DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Michael Hogard, RPN Chairperson Tomoko Fukushima, RN Member Tammy Hedge, RPN Member Carly Hourigan Public Member Sandra Larmour Public Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) JOSEPH BERGER for ) College of Nurses of Ontario
- and - )
JOEHANNA ABEJO ) NO REPRESENTATION for REGISTRATION NO. BJ248046 ) Joehanna Abejo ) KIMBERLEY ISHMAEL ) Independent Legal Counsel
) Heard: August 6, 2024, via videoconference
DECISION AND REASONS
Publication Ban
By Order of the Discipline Panel dated August 6, 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 Joehanna Abejo.
This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on August 6, 2024.
The Allegations
The allegations against Joehanna Abejo (the “Member”) as stated in the Notice of Hearing dated June 27, 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 working as a Registered Practical Nurse at Homewood Health Centre, in Guelph, Ontario (the “Facility”), you contravened a standard or practice of the profession or failed to meet the standards of practice of the profession, as follows:
a. On or about November 30, 2020, you administered eleven medications to [Patient A] which were prescribed to a different patient;
b. On or about May 11, 2021, you administered 16 mg of Buprenorphine / Suboxone to [Patient B], instead of 12 mg of Buprenorphine / Suboxone, as ordered; and/or
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that while working as a Registered Practical Nurse at the Facility, 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, as follows:
a. On or about November 30, 2020, you administered eleven medications to [Patient A] which were prescribed to a different patient;
b. On or about May 11, 2021, you administered 16 mg of Buprenorphine / Suboxone to [Patient B], instead of 12 mg of Buprenorphine/Suboxone, as ordered.
Member’s Plea
The Member admitted the allegations set out in paragraphs #1(a), #1(b), #2(a) and #2(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 advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which as amended reads, unedited and without exhibits mentioned therein, as follows:
THE MEMBER
Joehanna Abejo (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on March 4, 2020.
The Member was employed at Homewood Health Centre, a mental health facility in Guelph, Ontario (the “Facility”) from July 6, 2020, until June 2, 2021. At the time of the incidents described below, the Member worked on an in-patient unit of the Facility devoted to treating patients exhibiting life-threatening or illness-related behaviours related to psychiatric illness or disorder (the “Unit”).
The Member has no prior discipline history with CNO.
INCIDENT 1
On November 30, 2020, at approximately 9:15 p.m., the Member accidentally administered eleven medications to “Patient A”, which were prescribed to another patient, “Patient X”.
Patient X was transferred to the Unit from another unit within the Facility at approximately 5:30 p.m. on November 30, 2020. At that time, the Unit’s charge nurse decided that the Member would be the primary nurse responsible for accepting Patient X’s transfer on to the Unit and providing care to Patient X.
The Member asked the charge nurse if Patient X’s facility wrist band needed to be changed when Patient X arrived on the Unit from a different unit within the Facility. The charge nurse advised the Member that Patient X’s wrist band did not need to be changed.
The Member recalls introducing herself and speaking with Patient X for five to ten minutes after Patient X was transferred onto the Unit at around 6:00 p.m. on November 30, 2020.
At around 9:00 or 9:30 p.m. that night, the Member noticed that Patient X had not come to the medication room to receive his medication. The Member went and found the patient she thought was Patient X (but turned out to be Patient A).
If the Member were to testify, she would state that she addressed Patient A by Patient X’s name and Patient A did not correct the Member. The Member would state that she reminded the patient that their medications were due and asked the patient to get their medications whenever they were ready. Patient A followed the Member to the Unit’s medication room. The Member would testify that she obtained Patient X’s medications and scanned them on the Facility’s medication administration system and then scanned Patient A’s wristband, under the impression that she was scanning Patient X’s wristband.
An error alert came up on the Facility’s medication administration system. If the Member were to testify, she would state that she assumed that the error alert was because she had not changed Patient X’s wristband after his transfer from another unit on the Facility. Based on this assumption, the Member overrode the system error alert message. The Member would testify that she checked Patient A’s wristband and thought she saw Patient X’s name. The Member would testify that she attempted to verify that she had the right patient by asking the patient if his name was Patient X and if his birth date was Patient X’s birth date. The Member would state Patient A confirmed having Patient X’s name and birthdate. The Member administered eleven medications to Patient A which were ordered to be administered to Patient X.
After the patient had taken the medication, another nurse on the unit (“Nurse A”) approached the Member and asked her what the patient had needed. At this point, the Member and Nurse A discovered that the Member had accidentally administered medication to Patient A instead of Patient X.
Since Patient A was assigned to Nurse A, Nurse A called the doctor on duty, who advised that Patient A should be monitored throughout the night and there was no need to send Patient A the Emergency Room.
On November 30, 2020, the Member wrote a Medication Event note regarding this incident, as follows:
“[Patient A] came up to the med door to ask for medication. Writer scanned patient’s armband; armband was not authenticated. Writer verified pt by asking pt to confirm name and DOB. Writer administered the following medications – Naproxen 500 mg, Acetaminophen 1000 mg, Gabapentin 600 mg, Clomipramine 50 mg, Quitiapine XR 400 mg, Hydromorphone SR 6 mg, Valporic Acid 1000mg, Aripiprazole 5mg, Clonazepam 1 mg, Quitiapine 400 mg, and Trihexyphenidyl 5 mg”.
Following the discovery of the Member’s dispensing error, and despite Facility staff checking Patient A’s vitals hourly overnight on November 30, 2020, Patient A was discovered absent vital signs on the morning of December 1, 2020. Patient A was pronounced deceased later that morning. The medical cause of death was determined to be combined drug toxicity with hypertensive heart disease.
The Facility investigated the incident and identified a number of gaps with respect to the Member’s medication administration practice. The Facility noted that the Member was incorrect in her practice by asking the patient to confirm their name and date of birth in a closed question format rather than an open question format, thus enabling the Patient A to passively confirm information about Patient X’s identity, provided by the Member. The Facility found that it was clear the Member had no intent to harm Patient A and upon identification of the error, had appropriately reported the error, took accountability for her actions and sought guidance to support follow-up for next steps.
The Facility suspended the Member’s employment without pay for five days and required her to participate in a mandatory Learning Plan and review of relevant Facility and CNO policies, as a result of this incident.
INCIDENT 2
At 8:30 p.m. on May 11, 2021, the Member incorrectly administered 16 mg of Buprenorphine (Suboxone) to “Patient B”, which represented Patient B’s morning dose, rather than 12 mg of Buprenorphine, the patient’s nighttime dose.
Another nurse at the Facility, “Nurse B”, performed an independent double check of the medication administered by the Member to Patient B. Nurse B acknowledges that they did not notice that the dose provided by the Member to Patient B was the morning dose of Buprenorphine instead of the nighttime dose.
If the Member were to testify, she would state that at 8:30 p.m. on May 11, 2021, Patient B had asked the Member for their night-time medication, which was ordered to be administered at 10 p.m. The Member would testify that she scanned the patient’s arm band, verified their name and date of birth, and scanned the patient’s Buprenorphine, which she had taken out. The Member received an alert on the Facility’s medication administration system that she was giving Patient B’s medications early, which she overrode.
If the Member were to testify, she would state that that she had some leeway to provide Patient B’s medications early, and assumed that the error alert was generated because the Member was administering Patient B’s medication approximately 90 minutes early.
The Member would testify that she only discovered her medication error after she noticed that the Facility’s system continued to show that Patient B’s nighttime Buprenorphine was due to be administered. After consulting with another nurse, the Member realized that she had mistakenly provided Patient B with a dose of Buprenorphine intended for the following morning.
The Member recorded this incident in a progress note and promptly advised a charge nurse and duty doctor at the Facility of her medication error.
Following the discovery of the Member’s medication error, Patient B was monitored throughout the night and the following morning; no adverse impact from the Member’s medication error was noted.
Following this incident, and due to the Member’s repeated incidents of disregarding and overriding the Facility’s medication administration system’s warnings, the Facility terminated the Member’s employment on June 2, 2021.
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.
- CNO’s Code of Conduct provides, in relation to the principle requiring nurses to maintain patient’s trust by providing safe and competent care, that:
Nurses use appropriate knowledge, skill and judgment when assessing the health needs of patients;
Nurses use accurate sources of information, such as research, to inform their practice; and
Nurses are accountable to, and practice under, relevant laws and CNO’s standards of practice.
- CNO’s Code of Conduct further 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;
Nurses clearly communicate to patients the details of care or a service they intend to provide; and
Nurses have a duty to report any error, behaviour, conduct or system issue that affects patient safety.
- 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
CNO’s Professional Standards provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies. 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 each nurse is accountable to the public and responsible for ensuring their practice meets legislative requirements and the standards of the profession. Nurses are responsible for their actions and the consequences of those actions. Nurses demonstrate this standard by providing, facilitating, advocating and promoting the best possible care for clients; taking action in situations in which client safety and well-being are compromised; taking responsibility for errors when they occur and taking appropriate action to maintain client safety.
The Professional Standards also provide, in relation to the knowledge standard, that nurses demonstrate the standard by providing a theoretical and/or evidence-based rationale for all decisions; and being aware of how practice environments affect professional practice.
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
CNO’s Medication Standard outlines nurses’ accountabilities when engaging in medication practices, such as administration, dispensing, medication storage, inventory management and disposal. CNO’s Medication Standard provides that three principles outline the expectations related to medication practices that promote public protection including authority, competence and safety.
CNO’s Medication Standard provides, in relation to safety, that nurses promote safe care, and contribute to a culture of safety within their practice environments, when involved in medication practice.
Nurses are expected to take appropriate action to resolve or minimize the risk of harm to a client from a medication error or adverse reaction; report medication errors, near misses or adverse reactions in a timely manner; and collaborate in the development, implementation and evaluation of system approaches that support safe medication practices within the health care team.
Attached as Exhibit “C” is a copy of CNO’s Medication standard that was in force at the time of the incidents.
The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards, and Medication Standard when she administered 11 medications to Patient A which were prescribed to Patient X and administered 16 mg of Buprenorphine to Patient B instead of the 12 mg of Buprenorphine that was ordered.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1 (a) and (b), 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 37 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2(a) and (b) of the Notice of Hearing, and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 4 to 24 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(a) and #2(b) of the Notice of Hearing. With respect to allegations #2(a) and #2(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.
Allegation #1(a) in the Notice of Hearing is supported by paragraphs 4 to 16 and 25 to 38 in the Agreed Statement of Facts. The Panel found and the Member admitted that while employed at Homewood Health Centre (the “Facility”) she committed an act of professional misconduct by contravening the standards of practice of the profession when she mistook Patient A for Patient X and administered eleven medications to Patient A which were prescribed to Patient X and ignored and overrode the error alert that came up on the Facility’s medication administration system. The Member admitted that she asked Patient A to confirm his identity in a way that required a “yes or no” answer, which was a contributing factor. There was a clear breach of the Medication Standard, the Code of Conduct and the Professional Standards, all of which protect the patient’s right to safe, collaborative and competent care.
Allegation #1(b) in the Notice of Hearing is supported by paragraphs 17 to 24 and 25 to 38 in the Agreed Statement of Facts. The Panel found and the Member admitted that she committed an act of professional misconduct by contravening the standards of practice of the profession when she incorrectly administered 16 mg of Buprenorphine/Suboxone to Patient B instead of the prescribed 12 mg of Buprenorphine/Suboxone. This allegation is what brought the Member to the College’s attention, as again the Member overrode the alert on the Facility’s medication administration system, thus administering the morning dose at the incorrect time.
Allegations #2(a) and #2(b) in the Notice of Hearing are supported by paragraphs 4 to 24 and 39 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 her professional obligations in contravening the Code of Conduct, the Professional Standards and the Medication Standard.
The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing as she failed to administer medications to the correct patient, failed to administer the correct medication dosage to another patient and in both incidents overrode the error alert that came up on the Facility’s medication administration system. The Member knew or ought to have known that her conduct was unacceptable and fell well below the standards of a professional.
Penalty
College Counsel and the Member 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 2 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) The Member will attend 2 meetings with a Regulatory Expert (the “Expert”), at the Member’s own expense and within 6 months from the date that this Order becomes final. To comply, the Member is required to ensure that:
i. The Expert has expertise in nursing regulation and has been approved by CNO in advance of the meetings;
ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;
iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules and decision tools (where applicable):
Code of Conduct,
Practice Standard: Medication, and
Practice Standard: Documentation, Revised 2008;
iv. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires;
v. The subject of the sessions with the Expert will include:
the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;
vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards their report to CNO, in which the Expert will confirm:
the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into the Member’s behaviour;
vii. If the Member does not comply with any one or more of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on the Member’s certificate of registration;
b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify the Member’s employer(s) of the decision. To comply, the Member is required to:
i. Inform any employer of the decision prior to commencing or prior to resuming employment in any nursing position;
ii. Ensure that CNO is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any nursing position;
iii. Provide the Member’s employer(s) with a copy of:
the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;
iv. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to CNO, in which it will confirm:
that they received a copy of the required documents, and
that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession.
All documents delivered by the Member to CNO, the Expert or the Member’s employer(s) will be delivered by verifiable method, the proof of which the Member will retain.
College Submissions on Penalty
College Counsel made submissions on penalty which included the following:
The aggravating factor in this case was that the very serious misconduct of medication errors, which had a direct impact on patient safety, was repeated within a six-month period.
The mitigating factors in this case included that the Member had no previous discipline history. After both medication error incidents, the Member reported the errors appropriately, took accountability for her actions and recorded both incidents, and sought guidance and support with respect to follow up and next steps. The Member again took responsibility for her conduct by admitting to the allegations before this Panel, demonstrated remorse and accepted accountability for her actions by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College.
The proposed penalty provides for specific and general deterrence through the oral reprimand and the two-month suspension of the Member’s certificate of registration, which send a strong message that this kind of behaviour is unacceptable and that the Member and members-at-large ought to avoid these types of errors.
The proposed penalty provides for remediation and rehabilitation through the two meetings with a Regulatory Expert, and a review of the College’s standards, to assist the Member with an ethical return to practice once the suspension has been served.
The 12-month employer notification period provides an added layer of public protection.
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. Finch (Discipline Committee, 2005): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. This case involved allegations of contravening the standards of practice by failing to administer medications, failing to record vital signs, speaking to a client in a loud or threatening manner, and verbal and/or emotional abuse. The panel found that the member’s conduct was disgraceful, dishonourable and unprofessional. The member also asked a nursing student not to report her medication error. The penalty included an oral reprimand, a 60-day suspension of the member’s certificate of registration, a requirement that the member review a video and complete the One is One Too Many abuse prevention self-directed package, at least one meeting with a Practice Consultant and 12 months of employer notification.
CNO v. Diggins (Discipline Committee, 2009): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. This case involved medications administered to a client via the wrong route on one or more occasions. The member attempted to cover up her actions by failing to report the error(s), falsified records, and asked the client not to report the error. The penalty included an oral reprimand, a three-month suspension of the member’s certificate of registration, and terms, conditions and limitations on her certificate of registration including two meetings with an Expert to review specific practice standards and 12 months of employer notification.
CNO v. Rogers (Discipline Committee, 2020): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. This case involved a member who administered evening medications in the morning, kissed a patient on their lips after providing care and failed to complete a transfer of accountability with the next nursing shift at the end of her shift on one occasion. 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.
College Counsel submitted that the Joint Submission on Order meets the goals of penalty. The Member’s conduct, when contrasted with the cases submitted, is less severe as it did not involve falsifying documents and a lack of accountability. In the case before this Panel, the Member demonstrated remorse for her conduct and did not try to cover up her actions.
Member’s Submissions on Penalty
The Member did not make 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 two-month suspension of the Member’s certificate of registration, which sends a clear message to the membership that this type of conduct is not acceptable.
The proposed penalty provides for specific deterrence through the oral reprimand and the two-month suspension of the Member’s certificate of registration, which will deter the Member from repeating this conduct in the future.
The proposed penalty provides for remediation and rehabilitation through the two meetings with a Regulatory Expert, which will give the Member the opportunity to reflect on her conduct and obtain the tools necessary to improve her future practice, as well as allow for the Member to return to a safe and ethical practice.
Overall, the public is protected because the penalty in its totality provides for an added layer of protection with the 12 months of employer notification. The employer’s oversight reduces the likelihood of future medication errors occurring.
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.
I, Michael Hogard, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.