling Patient A that Patient A’s mother was dead.

9. The Member subsequently told another RPN at the Nursing Station that she told Patient A “stuff like that all the time because [Patient A] has dementia and will forget about it” or words to that effect. Patient A was sitting beside the Nursing Station, and close enough to hear the Member’s comments, when the Member made this statement to her colleague.

10. The incident was witnessed by two RPNs at the Facility and the family member of a patient on the Unit. The family member of the patient on the Unit submitted a report to the Facility about the Member’s conduct towards Patient A.

The Member made inappropriate and unprofessional comments to and about Patient B, forced Patient B’s soiled hands towards Patient B’s mouth, and used unnecessary force while providing care to Patient B

11. On or about August 14, 2021, the Member made inappropriate and unprofessional comments about and directed at [ ] (“Patient B”), forced Patient B’s soiled hands towards Patient B’s mouth, and used unnecessary force while providing care to Patient B, as outlined below.

12. Patient B was a patient at the Facility. Patient B was 72 years old at the time of the incident. Patient B was diagnosed with comorbidities, including, but not limited to, multiple sclerosis and cognitive decline.

13. At approximately 17:30 hours on August 14, 2021, the Member and another RPN at the Facility were changing Patient B’s bed sheets.

14. While they were changing the bed sheets, Patient B had a bowel movement. Fecal matter got onto Patient B and the bed as a result. Patient B attempted to clean the fecal matter herself and soiled her hands with feces.

15. The Member became angry and said to Patient B: “I even put pants on you and yet you still covered yourself in shit,” or words to that effect, and “You don’t do this! You don’t cover yourself in shit when your husband is here,” or words to that effect.

16. The Member then took Patient B’s hands, which were covered in fecal matter, and pushed them towards Patient B’s mouth. The Member told Patient B to “eat shit”, or words to that effect, as she forced Patient B’s soiled hands towards Patient B’s mouth.

17. The other RPN helping to change Patient B’s sheets intervened to stop the Member before she could force Patient B’s hands to Patient B’s mouth.

18. The Member was also rough and forceful with Patient B while changing Patient B’s bedding. The Member rolled and handled Patient B roughly, and Patient B commented to the Member that she was being rough. The force the Member used in changing Patient B’s bedding was unnecessary and inappropriate.

The Member made inappropriate and unprofessional comments to and about Patient C

19. On or about August 21, 2021, the Member made inappropriate and unprofessional comments about and directed at [ ] (“Patient C”), as outlined below.

20. Patient C was a patient at the Facility. Patient C was 90 years old at the time of the incident.

21. At approximately 05:00 hours on August 21, 2021, the Member answered Patient C’s call bell, and saw that Patient C had been incontinent and needed a brief change.

22. The Member rolled Patient C so that she could change Patient C’s brief. Patient C was experiencing continuous bowel movements while being changed and the Member changed Patient C’s brief three times as a result.

23. The Member was calm in her interactions with Patient C until the third brief change. During the third brief change, Patient C had a bowel movement while the Member was changing Patient’s C’s brief. The Member got upset and said to Patient C: “You shit all over me again”, or words to that effect.

24. The Member also accused Patient C of deliberately pushing down on her stomach to have a bowel movement during the brief change. the Member said to Patient C: “You deliberately shit on me three times”, or words to that effect.

25. At this point, another RPN at the Facility, who had observed the exchange between the Member and Patient C from the hallway, went into Patient C’s room to diffuse the situation, assist the Member in changing Patient C’s brief, and take over communication with Patient C.

26. Patient C’s daughter learned of the Member’s conduct from Patient C and Patient C’s roommate, who overheard the exchange between the Member and Patient C. Patient C’s daughter reported the incident to the Facility the next day and advised the Facility that the Member was no longer to provide care to Patient C.

Member’s Health

27. If the Member were to testify, she would state that she was suffering from a health condition during the relevant time period that affected her behaviour and judgment. She would further testify that, since the incidents described above, she has sought treatment for her health condition.

CNO STANDARDS

Code of Conduct

28. 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.

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

30. CNO’s Code of Conduct further provides, in relation to the principle requiring nurses to maintain patients’ trust by providing safe and competent care, that:

• Nurses seek advice and collaborate with the health care team to uphold safe patient care; and

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

31. In addition, CNO’s Code of Conduct provides, in relation to the principle requiring nurses to maintain public confidence in the nursing profession, that:

• Nurses are accountable for their own actions and decisions; and

• Nurses are responsible for maintaining their health. They seek help if their health affects their ability to practice safely.

32. Attached as Exhibit “A” is a copy of CNO’s Code of Conduct which was in force at the time of the incidents.

Professional Standards

33. 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.

34. CNO’s Professional Standards provides, in relation to the accountability standard statement, 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 ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation.

35. CNO’s Professional Standards further provides, in relation to the ethics standard statement, that ethical nursing includes acting with integrity, honesty and professionalism in all dealings with the patient and other health care team members.

36. CNO’s Professional Standards also provides, in relation to the leadership standard statement, that nurses demonstrate their leadership by providing, facilitating, and promoting the best possible care/service to the public. In addition, nurses demonstrate the 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].

37. Furthermore, CNO’s Professional Standards provides, in relation to the relationship standard statement and the therapeutic nurse-patient relationship, that nurses demonstrate empathy and caring in all relationships with patients, families, and significant others and it is the responsibility of the nurse to establish and maintain the therapeutic relationship. Nurses demonstrates this standard by:

• demonstrating respect and empathy for, and interest in [patients];

• recognizing the potential for [patient] abuse.

38. Attached as Exhibit “B” is a copy of CNO’s Professional Standards which was in force at the time of the incidents and has since been retired.

Therapeutic Nurse-Client Relationship

39. CNO’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) contains four standard statements, with accompanying indicators, which describe nurses’ accountabilities with respect to therapeutic communication, patient-centred care, maintaining boundaries and protecting the patient from abuse. The TNCR Standard provides that the nurse-patient relationship is built on trust, respect, empathy, professional intimacy and requires the appropriate use of power inherent in the care provider’s role.

40. CNO’s TNCR Standard provides, in relation to the therapeutic communication standard statement, that nurses use a wide range of effective communication strategies and interpersonal skills to appropriately establish, maintain, re-establish and terminate the nurse-patient relationship. Nurses meet the standard by:

• being aware of her/his verbal and non-verbal communication style and how [patients] might perceive it;

• modifying communication style, as necessary, to meet the needs of the [patient];

• recognizing that all behaviour has meaning and seeking to understand the cause of a [patient’s] unusual comment, attitude or behaviour; and

• reflecting on interactions with a [patient] and the health care team, and investing time and effort to continually improve communication skills.

41. CNO’s TNCR Standard provides, in relation to the patient-centred care standard statement, that nurses work with the patient to ensure that all professional behaviours and actions meet the therapeutic needs of the patient. Nurses meet the standard by:

• recognizing that the [patient’s] well-being is affected by the nurse’s ability to effectively establish and maintain a therapeutic relationship; and

• reflecting on how stress can affect the nurse-[patient] relationship, and appropriately managing the cause of the stress so the therapeutic relationship isn’t affected.

42. CNO’s TNCR Standard defines abuse as:

[T]he misuse of the power imbalance intrinsic in the nurse-[patient] relationship. It can also mean the nurse betraying the [patient]’s trust, or violating the respect or professional intimacy inherent in the relationship, when the nurse knew, or ought to have known the action could cause, or could be reasonably expected to cause physical, emotional or spiritual harm to the [patient]. Abuse may be verbal, emotional, physical, sexual, financial or take the form of neglect. The intent of the nurse does not justify a misuse of power within the nurse-[patient] relationship.

43. CNO’s TNCR Standard also provides, in relation to the protecting the patient from abuse standard statement, that nurses protect patients from harm by ensuring that abuse is prevented or stopped and reported. Nurses demonstrate having met the standard by:

• not engaging in behaviours toward a patient that may be perceived by the patient and/or others to be violent, threatening, or intending to inflict physical harm; and

• not exhibiting physical, verbal and non-verbal behaviours toward a [patient] that demonstrate disrespect for the [patient] and/or are perceived by the [patient] and/or others as abusive.

44. In addition, CNO’s TNCR Standard provides that verbal and emotional abuse includes, but is not limited to, sarcasm, intimidation, including threatening gestures/actions, teasing or taunting, insensitivity to the patient’s preferences, swearing and an inappropriate tone of voice such as one expressing impatience. CNO’s TNCR Standard further provides that physical abuse includes, but is not limited to, pushing, shaking, using force and handling a patient in a rough manner.

45. Attached as Exhibit “C” is a copy of CNO’s TNCR Standard which was in force at the time of the incidents.

46. With respect to Patient A, the Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards and TNCR Standard when she made inappropriate and unprofessional comments about and/or directed at Patient A as follows:

• the Member told Patient A to “shut up”, “shut it”, or words to that effect;

• when Patient A called for her mother, the Member told Patient A that her mother was dead, or words to that effect; and

• the Member told colleagues, in front of Patient A, that “I tell [Patient A] stuff like that all the time because she has dementia and will forget about it”, or words to that effect.

47. Regarding Patient B, the Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards and TNCR Standard when she made inappropriate and unprofessional comments about and/or directed at Patient B and when she provided inadequate care to Patient B as follows:

• the Member told Patient B, “You don’t do this! You don’t cover yourself in shit when your husband is here”, or words to that effect;

• the Member told Patient B to “eat shit” or words to that effect;

• the Member tried to force Patient B’s hands, which had fecal matter on them, towards Patient B’s mouth; and

• the Member used unnecessary force and was rough in the care she provided to Patient B.

48. With respect to Patient C, the Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards and TNCR Standard when she made inappropriate and unprofessional comments about and/or directed at Patient C as follows:

• the Member told Patient C, “You shit all over me again”, or words to that effect; and

• the Member stated that Patient C had “deliberately shit on [her] 3 times”, or words to that effect.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

49. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a)(i), 1(a)(ii), 1(a)(iii), 1(b)(i), 1(b)(ii), 1(c)(i), 1(c)(ii), 1(d)(i) and 1(d)(ii) of the Notice of Hearing in that 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 48 above.

50. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2(a)(i), 2(a)(ii), 2(a)(iii), 2(d)(i) and 2(d)(ii) of the Notice of Hearing in that she verbally and emotionally abused Patient A and Patient C, as described in paragraphs 4 to 10, 19 to 26 and 42 to 45 above.

51. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2(b)(i), 2(b)(ii), 2(c)(i), 2(c)(ii) of the Notice of Hearing in that she verbally, physically and emotionally abused Patient B, as described in paragraphs 11 to 18 and 42 to 45 above.

52. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3(a)(i), 3(a)(ii), 3(a)(iii), 3(b)(i), 3(b)(ii), 3(c)(i), 3(c)(ii), 3(d)(i) and 3(d)(ii) of the Notice of Hearing, and in particular her conduct was disgraceful, dishonourable and unprofessional, as described in paragraphs 4 to 48 above.

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), (b)(i), (ii), (c)(i), (ii), (d)(i), (ii), #2(a)(i), (ii), (iii), (b)(i), (ii), (c)(i), (ii), (d)(i), (ii), #3(a)(i), (ii), (iii), (b)(i), (ii), (c)(i), (ii) and (d)(i) and (ii) of the Notice of Hearing. With respect to allegations #2(a)(i), (ii), (iii) and (d)(i) and (ii), the Panel finds that the Member verbally and emotionally abused Patient A and Patient C. With respect to allegations #2(b)(i), (ii) and (c)(i) and (ii), the Panel finds that the Member verbally, physically and emotionally abused Patient B. As to allegations #3(a)(i), (ii), (iii), (b)(i), (ii), (c)(i), (ii) and (d)(i) and (ii), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be disgraceful, dishonourable and unprofessional.

Reasons for Decision

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

Allegations #1(a)(i), (ii), (iii), (b)(i), (ii), (c)(i), (ii), (d)(i), (ii) in the Notice of Hearing are supported by paragraphs 4 to 49 in the Agreed Statement of Facts. While employed as a part-time Registered Practical Nurse (“RPN”) at Chatham Kent Health Alliance (the “Facility”), the Member heard Patient A yelling and in response to Patient A yelling the Member told her to “shut up”, “shut it”, and/or words to that effect. When Patient A began to call out for her mother the Member responded by telling Patient A that her mother was dead. The Member told another RPN that she told Patient A stuff like that all the time because Patient A has dementia. The Member made inappropriate and unprofessional comments about and directed at Patient B. The Member became angry at Patient B and said to her “I even put pants on you and yet you still covered yourself in shit”, or words to that effect. The Member told Patient B to “eat shit” or words to that effect. The Member got upset with Patient C and told her “You shit all over me again”, or words to that effect and said to Patient C “You deliberately shit on me three times”, or words to that effect. The Member admitted to contravening the College’s Code of Conduct, the Professional Standards and the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”). The Member breached the Code of Conduct Standard in disrespecting the dignity of her patients and not treating her patients with care and compassion. The Member’s lack of respect, empathy and role-modelling professional values, beliefs and attributes breached the Professional Standard. The Member breached the TNCR Standard when the Member exhibited verbal behaviours toward Patients A, B, and C demonstrating disrespect for the patients that could be perceived by the patient and/or others as abusive.

Allegations #2(a)(i), (ii), (iii) and (d)(i) and (ii) in the Notice of Hearing are supported by paragraphs 4 to 10, 19 to 26, 42 to 45 and 50 in the Agreed Statement of Facts. The Member admitted that when she told Patient A to “shut up”, “shut it” and/or words to that effect and responded to Patient A that her mother was dead when Patient A was calling out for her mother, as well as when she told Patient C “You shit all over me again”, or words to that effect and said to Patient C “You deliberately shit on me three times”, or words to that effect, she verbally and emotionally abused Patient A and Patient C.

Allegations #2(b)(i), (ii) and (c)(i) and (ii) in the Notice of Hearing are supported by paragraphs 11 to 18, 42 to 45 and 51 in the Agreed Statement of Facts. The Member admitted that when she became angry and said to Patient B “I even put pants on you and yet you still covered yourself in shit”, “You don’t do this! You don’t cover yourself in shit when your husband is here” and “eat shit”, or words to that effect, forced Patient B’s soiled hands towards Patient B’s mouth, used unnecessary force while providing care to Patient B and was rough and forceful with Patient B while changing Patient B’s bedding, she verbally, physically and emotionally abused Patient B.

Allegations #3(a)(i), (ii), (iii), (b)(i), (ii), (c)(i), (ii) and (d)(i) and (ii) in the Notice of Hearing are supported by paragraphs 4 to 48 and 52 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in verbally and physically abusing three patients was clearly relevant to the practice of nursing and was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations in contravening the College’s Code of Conduct, the Professional Standards and the TNCR Standard.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing as she failed to meet the standards of a professional through repeatedly failing to provide safe, appropriate care to her patients. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional.

Finally, the Panel finds that the Member’s conduct was disgraceful as it shames the Member and by extension the profession. The conduct of repeatedly abusing patients verbally and physically casts serious doubt on the Member’s moral fitness and inherent ability to discharge the high obligations the public expects professionals to meet.

Penalty

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

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

2. Directing the Executive Director to suspend the Member’s certificate of registration for 5 months. This suspension shall take effect from the date the Member obtains an active certificate of registration in a practicing class 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 the Member obtains an active certificate of registration in a practicing class. 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 the Member obtains an active certificate of registration in a practicing class. To comply, the Member is required to ensure that:

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

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

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

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

1. Code of Conduct, and

2. Therapeutic Nurse-Client Relationship;

iv. Before the first meeting, the Member reviews and completes the CNO’s self-directed learning package, One is One Too Many, at the Member’s own expense, including the self-directed Nurses’ Workbook;

v. 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 and Nurses’ Workbook;

vi. 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;

vii. 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;

viii. 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 the meetings, the Member and the Mentor will discuss the Member’s efforts to ensure the Member’s care and interactions with patients are meeting the standards of practice of the profession and the Member’s reflections on how the Member is handling situations differently. 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 a copy of the proposed mentor’s résumé 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; and

iv. The Mentor will advise CNO in writing when the meetings have ended.

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

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

Penalty Submissions

Submissions were made by College Counsel.

The aggravating factors in this case were:

• The seriousness of the Member’s conduct;

• The Member demonstrated a repeated pattern of verbal, emotional and physical abuse directed towards vulnerable patients;

• The Member’s conduct breached numerous standards; and

• The Member’s conduct brought discredit to the Member and other members of the profession.

The mitigating factors in this case were:

• The Member has no prior discipline history with the Discipline Committee;

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

• The Member admitted to the allegations; and

• The Member was suffering from a health condition that she has received treatment for.

The proposed penalty provides for general deterrence through the 5-month suspension of the Member’s certificate of registration, which sends a clear message to the membership that this type of conduct will not be tolerated.

The proposed penalty also provides for specific deterrence through the oral reprimand and the 5-month suspension of the Member’s certificate of registration. During this time, the Member will be guided through a process whereby she will gain increased knowledge and will have time to reflect on the serious consequences of not following her professional obligations. The oral reprimand will assist the Member in gaining greater understanding of the impact of her conduct.

The proposed penalty provides for remediation and rehabilitation through a minimum of 2 meetings with a Regulatory Expert, reviewing the Code of Conduct and the TNCR Standard, as well as completing the self-directed learning package One is One Too Many, the self-directed Nurses’ Workbook and completing the Reflective Questionnaires.

Overall, the public is protected as the Member’s 5-month suspension will provide her with the opportunity to reflect and improve her practice. The 12 months of employer notification, as well as no independent practice for 12 months will ensure that once she returns to work, the Member’s employer will be aware of this decision, and they will continue to provide supervision. For a period of 12 months from the date the Member returns to the practice of nursing, the Member will meet with a Mentor to discuss the Member’s efforts to ensure the Member’s care and interactions with patients are meeting the standards of practice of the profession and the Member’s reflection on how the Member is handling situations differently.

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. Mymryk (Discipline Committee, 2020): The member was present, and self represented. It was an uncontested hearing and evidence was submitted through an Agreed Statement of Facts and the penalty was based on a Joint Submission on Order. The member acknowledged a pattern of verbal and physical abuse. The Member yelled at a patient, used inappropriate tones, hit a patient, forced a patient to eat and threw liquid at a patient. The penalty included an oral reprimand, a 7-month suspension of the member’s certificate of registration, a minimum of 2 meetings with a Regulatory Expert, 24 months of employer notification and 24 months of no independent practice in the community.

CNO v, Agustin (Discipline Committee, 2019): The member was present and was represented. It was an uncontested hearing and evidence was submitted through an Agreed Statement of Facts and the penalty was based on a Joint Submission on Order. The Member acknowledged a pattern of verbal and physical abuse. The Member spoke loudly, using inappropriate language and hit a patient in the face with a slipper. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration, 2 meetings with a Nursing Expert and 18 months of employer notification.

The Member made no submissions on penalty.

Penalty Decision

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

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

2. The Executive Director is directed to suspend the Member’s certificate of registration for 5 months. This suspension shall take effect from the date the Member obtains an active certificate of registration in a practicing class and shall continue to run without interruption as long as the Member remains in a practicing class.

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

   a) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at the Member’s own expense and within 6 months from the date the Member obtains an active certificate of registration in a practicing class. 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 the Member obtains an active certificate of registration in a practicing class. To comply, the Member is required to ensure that:

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

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

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

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

1. Code of Conduct, and

2. Therapeutic Nurse-Client Relationship;

iv. Before the first meeting, the Member reviews and completes the CNO’s self-directed learning package, One is One Too Many, at the Member’s own expense, including the self-directed Nurses’ Workbook;

v. 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 and Nurses’ Workbook;

vi. 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;

vii. 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;

viii. 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 the meetings, the Member and the Mentor will discuss the Member’s efforts to ensure the Member’s care and interactions with patients are meeting the standards of practice of the profession and the Member’s reflections on how the Member is handling situations differently. 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 a copy of the proposed mentor’s résumé 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; and

iv. The Mentor will advise CNO in writing when the meetings have ended.

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

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

Reasons for Penalty Decision

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

The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility. The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection.

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, Lalitha Poonasamy, Public Member, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.