DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Sherry Szucsko-Bedard, RN Chairperson Jane Hess, RN Member Carly Hourigan Public Member Ahamad Mohammed, RPN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ALYSHA SHORE for College of Nurses of Ontario
- and -
KING K. NUTAKOR Registration No. 0400218 PHILIP ABBINK for King K. Nutakor
ALEX SMITH AND CHRISTOPHER WIRTH Independent Legal Counsel
Heard: October 9, 2024, via videoconference
DECISION AND REASONS
Publication Ban
By Order of the Discipline Panel dated October 9, 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 name of the patient, or any information that could disclose their identity, referred to orally or in any documents presented at the Discipline hearing of King K. Nutakor.
This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on October 9, 2024.
The Allegations
The allegations against King K. Nutakor (the “Member”) as stated in the Notice of Hearing dated August 20, 2024 are as follows:
IT IS ALLEGED THAT:
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that while you were employed as a Registered Nurse at Brant Community Healthcare System in Brant, Ontario, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession on or around December 8, 2022 when you:
- failed to make attempts to de-escalate [Patient A] prior to initiating a physical intervention; and/or
- placed a pillow over [Patient A]’s face and pressed down;
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 you were employed as a Registered Nurse at Brant Community Healthcare System in Brant, Ontario, you abused [Patient A] verbally, physically, and/or emotionally on or around December 8, 2022 when you placed a pillow over [Patient A]’s face and pressed down; 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 you were working as a Registered Nurse at Brant Community Healthcare System in Brant, 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 on or around December 8, 2022, when you:
- failed to make attempts to de-escalate [Patient A] prior to initiating a physical intervention; and/or
- placed a pillow over [Patient A]’s face and pressed down.
Member’s Plea
The Member admitted the allegations set out in paragraphs 1(a), 1(b), 2, 3(a) and 3(b) 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 the Exhibits referenced therein, as follows:
THE MEMBER
King K. Nutakor (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on December 31, 2003.
The Member was employed as an RN at Brant Community Healthcare System (the “Facility”) from June 6, 2022 to December 20, 2022 as a full-time RN on the Inpatient Mental Health and Addictions unit (the “Unit”).
THE UNIT
The Unit has 18 beds in two areas: 14 beds in general psychiatric population and 4 beds in the psychiatric intensive care unit (“PICU”).
Staffing on the night shift consists of two teams: 2 registered staff on PICU and 3 with the general population. One Charge Nurse is responsible for the entire Unit and carries their own patient load. Despite the separation of the Unit, if there is ever an incident, all staff assist with de-escalation.
INCIDENT RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
On December 7, 2022, police brought Patient A to the Facility. Patient A was assigned to the Member’s care.
Patient A was in restraints while in the Emergency Department. When she was brought to the PICU, the restraints were removed.
Later during the shift, at 0413 hours, Patient A became agitated and upset by noise made by other patients in the hallway as she wanted to sleep.
Patient A left the PICU and went to the hallway to confront the noisy patients.
Within seconds of entering the hallway, Patient A threw her water bottle at a staff member, hitting the staff member with the water bottle.
A security guard was in the hallway when Patient A arrived. The security guard was familiar with Patient A from prior admissions and knew Patient A was capable of becoming violent. The security guard immediately called for back-up and attempted to de-escalate the situation, by backing Patient A up to a corner.
Before she was given a chance to de-escalate the Patient or any other security guards arrived, the Member came into the hallway and walked directly over to Patient A.
The Member took Patient A by the arm and told her she was going back to her room. The security guard took the Patient’s other arm and followed the Member and Patient A back to her room.
The Charge Nurse observed the interaction, called a Code White, and followed the three back to Patient A’s room. They arrived in the Patient’s room less than 30 seconds after the Patient had left the room.
Upon entering Patient A’s room, the Member and the security guard placed the Patient onto her bed. At first the Patient seemed somewhat calm and was being loosely restrained by the Member and the security guard.
The Member then moved the Patient onto her back and attempted to get control of her head by placing his hand on her forehead as she was trying to bite him. This escalated the Patient who then began punching and kicking the security guard and attempted to bite the Member’s hand.
In response, the Member grabbed a pillow and put it over Patient A’s face and pushed down with force. The Charge Nurse yelled “no” to the Member and tried to grab the pillow out of his hands. At the same time, the security guard released her hold on one of the Patient’s limbs in an attempt to push the pillow off the Patient. After a few seconds, the pillow ended up on the floor. They then continued to restrain the Patient until other security guards arrived (within less than one minute) and a 4-point restraint was applied to Patient A.
If the Member were to testify, he would say that he used the pillow in order to protect himself from being bitten by the Patient in a very fast-moving situation where he had little time to consider his actions. He acknowledges, however, that this was not appropriate. He would also express his remorse for his behaviour during this incident, his commitment to learning from this experience and ensuring such conduct is not repeated.
The incident was captured on video surveillance.
Both the Charge Nurse and security guard raised concerns with the Member’s conduct to him directly as well as to the Facility.
CNO STANDARDS
Code of Conduct
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.
With respect to the principle that nurses respect the dignity of patients and treat them as individuals, CNO’s Code of Conduct provides that nurses treat patients with care and compassion.
Regarding the principle that nurses maintain patients’ trust by providing safe and competent care, CNO’s Code of Conduct provides 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.
With respect to the principle that Nurses work respectfully with colleagues to best meet patients’ needs, CNO’s Code of Conduct provides that nurses collaborate and communicate with colleagues in a clear, effective, professional and timely way and nurses work together with other health care experts to improve their patients’ care.
Attached as Exhibit “A” is a copy of CNO’s Code of Conduct that was in force at the time of the incidents.
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 this standard by providing, facilitating, advocating and promoting the best possible care for patients.
CNO’s Professional Standards further provides, in relation to the leadership standard, that nurses demonstrate their leadership by providing, facilitating and promoting the best possible care/service to the public. In addition, a nurse demonstrates 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.
CNO’s Professional Standards also provides, in relation to the relationship standard and the therapeutic nurse-patient relationship, that a nurse demonstrates this standard by demonstrating respect and empathy for, and interest in patients and recognizing the potential for patient abuse.
CNO’s Professional Standards also provides, in relation to the relationship standard and the professional relationship, that a nurse demonstrates leadership by role-modelling positive collegial relationships and using a wide range of communication and interpersonal skills to effectively establish and maintain collegial relationships.
Attached as Exhibit “B” is a copy of CNO’s Professional Standards that was in force at the time of the incidents and has since been retired.
Therapeutic Nurse-Client Relationship
CNO’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) contains four standard statements 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.
CNO’s TNCR Standard places the responsibility for establishing and maintaining the therapeutic nurse-patient relationship on the nurse. The TNCR Standard provides that the nurse-patient relationship is built on trust, respect, empathy, professional intimacy and requires the appropriate use of power.
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.
CNO’s TNCR Standard requires nurses to protect the patient from harm by ensuring that abuse is prevented or stopped and reported. A nurse demonstrates having met the standard by actions such as 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.
Attached as Exhibit “C” is a copy of the TNCR Standard that was in force at the time of the incidents.
The Member admits and acknowledges that his conduct towards Patient A was a breach of CNO’s Code of Conduct, Professional Standards and TNCR Standard.
The Member further admits and acknowledges that his conduct amounted to physical and emotional abuse.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 1 (a) and (b) of the Notice of Hearing in that he contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 5 to 37 above.
The Member admits that he committed the acts of professional misconduct as alleged in paragraph 2 of the Notice of Hearing in that he emotionally and physically abused Patient A, as described in paragraphs 5 to 37 above.
The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 3 (a) and (b) of the Notice of Hearing, and in particular his conduct was dishonourable and unprofessional, as described in paragraphs 5 to 37 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), 1(b), 2, 3(a) and 3(b) of the Notice of Hearing. With respect to allegation #2, the Panel finds that the Member emotionally and physically abused Patient A. As to allegations #3(a) and #3(b), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonourable and unprofessional.
Reasons for Decision
The Panel considered the Agreed Statement of Facts and the Member’s plea and finds that this evidence supports findings of professional misconduct as alleged in the Notice of Hearing.
Allegations #1(a) and #1(b) in the Notice of Hearing are supported by paragraphs 5 to 38 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct demonstrated a breach of several key College standards, including the Code of Conduct, the Professional Standards, and the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”). Specifically, the Member’s failure to attempt de-escalation breached the Code of Conduct, which emphasizes treating patients with respect. Additionally, the Member’s use of a pillow to restrict Patient A’s breathing violated the TNCR Standard, which mandates the protection of patients from abuse. This action was not only physically harmful but also emotionally abusive, as it disregarded Patient A’s dignity, vulnerability, and the power imbalance inherent in the nurse-patient relationship. By failing to ensure safe and competent care, the Member breached the College’s standards relating to patient safety, accountability, and professional ethics, which were pivotal in the Panel’s conclusion that misconduct had occurred. It is expected that nurses advocate for the best possible care for patients and in this case the Member failed to do so when he physically and emotionally abused the patient.
Allegation #2 in the Notice of Hearing is supported by paragraphs 5 to 37 and 39 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in placing a pillow over the patient’s face and applying force constituted physical and emotional abuse. This is inherently abusive and may have caused harm to the patient.
Allegations #3(a) and #3(b) in the Notice of Hearing are supported by paragraphs 5 to 37 and 40 in the Agreed Statement of Facts. As the Member was providing direct care to a patient when the incidents occurred, the Panel finds that the Member’s conduct was relevant to the practice of nursing. It was unprofessional as it demonstrated a serious and persistent disregard for his professional obligations to maintain therapeutic relationships based on trust and respect. The Panel finds that the Member’s actions lacked the integrity required by the College’s Code of Conduct and the Professional Standards, further supporting the finding of professional misconduct.
The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing by using excessive force, specifically by placing a pillow over Patient A’s face and applying pressure to control the patient. The Member’s actions reflected a significant lapse in judgment and a disregard for the professional standards expected of a nurse. The Member knew, or ought to have known, that this conduct was unacceptable and fell well below the standards of a professional. Such behavior undermines the trust that patients and the public place in the nursing profession and is fundamentally incompatible with the ethical obligations nurses have to their patients.
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:
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 a minimum of 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. 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 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: 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.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.
College Submissions on Penalty
College Counsel made submissions regarding the aggravating and mitigating factors in this case, emphasizing the importance of balancing the need for public protection, maintaining public confidence in the profession, and ensuring that the penalty serves as a deterrent for both the Member and the broader nursing community.
The aggravating factors in this case included the vulnerability of the patient, as Patient A was in a psychiatric intensive care unit (“PICU”) and the seriousness of the Member’s conduct, which involved physical and emotional abuse, and that it brought discredit to the profession and demonstrated a disregard for the Member’s professional obligations.
The mitigating factors in this case were also noted, such as the Member’s over 20 years of practice without a prior disciplinary history. College Counsel highlighted that the Member took accountability for his actions by admitting to the allegations, expressing remorse, and demonstrating a commitment to learning from this incident to prevent its recurrence. Additionally, the incident was a single, isolated occurrence in a fast-moving situation.
The proposed penalty, according to College Counsel, is appropriate as it achieves the goals of public protection, specific and general deterrence, and rehabilitation. The three-month suspension of the Member’s certificate of registration, an oral reprimand, a minimum of two meetings with a Regulatory Expert and the 12 months of employer notification address the seriousness of the misconduct while providing a pathway for the Member’s remediation and reintegration into safe nursing practice.
College Counsel submitted the following cases to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee:
CNO v. Kennedy (Discipline Committee, 2022): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member used physical force on a patient with aggressive behavior. The panel found that the member had breached the standards and engaged in physical abuse. The penalty included an oral reprimand, a three-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and 12 months of employer notification, which mirrors the proposed penalty in the case before this Panel.
CNO v. Hayden (Discipline Committee, 2018): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member punched a patient multiple times in response to being spat on by the patient. The panel found that the member’s conduct amounted to physical abuse. The penalty included an oral reprimand, a four-month suspension of the member’s certificate of registration, two meetings with a Nursing Expert and 12 months of employer notification. College Counsel submitted that the conduct in this case was more severe, given the repeated physical abuse, yet the overall structure of the penalty is similar.
These cases illustrate that the proposed penalty is within the reasonable range for professional misconduct involving patient abuse, ensuring the protection of the public while recognizing the mitigating factors in the case before this Panel.
Member’s Submissions on Penalty
The Member’s Counsel indicated that he agreed with the College’s submissions on the generally applicable principles for penalty decisions. The Member’s Counsel submitted that the Member admitted the allegations early in the process, which saved the College significant time and resources. The Member has demonstrated insight into his actions and is committed to addressing the issues that led to the misconduct. It was noted that the Member has had no prior history of misconduct in over 20 years of nursing practice. The Member’s Counsel described the incident as occurring in a fast-moving and high-pressure situation, with the Member’s use of the pillow lasting only a few seconds before it fell to the floor. The situation was brief, isolated, and involved a single patient.
The Member’s Counsel acknowledged that while the Member made an incorrect choice in the moment, he has taken full responsibility for his actions, expressed genuine remorse, and is committed to ensuring such behavior is not repeated. The proposed penalty, including a three-month suspension of the Member’s certificate of registration and conditions for further learning, provides the Member with an opportunity for rehabilitation while also serving the goals of public protection and deterrence.
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 general deterrence through sending a clear message to the nursing profession that abusive conduct toward patients, regardless of the circumstances, will not be tolerated. The three-month suspension of the Member’s certificate of registration serves as a strong reminder to all nurses of the importance of adhering to professional standards, particularly those related to patient safety and dignity.
The proposed penalty provides for specific deterrence through the oral reprimand and the three-month suspension of the Member’s certificate of registration, which serves to discourage the Member from repeating similar misconduct in the future. These measures ensure that the Member fully understands the gravity of the actions and the professional consequences that arise from breaching standards.
The proposed penalty provides for remediation and rehabilitation through a minimum of two meetings with a Regulatory Expert, where the Member will review reflective questionnaires, learning modules, and the TNCR Standard, as well as the College’s Code of Conduct. This educational approach supports the Member’s return to safe practice while reinforcing the necessary professional obligations and standards.
Overall, the public is protected through the Member’s suspension, ensuring that the Member is temporarily removed from practice to reflect on the seriousness of the misconduct. The employer notification period further safeguards the public by requiring the Member’s future employer to be aware of the prior misconduct, thus ensuring ongoing accountability in the workplace.
The Panel acknowledges that the Member has cooperated with the College and, by agreeing to the facts and proposed penalty, has accepted responsibility for his actions. This cooperation is recognized as a mitigating factor, as it demonstrates the Member’s commitment to addressing his misconduct and learning from the experience.
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. These cases involved instances of physical abuse, and the penalties imposed reflected the seriousness of the misconduct while supporting rehabilitation and public protection. The proposed penalty in the case before this Panel falls within this range, ensuring fairness and consistency in the disciplinary process.
I, Sherry Szucsko-Bedard, RN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.