College of Nurses of Ontario v. Stewart, 2024 ONCNO 139301

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Lalitha Poonasamy Chairperson, Public Member

Simon-Matthew Bate, NP Member

Sylvia Douglas Public Member

Amrutha Kumar, RN Member

Kimberly Wagg, RPN Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) JOSEPH BERGER for

) College of Nurses of Ontario

• and - )

IAN STEWART ) STEVEN LAHTI for

Registration No. JG689682 ) Ian Stewart

) CHRISTOPHER WIRTH

) Independent Legal Counsel

) Heard: August 30, 2024, via videoconference

DECISION AND REASONS

Publication Ban

By Order of the Discipline Panel dated August 30,2024, 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(s) of the patient(s), or any information that could disclose the identity(ies) of the patient(s), referred to orally or in any documents presented at the Discipline hearing of Ian Stewart.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on August 30, 2024.

The Allegations

The allegations against Ian Stewart (the “Member”) as stated in the Notice of Hearing dated August 30, 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 Providence Care in Kingston, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as follows:

(a) on or around April 25, 2021:

i. you signed the medication administration record for Patient [A] indicating that you administered Sodium Bicarbonate 1000 mg and Baclofen 10mg before you administered these medications; and/or

ii. you failed to administer Sodium Bicarbonate 1000 mg and Baclofen 10mg to Patient [A];

(b) on or around August 29, 2021, with respect to Patient [B], you failed to

i. properly administer oxygen as ordered; and/or

ii. assess the patient prior to the end of your shift;

(c) on or around September 1, 2021, you failed to administer Sodium Bicarbonate 1000 mg and Baclofen 10mg to Patient [A];

(d) on or around September 2, 2021, you failed to administer humidified air to Patient [C]; and/or

(e) on or around September 2, 2021:

i. you signed the medication administration record for Patient [D] indicating that you administered Dupilumab 300 mg before you administered the medication; and/or

ii. you failed to administer Dupilumab 300 mg to Patient [D];

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(15) of Ontario Regulation 799/93, in that while employed as a Registered Practical Nurse at Providence Care in Kingston, Ontario, you signed or issued, in your professional capacity, a document that you knew or ought to have known contained a false or misleading statement, as follows:

(a) on or around April 25, 2021, you signed the medication administration record for Patient [A] indicating that you administered Sodium Bicarbonate 1000 mg and Baclofen 10mg before you administered these medications; and/or

(b) on or around September 2, 2021, you signed the medication administration record for Patient [D] indicating that you administered Dupilumab 300 mg before you administered the medication; and/or

3. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that while employed as a Registered Practical Nurse at Providence Care in Kingston, Ontario, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional, as follows:

(a) on or around April 25, 2021:

i. you signed the medication administration record for Patient [A] indicating that you administered Sodium Bicarbonate 1000 mg and Baclofen 10mg before you administered these medications; and/or

ii. you failed to administer Sodium Bicarbonate 1000 mg and Baclofen 10mg to Patient [A];

(b) on or around August 29, 2021, with respect to Patient [B], you failed to

i. properly administer oxygen as ordered; and/or

ii. assess the patient prior to the end of your shift;

(c) on or around September 1, 2021, you failed to administer Sodium Bicarbonate 1000 mg and Baclofen 10mg to Patient [A];

(d) on or around September 2, 2021, you failed to administer humidified air to Patient [C]; and/or

(e) on or around September 2, 2021:

i. you signed the medication administration record for Patient [D] indicating that you administered Dupilumab 300 mg before you administered the medication; and/or

ii. you failed to administer Dupilumab 300 mg to Patient [D].

Member’s Plea

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

THE MEMBER

1. Ian Stewart (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on March 4, 2008. The Member resigned his certificate of registration on December 29, 2023.

2. The Member was employed at Providence Care, a mental health, rehabilitation and complex care centre (the “Facility”) from March 2008 until his termination in January 2022.

PRIOR HISTORY

3. The Member has no prior disciplinary findings with CNO.

THE FACILITY

4. The Facility is in Kingston, Ontario.

5. The Member worked as a full-time RPN in the Complex Medicine unit (the “Unit”).

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Failure to administer medication as ordered and falsifying a record re Patient [A]

6. On April 25, 2021, the Member worked the day shift from 07:00-15:00. The Member was assigned to [ ] (“Patient A”).

7. Patient A had an order for Baclofen 10 mg and Sodium Bicarbonate 1000 mg to be administered at 14:00. The Member documented in Patient A’s MAR that he administered these medications.

8. “Colleague A”, RN, was assigned to Patient A’s care for the next shift. Colleague A was prompted to remove two 14:00 hour medications from the Automated Dispensing Unit (the “ADU”). Colleague A checked the MAR and noted that the Member documented the medications as administered at 14:00. The Facility’s ADU records also showed that the Member did not withdraw the medications from the machine. Colleague A completed an incident report.

9. Management discussed the incident with the Member. He confirmed that he may have signed that he had administered the medication on the MAR before going into Patient A’s room. If the Patient was not in his room, the Member may have forgotten to change his documentation in the MAR.

10. On September 1, 2021, the Member was assigned to Patient A’s care from 07:00 to 15:00. The nurse on the next shift, “Colleague B”, reviewed Patient A’s MAR and noticed that his 14:00 medications had not been administered. She checked the ADU, and it indicated the medications had not been withdrawn. She completed an incident report.

11. With respect to the September 1, 2021, medication error, the Member admits that he failed to administer the medication. If the Member were to testify, he would state that he was distraught after learning one of his long-time patients had died and was not in the position to provide the best possible care to his patients.

Failure to administer oxygen as ordered and assess Patient [B] prior to the end of shift

12. On August 29, 2021, the Member was assigned to [ ] (“Patient B”) from 15:00 to 19:00 hours.

13. Patient B was a patient at the Facility from 2014 until her death in 2021. At the time of the incident, Patient B was 63 years old with a diagnosis of multi-system atrophy and had minimal to no mobility. Patient B breathed with a tracheostomy tube and hood. Patient B had an order for continuous oxygen at a rate of 35% set at 8L and had an order for sodium chloride to be administered through inhalation by way of a nebulizer.

14. On August 29, 2021, the Member documented the following with respect to his care of Patient B:

• Progress notes entered at 19:02 documented administration of nebulizer and feeds at 16:10. The Patient’s father was present when the medication was administered.

• Tracheostomy assessment at 15:18, no leak detected.

• Administered medications, including nebulized medication at 16:06.

• Vital signs and oxygen saturation checked at 16:11.

15. Based on the ADU records, the Member removed the sodium chloride to be administered through the nebulizer at 15:40.

16. “Colleague C”, the next nurse to care for Patient B came on shift at 19:00. Colleague C found Patient B without vital signs at 19:18. Colleague C observed that Patient B’s oxygen was connected to the wall and turned on but was not connected to the Patient’s trach hood.

17. Colleague C called another colleague, “Colleague D”, to Patient B’s room. Colleague D also observed that the oxygen tube was not connected to the trach hood. The tube was inserted through the bedrails, laid on the bed and was not attached to the trach hood. The nebulizer was connected to the air compressor on the Patient’s bedside. Two witnesses noted that liquid remained inside the nebulizer’s chamber indicating that the medication had not been fully administered. An incident report was completed, and Colleague C sent an email to management.

18. The Facility investigated the incident.

19. From the video surveillance, the Member entered Patient B’s room at 15:58, the Patient’s father left the room at 16:03 and did not return. The Member left Patient B’s room at 16:05. The Member documented the administration of the nebulized medication in the Patient’s MAR at 16:06.

20. The Member was in and out of Patient B’s room over the next 24 minutes, enough time for the nebulized medication to be fully administered. However, Colleague C and Colleague D reported seeing fluid in the nebulizer, indicating the medication was not fully administered. The nebulizer was thrown out by Colleague D before any photographs were taken.

21. From the video surveillance, the Member entered Patient B’s room at 17:19 and remained until 17:41 (the Member exited the room very briefly). This was the last time the Member was in Patient B’s room before the end of his shift at 19:00.

22. During a meeting with the Facility, the Member claimed he administered the medication one of the times he was in Patient B’s room. The Member maintained he connected the Patient’s oxygen tube after administering the nebulized medication. He suggested it might have popped off if the Patient coughed; that the Patient was not dependent on humified oxygen since she had gone without it when she out of the Facility with her father.

23. According to a respiratory therapist, it is unlikely that the oxygen tube would disconnect from the trach hood given that Patient B was immobile.

24. A coroner completed an investigation. The coroner concluded that Patient B was not sufficiently mobile to cause a disconnection of the oxygen tube.

25. The Member was the last individual to provide care to Patient B. The Member exited the Patient’s room at 17:41. The Member’s shift ended at 19:00. Patient B was found without vital signs at 19:18.

Failure to administer humidified air to Patient [C] by way of a trach hood

26. On September 2, 2021, the Member was assigned to [ ] (“Patient C”) from 07:00 to 19:00.

27. The Member documented in Patient C’s chart throughout his shift, including at 11:25, 15:09, and 18:13 concerning the Patient’s trach.

28. “Colleague E”, RN, worked with the Member on the Unit. Colleague E took over care of Patient C at 15:00. Colleague E entered Patient C’s room shortly after 15:00. She noticed that the humidified air was not connected to the Patient’s trach hood. The tubing and the hood were hanging on the wall and not on the Patient. Colleague E rectified the situation and there was no harm to the Patient. While Patient C could breathe without oxygen, she had a standing order for humidified air by way of trach hood.

29. Colleague E reported the issue to her Charge Nurse, Colleague A, who completed an incident report.

30. During the Facility’s investigation, the Member stated that if the oxygen tubing and hood were hanging on the wall, then he must not have placed them on Patient C because they were breathing adequately at the time and did not require oxygen.

31. According to the Facility, the provision of humidified air by way of a trach hood is considered standard practice for all patients.

Failure to administer medication as ordered and falsifying a record re Patient [D]

32. On September 2, 2021, the Member was assigned to [ ] (“Patient D”) from 07:00 to 19:00.

33. Patient D had an order for Dupilumab 300 mg every two weeks. The medication was stored in an ADU refrigerator.

34. The Member signed off the administration of this medication on Patient D’s MAR at 08:39. Patient D advised a staff member that she had not received the medication. When staff checked, they saw the medication signed off on the MAR. They checked the ADU refrigerator and found the box containing one dose (the box holds two doses). Colleague A contacted the Member to determine if he had administered the medication because the Patient was adamant that she had not received it. The Member advised that the medication had been given to Patient D.

35. The ADU records indicate that the medication had not been accessed by the Member on the day in question. The pharmacy also confirmed that it only gave the Facility one dose of the medication, thus it was not possible for the Member to have administered the medication if a dose remained in the box. Colleague A completed a medication incident report.

CNO STANDARDS

36. CNO has published nursing standards to set out the expectations for the practice of nursing. CNO’s published standards inform nurses of their accountabilities and apply to all nurses regardless of their role, job description or area of practice.

Code of Conduct

37. 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:

a. Nurses respect the dignity of patients and treat them as individuals.

b. Nurses work together to promote patient well-being.

c. Nurses maintain patients’ trust by providing safe and competent care.

d. Nurses work respectfully with colleagues to best meet patients’ needs.

e. Nurses act with integrity to maintain patients’ trust.

f. Nurses maintain public confidence in the nursing profession.

38. CNO’s Code of Conduct provides, in relation to the principle requiring nurses to provide safe and competent care, that nurses are accountable for engaging in safe medication practices as set out in CNO’s Medication practice standard, including having proper legal authority and requisite knowledge, skill and judgment.

39. CNO’s Code of Conduct also provides, in relation to the principle requiring nurses to provide safe and competent care, that nurses are accountable for maintaining, and keeping clear, complete, accurate and timely documentation as set out in CNO’s Documentation practice standard, including accurate record keeping.

40. 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.

41. 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

42. CNO’s Professional Standards provides that each nurse is accountable to the public and responsible for ensuring their practice and conduct meets legislative requirements and the standards of the profession. It also states that nurses are responsible for their actions and the consequences of those actions, and they are also accountable for conducting themselves in ways that promote respect for the profession.

43. CNO’s Professional Standards further provide that ethical nursing care means promoting the values of patient well-being, respecting patient choice, assuring privacy and confidentiality, respecting the sanctity and quality of life, maintaining commitments, respecting truthfulness and ensuring fairness in the use of resources. It also includes acting with integrity, honesty and professionalism in all dealings with the patient and other health care team members.

44. 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.

Medication Standard

45. CNO’s Medication Standard provides an outline related to nurses’ accountabilities when engaging in medication practices. Three principles outline the expectations related to medication practices that promote public protection:

a. Authority - Nurses must have the necessary authority to perform medication practices.

b. Competence - Nurses ensure that they have the knowledge, skill and judgment needed to perform medication practices safely.

c. Safety - Nurses promote safe care and contribute to a culture of safety within their practice environments, when involved in medication practices.

46. CNO’s Medication Standard provides, in relation to the principle requiring nurses to promote safety, that nurses must take appropriate action to prevent, resolve or minimize the risk of harm to a patient from a medication error or adverse reaction.

47. Attached as Exhibit “C” is a copy of CNO’s Medication Standard that was in force at the time of the incidents.

Documentation Standard

48. CNO’s Documentation Standard helps nurses understand the importance of accurate and timely documentation, and how to apply the standards to their individual practice.

49. The Documentation Standard provides that nurses are accountable for ensuring their documentation of patient care is “accurate, timely and complete.” The standard further clarifies that a nurse meets the standard by:

a. 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.

b. Documenting both objective and subjective data.

c. Documenting in a timely manner and completing documentation during, or as soon as possible after the care or event.

d. Ensuring that relevant patient care information is captured in a permanent record.

50. Attached as Exhibit “D” is a copy of CNO’s Documentation Standard that was in force at the time of the incidents.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

51. The Member admits and acknowledges that he contravened the Code of Conduct, Professional Standards, Documentation Standard and Medication Standard when he falsely documented administering Patient A’s medications and failed to administer Patient A’s medications on April 25, 2021.

52. The Member admits and acknowledges that he contravened the Code of Conduct and the Professional Standards when he failed to properly administer oxygen as ordered and assess Patient B prior to the end of his shift on August 29, 2021.

53. The Member admits and acknowledges that he contravened the Code of Conduct, Professional Standards, and the Medication Standard when he failed to administer Patient A’s medication on September 1, 2021.

54. The Member admits and acknowledges that he contravened the Code of Conduct and the Professional Standards when he failed to administer humidified air to Patient C on September 2, 2021.

55. The Member admits and acknowledges that he contravened the Code of Conduct, Professional Standards, Documentation Standard and Medication Standard when he falsely documented administering Patient D’s medications and failed to administer Patient D’s medications on September 2, 2021.

56. The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 1 (a)(i)(ii), (b)(i)(ii), (c), (d), (e) and 2 (a) and (b) of the Notice of Hearing, as described in paragraphs 6-50 above.

57. The Member admits that he committed the acts of professional misconduct as alleged in paragraphs 3 (a)(i) (ii), (b)(i)(ii), (c), (d), and (e) of the Notice of Hearing, and in particular his conduct was disgraceful, dishonourable and unprofessional, as described in paragraphs 6-50 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), (b)(i), (ii), (c), (d), (e)(i), (ii), #2(a), (b) and #3(a)(i), (ii), (b)(i), (ii), (c), (d), (e)(i) and (ii) of the Notice of Hearing. As to allegations #3(a)(i), (ii), (b)(i), (ii), (c), (d), (e)(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), (b)(i), (ii), (c), (d), (e)(i) and (ii) in the Notice of Hearing are supported by paragraphs 6 - 56 in the Agreed Statement of Facts. The Member admitted and the Panel found that he committed professional misconduct when:

• he contravened the Code of Conduct, the Professional Standards, the Documentation Standard and the Medication Standard when he falsely documented administering Patient [A]’s medications and failed to administer Patient [A]’s medications on April 25, 2021;

• he contravened the Code of Conduct and the Professional Standards when he failed to properly administer oxygen as ordered and assess Patient [B] prior to the end of his shift on August 29, 2021;

• he contravened the Code of Conduct, the Professional Standards and the Medication Standard when he failed to administer Patient [A]’s medication on September 1, 2021;

• he contravened the Code of Conduct and the Professional Standards when he failed to administer humidified air to Patient [C] on September 2, 2021;

• he contravened the Code of Conduct, the Professional Standards, the Documentation Standard and the Medication Standard when he falsely documented administering Patient [D]’s medication and failed to administer Patient [D]’s medication on September 2, 2021.

Allegations #2(a) and (b) in the Notice of Hearing are supported by paragraphs 6 - 35 and 56 in the Agreed Statement of Facts. The Member admitted and the Panel found that he signed or issued, in his professional capacity, a document that he knew or ought to have known contained a false or misleading statement when he signed the medication administration records for Patient [A] and Patient [D] indicating that he had administered medications to these patients before he had done so.

Allegations #3(a)(i), (ii), (b)(i), (ii), (c), (d), (e)(i) and (ii) in the Notice of Hearing are supported by paragraphs 6 - 35 and 57 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct was relevant to the practice of nursing and was unprofessional as it demonstrated a serious and persistent disregard for his professional obligations in contravening the Code of Conduct, the Professional Standards, the Documentation Standard and the Medication Standard.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of dishonesty and deceit as he failed to provide safe, ethical and competent nursing care to his patients when he signed false and misleading documentation. When questioned by his colleagues, the Member was not honest with them regarding his care of and failure to assess Patient [B] prior to the end of his shift. Patient [B] was noted to be absent of signs of life 18 minutes after the Member’s shift ended. The Member knew or ought to have known that his conduct was unacceptable and fell well 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 Member’s conduct in contravening the College standards noted above casts serious doubt on the Member’s moral fitness and inherent ability to discharge the higher obligations the public expects professionals to meet.

Penalty

College Counsel and the Member’s Counsel advised that a Joint Submission on Order had been agreed upon and requested that the Panel make the following order:

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

2. Directing the Executive Director to suspend the Member’s certificate of registration for 4 months. This suspension shall take effect from the date 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 Practice Reflection Worksheets, online learning modules and decision tools (where applicable):

1. Code of Conduct,

2. Medication, and

3. 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 Practice Reflection Worksheets [and Nurses’ Workbook];

v. The subject of the sessions with the Expert will include:

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

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

3. strategies for preventing the misconduct from recurring,

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

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

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

1. the dates the Member attended the sessions,

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

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

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

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

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

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

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

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

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

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

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

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

c) 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.

College Submissions on Penalty

College Counsel made submissions which included the following.

The aggravating factors in this case were:

• The Member’s conduct was serious and repeated over a six month period and involved similar misconduct with four different patients;

• The Member’s conduct with respect to Patient [B] may have contributed to the severest patient outcome;

• The Member’s conduct was dishonest and has brought shame and discredit to the profession; and

• The Member’s conduct was a persistent disregard for his professional obligations.

The mitigating factors in this case were:

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

• The Member admitted to all of the allegations and entered into an Agreed Statement of Facts and a Joint Submission on Order with the College demonstrating accountability and remorse for his conduct; and

• By entering the Joint Submission on Order with the College, the Member saved the College from a costly contested hearing.

College Counsel submitted that the penalty meets the overall goals of penalty: it protects the public, enhances public confidence in the profession’s ability to regulate itself and specifically sends a message to the members at large that this type of conduct will not be tolerated. The penalty also provides for rehabilitation and remediation to ensure that the Member will be able to return to the practice of nursing with the skills and knowledge required of members of the profession.

The oral reprimand and the 4-month suspension of the Member’s certificate of registration are intended to provide the Member with a greater understanding of the expectations within the profession with the goal of protecting the public and sending a message to the Member, the general public and the membership at large that there are repercussions and consequences for this type of conduct and to deter repeated conduct. The minimum of two meetings with a Regulatory Expert will assist the Member to return to practice with the knowledge of the expectations required of the members at large as set out in the standards of practice. The employer notification provision is designed to provide additional oversight to the Member’s practice, to ensure public protection and to prevent recurrence of this type of conduct and it is consistent with prior decisions.

College Counsel submitted the following cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee:

CNO v. Fernandez (Discipline Committee, 2021): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The similarities between this case and the case before this Panel include that there were multiple patients involved and similar misconduct specific to medication administration. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, completion of nursing courses, 12 months of employer notification, 8-12 months of mentorship, and a 12 month restriction on independent practice in the community. The penalty in this case aligns with the penalty proposed in the case before this Panel.

CNO v. Parker (Discipline Committee, 2022): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The similarities between this case and the case before this Panel include that it involved 4 patients over a 12-month period in which the member failed to administer medications ordered, and failed to provide treatments as ordered. The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, 12 months of employer notification, three random spot audits of the member’s documentation and a 12 month restriction on independent practice in the community. The penalty in this case aligns with the penalty proposed in the case before this Panel.

CNO v. Robinson (Discipline Committee, 2021): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The similarities between this case and the case before this Panel albeit not exactly the same are, that it involved three patients over a three month period in which the member failed to administer medications ordered, failed to document delivery of medications in real time, failed to have witness verification of medication administration as per policy, and failed to complete or document assessments of patients. The Member was also found to have placed her colleague in a “choke hold.” The penalty included an oral reprimand, a 4-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, 18 months of employer notification, and three random spot audits of the member’s documentation. The penalty in this case aligns with the penalty proposed in the case before this Panel.

CNO v. Ohiegbomwan (Discipline Committee, 2020): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The similarities between this case and the case before this Panel, albeit not exactly the same are, that it involved two patients over a seven month period in which the member failed to assess as ordered, failed to maintain proper documentation of her patient, failed to monitor and assess patient condition and falsified a record. The penalty included an oral reprimand, a 3-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, completion of a nursing course, 18 months of employer notification, and three random spot audits of the member’s documentation. The penalty in this case aligns with the penalty proposed in the case before this Panel.

Member’s Submissions on Penalty

The Member’s Counsel and the Member indicated that they agreed with the College’s submissions.

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 the 4-month suspension of the Member’s certificate of registration, which sends a strong message to the profession and the members at large that this type of behaviour is unacceptable.

The proposed penalty provides for specific deterrence through the oral reprimand and the 4-month suspension of the Member’s certificate of registration, which will assist the Member to gain a greater understanding of how his conduct is perceived by the members of the profession and the public and that this type of behaviour will not be tolerated.

The proposed penalty provides for remediation and rehabilitation of the Member through a minimum of two meetings with a Regulatory Expert and review of the standards, which will establish a path for the Member to return to practice with the skills and knowledge necessary to deliver competent, ethical care.

Overall, the public is protected through the 12 months of employer notification and the 12 month restriction on independent practice in the community, which will provide additional oversight of the Member on his return to practice.

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

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

I, 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.

Chairperson