College of Nurses of Ontario v. Jenna Whitfield, 2024 ONCNO 142094

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Lalitha Poonasamy, Public Member, Chairperson Erin Cowan, RN Member Jane Hess, RN Member Sherry Szucsko-Bedard, RN Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO GLYNNIS HAWE for College of Nurses of Ontario

• and -

JENNA WHITFIELD Registration No. AD081726 NO REPRESENTATION for Jenna Whitfield

PATRICIA HARPER Independent Legal Counsel

Heard: December 2, 2024, via videoconference

DECISION AND REASONS

Publication Ban

By Order of the Discipline Panel dated December 2, 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 names of the patients, or any information that could disclose the identities of the patients, referred to orally or in any documents presented in the Discipline hearing of Jenna Whitfield.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on December 2, 2024.

The Allegations

The allegations against Jenna Whitfield (the “Member”) are stated in the Notice of Hearing dated October 3, 2024 pertaining to allegations in the time period of March to April 2020 (hereinafter referred to as Notice of Hearing #1) and in the Notice of Hearing dated October 3, 2024 pertaining to allegations in the time period of September 2021 to October 2022 (hereinafter referred to as Notice of Hearing #2) are as follows:

Notice of Hearing #1

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 working as a Registered Practical Nurse at the Brant Community Healthcare System, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession in that:

a) you misappropriated one or more of the narcotics prescribed to the patients listed in Appendix A;

b) you falsified witness signatures on narcotic disposal forms in the health records of the patients listed in Appendix A;

c) you failed to accurately or completely document the administration or disposal of one or more of the narcotics listed in Appendix A; and/or

d) on or about March 26, 2020, you accessed the personal health information of Patient [E], without clinical reason or consent or other authorization;

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(8) of Ontario Regulation 799/93, in that while employed as a Registered Practical Nurse at the Brant Community Healthcare System, you misappropriated property from your workplace and/or a patient, in that:

a) you misappropriated one or more of the narcotics prescribed to the patients listed in Appendix A; 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(13) of Ontario Regulation 799/93, in that, while employed as a Registered Practical Nurse at the Brant Community Healthcare System, you failed to keep records as required with respect to:

a) you falsified witness signatures on narcotic disposal forms in the health records of the patients listed in Appendix A; and/or

b) you failed to accurately and/or completely document the administration or disposal of one or more of the narcotics listed in Appendix A;

4. 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(14) of Ontario Regulation 799/93, in that, while employed as a Registered Practical Nurse at the Brant Community Healthcare System, you falsified a record relating to your practice with respect to:

a) you falsified witness signatures on narcotic disposal forms in the health records of the patients listed in Appendix A; and/or

5. 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 the Brant Community Healthcare System, you signed or issued, in your professional capacity, a document that you knew, or ought to have known contained a false or misleading statement with respect to, in that:

a) you falsified witness signatures on narcotic disposal forms in the health records of the patients listed in Appendix A; and/or

6. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that while employed as a Registered Practical Nurse at the Brant Community Healthcare System, 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 in that:

a) you misappropriated one or more of the narcotics prescribed to the patients listed in Appendix A;

b) you falsified witness signatures on narcotic disposal forms in the health records of the patients listed in Appendix A;

c) you failed to accurately or completely document the administration or disposal of one or more of the narcotics listed in Appendix A; and/or

d) on or about March 26, 2020, you accessed the personal health information of Patient [E], without clinical reason or consent or other authorization.

APPENDIX A

Item	Date	Time	Patient	Drug	Quantity
i.	March 8, 2020	0830	[A]	2mg/ml Hydromorphone	1mg
ii.	March 18, 2020	1025	[B]	2mg/ml Hydromorphone	2mg
iii.	April 9, 2020	2100	[C]	2mg/ml Hydromorphone	2mg
iv.	April 10, 2020	0300	[C]	2mg/ml Hydromorphone	2mg
v.	April 10, 2020	0430	[C]	1mg Tab Hydromophone	1mg
vi.	April 11, 2020	2120	[D]	2mg/ml Hydromorphone	2mg
vii.	April 12, 2020	0340	[D]	2 mg/ml Hydromorphone	2mg

Notice of Hearing #2

IT IS ALLEGED THAT:

1. You have committed an act of professional misconduct as provided by subsection 51(1)(a) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, in that while registered with the College of Nurses of Ontario as a Registered Practical Nurse, you were found guilty of an offence relevant to your suitability to practise, as follows:

a) on October 31, 2022, in the Ontario Court of Justice, you were found guilty of one count of theft under $5,000.00, contrary to Section 334 (b) of the Criminal Code of Canada;

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(1) of Ontario Regulation 799/93, in that while registered with the College of Nurses of Ontario as a Registered Practical Nurse, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession in that:

a) between September 8, 2021 and December 10, 2021, you misappropriated narcotics from St. Joseph’s Healthcare Hamilton;

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(8) of Ontario Regulation 799/93, in that while registered with the College of Nurses of Ontario as a Registered Practical Nurse, you misappropriated property from a patient or workplace, and in particular:

a) between September 8, 2021 and December 10, 2021, you misappropriated narcotics from St. Joseph’s Healthcare Hamilton;

4. 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(18) of Ontario Regulation 799/93, in that while registered with the College of Nurses of Ontario as a Registered Practical Nurse:

a) you contravened a term, condition or limitation on your certificate of registration, as provided by section 1.5(1)1.(i) of Ontario Regulation 275/94 of the Nursing Act, 1991, in that you failed to report findings of guilt arising in any jurisdiction relating to any offence to the College of Nurses of Ontario, as follows:

i. on October 31, 2022, in the Ontario Court of Justice, you were found guilty of one count of theft under $5,000.00, contrary to Section 334 (b) of the Criminal Code of Canada; and/or

b) you contravened a term, condition or limitation on your certificate of registration, as provided by section 1.5(1)1.(ii) of Ontario Regulation 275/94 of the Nursing Act, 1991, in that you failed to report charges arising in any jurisdiction relating to any offence to the College of Nurses of Ontario, as follows:

i. on or about January 10, 2022, you were charged with the following offences:

1. that on or between the 17^th day of August, 2021 and the 9^th day of December, 2021, at the City of Hamilton, you did unlawfully steal to wit: Hydromorphone valued at under $5,000.00, the property of St. Joseph’s Healthcare Hamilton, contrary to the provisions of Section 334 (b) of the Criminal Code of Canada; and/or

2. that on or between the 17^th day of August, 2021 and the 9^th day of December, 2021, at the City of Hamilton in the said region being the trustee of St. Joseph’s Healthcare Hamilton, for your own profit, did convert a secure drug dispense code to a use not authorized by the trust with intent to defraud and in contravention of the trust contrary to the provisions of Section 336 of the Criminal Code of Canada;

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(19) of Ontario Regulation 799/93, in that, in that while registered with the College of Nurses of Ontario as a Registered Practical Nurse, you contravened a provision of the Nursing Act, 1991, the Regulated Health Professions Act, 1991, or the regulations under either of those Acts, in that:

a) you contravened section 85.6.1 of the Health Professions Procedural Code, in that you failed to report a finding of guilt of an offence to the College of Nurses of Ontario, as follows:

i. on October 31, 2022, in the Ontario Court of Justice, you were found guilty of one count of theft under $5,000.00, contrary to Section 334 (b) of the Criminal Code of Canada; and/or

b) you contravened section 85.6.4 of the Health Professions Procedural Code, in that you failed to report being charged with an offence and/or information about any bail condition or other restriction imposed on, or agreed to, in connection with a charge to the College of Nurses of Ontario, as follows:

i. on or about January 7, 2022, you gave an undertaking to comply with conditions of release; and/or

ii. on or about January 10, 2022, you were charged with the following offences:

1. that on or between the 17^th day of August, 2021 and the 9^th day of December, 2021, at the City of Hamilton, you did unlawfully steal to wit: Hydromorphone valued at under $5,000.00, the property of St. Joseph’s Healthcare Hamilton, contrary to the provisions of Section 334 (b) of the Criminal Code of Canada; and/or

2. that on or between the 17^th day of August, 2021 and the 9^th day of December, 2021, at the City of Hamilton in the said region being the trustee of St. Joseph’s Healthcare Hamilton, for your own profit, did convert a secure drug dispense code to a use not authorized by the trust with intent to defraud and in contravention of the trust contrary to the provisions of Section 336 of the Criminal Code of Canada;

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 registered with the College of Nurses of Ontario as a Registered Practical Nurse, 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 in that:

a) between September 8, 2021 and December 10, 2021, you misappropriated narcotics from St. Joseph’s Healthcare Hamilton;

b) on October 31, 2022, in the Ontario Court of Justice, you were found guilty of one count of theft under $5,000.00, contrary to Section 334 (b) of the Criminal Code of Canada; and/or

c) you failed to report charges, an undertaking to comply, and/or findings of guilt to the College of Nurses of Ontario, as follows:

i. on or about January 7, 2022, you gave an undertaking to comply with conditions of release;

ii. on or about January 10, 2022, you were charged with the following offences:

1. that on or between the 17^th day of August, 2021 and the 9^th day of December, 2021, at the City of Hamilton, you did unlawfully steal to wit: Hydromorphone valued at under $5,000.00, the property of St. Joseph’s Healthcare Hamilton, contrary to the provisions of section 334 (b) of the Criminal Code of Canada; and/or

2. that on or between the 17^th day of August, 2021 and the 9^th day of December, 2021, at the City of Hamilton in the said region being the trustee of St. Joseph’s Healthcare Hamilton, for your own profit, did convert a secure drug dispense code to a use not authorized by the trust with intent to defraud and in contravention of the trust contrary to the provisions of section 336 of the Criminal Code of Canada; and/or

iii. on October 31, 2022, in the Ontario Court of Justice, you were found guilty of one count of theft under $5,000.00, contrary to Section 334 (b) of the Criminal Code of Canada.

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a), (b), (c), (d), 2(a), 3(a), (b), 4(a), 5(a) and 6(a), (b), (c) and (d) in the Notice of Hearing #1 and in paragraphs 1(a), 2(a), 3(a), 4(a)(i), (b)(i)(1), (2), 5(a)(i), (b)(i), (b)(ii)(1), (2) and 6(a),(b), (c)(i), (c)(ii)(1), (2) and (c)(iii) in the Notice of Hearing #2. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admissions were voluntary, informed and unequivocal.

Agreed Statement of Facts

College Counsel and the Member advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited and without exhibits mentioned therein, as follows:

THE MEMBER

1. Jenna Whitfield (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on November 14, 2014.

2. The Member was employed at St. Joseph’s Healthcare Hamilton – Charlton Campus (the “Facility”) in Hamilton, Ontario, beginning on January 5, 2015. The Member worked as an RPN in the Emergency Department (“ED”) until in or around August 2021, at which time the Member transferred to a Porter position, a non-nursing role. The Facility terminated the Member’s employment on June 29, 2022.

3. The Member was also employed part-time at Brant Community Healthcare System (the “Hospital”) in Brantford, Ontario, from January 7, 2020 to April 29, 2020.

4. On April 13, 2022, the Inquiries, Complaints and Reports Committee (“ICRC”) imposed terms, conditions and limitations on the Member’s certificate of registration on an interim basis.

5. On February 16, 2023 the Member’s certificate of registration was administratively suspended for non-payment of fees. On March 20, 2023, the Member’s certificate of registration expired. The Member is not presently entitled to practice nursing in Ontario.

NOTICES OF HEARING

6. The ICRC referred two sets of allegations against the Member:

(a) on April 26, 2023, the ICRC referred allegations in respect of incidents at the Hospital, which are contained in a Notice of Hearing dated May 27, 2024 (“NOH #1”); and

(b) on October 25, 2023, the ICRC referred allegations in respect of incidents at the Facility, which are contained in a Notice of Hearing dated May 27, 2024 (“NOH #2”).

7. The Member admits the allegations contained in both Notices of Hearing.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

The Hospital – Narcotics Incidents

8. During her employment at the Hospital, the Member worked for the Centralized Resource Team (the “CRT”). The CRT is a float team; staff are dispatched to hospital departments on an as-needed basis.

9. The Hospital keeps a combination of electronic and paper records. Narcotics are kept in a locked drawer. Upon removing a narcotic, a nurse records the patient’s name, date, physician, and amount withdrawn on the paper narcotic sheet. When the medication is administered, the nurse scans it, which documents in the patient’s electronic record that the medication has been administered. A nurse does not require a witness to withdraw or administer narcotics. If a narcotic is wasted, it must be done in the presence of a witness, who co-signs the paper record.

March 8, 2020

10. On March 8, 2020, the Member was assigned to Unit B7 Medical. Patient [A] was a patient of the Unit. He had a standing order for PRN 1ml of hydromorphone 2mg/ml.

11. At 0830, the Member withdrew 2mg of 2mg/ml hydromorphone for Patient [A]. At 0840, the Member documented administering 1mg of 2mg/ml hydromorphone to Patient [A]. The Member then documented wasting the remaining 1mg hydromorphone, including with a witness signature on the narcotic disposal form.

12. The Member admits that she did not waste the remaining 1mg of hydromorphone. Rather, the Member admits that she misappropriated 1mg of hydromorphone for personal use. The Member also admits that she falsified a witness signature on the narcotic disposal form.

March 18, 2020

13. On March 18, 2020, the Member was assigned to the ED.

14. At 1025, the Member withdrew 2mg of 2mg/ml hydromorphone for Patient [B], a patient in the ED. The Member then documented wasting all of the hydromorphone, including with a witness signature on the narcotic disposal form.

15. The Member admits that she did not waste the 2mg of hydromorphone. Rather, the Member admits that she misappropriated 2mg of hydromorphone for personal use. The Member also admits that she falsified a witness signature on the narcotic disposal form.

April 9-10, 2020

16. During the night shift on April 9, 2020, the Member was assigned to Unit B8 Medical.

17. At 2100 on April 10, 2020, the Member withdrew 2mg hydromorphone for Patient [C]. She then documented wasting 1.75mg hydromorphone. The Member signed the wastage form, along with a witness. The Member did not document administering or wasting the remaining 0.25mg.

18. The Member admits that she did not waste 1.75mg of hydromorphone. Rather, the Member admits that she misappropriated the entirety of the 2mg of hydromorphone for personal use. The Member also admits that she falsified a witness signature on the narcotic disposal form.

19. At 0300 on April 10, 2020, the Member withdrew 2mg hydromorphone for Patient [C]. She then documented wasting 1.75mg hydromorphone. The Member signed the wastage form, along with a witness. The Member did not document administering or wasting the remaining 0.25mg.

20. The Member admits that she did not waste 1.75mg of hydromorphone. Rather, the Member admits that she misappropriated the entirety of the 2mg of hydromorphone for personal use. The Member also admits that she falsified a witness signature on the narcotic disposal form.

21. At 0430 on April 10, 2020, the Member documented withdrawing a 1mg tab of hydromorphone for Patient [C]. At 0427, the Member documented administering 0.5mg of hydromorphone tab to Patient [C]. The Member did not document administering or wasting the remaining 0.5mg hydromorphone.

22. The Member admits that she did not administer 0.5mg tab hydromorphone to Patient [C]. Rather, the Member admits that she misappropriated the entirety of the 1mg tab of hydromorphone for personal use. The Member also admits that she falsified her documentation that she had administered 0.5mg hydromorphone to Patient [C].

April 11-12, 2020

23. On April 11, 2020, the Member was assigned to the Integrated Stroke Unit at the Hospital.

24. At 2120 on April 11, 2020, the Member withdrew 2mg hydromorphone for Patient [D]. The Member then documented wasting 1.5mg hydromorphone, including with a witness signature on the narcotic disposal form.

25. The Member admits that she did not administer 0.5mg of hydromorphone to Patient [D], nor did she waste 1.5mg hydromorphone. Rather, the Member admits that she misappropriated 2mg hydromorphone for personal use. The Member also admits that she falsified a witness signature on the narcotic disposal form.

26. At 0340 on April 12, 2020, the Member withdrew 2mg hydromorphone for Patient [D]. The Member then documented wasting 1.5mg hydromorphone, including with a witness signature on the narcotic disposal form.

27. The Member admits that she did not administer 0.5mg hydromorphone to Patient [D], nor did she waste 1.5mg hydromorphone. Rather, the Member admits that she misappropriated 2mg hydromorphone for personal use. The Member also admits that she falsified a witness signature on the narcotic disposal form.

The Hospital – Privacy Breach

28. When the Member was hired by the Hospital, she was required to review a confidentiality policy entitled “New Hire Information Re Privacy/Confidentiality”. The Member also completed a course entitled “Foundations of FIPPA and Privacy”, on January 9, 2020.

29. Patient [E] visited the Hospital on two occasions in March 2020 with symptoms of COVID-19.

30. At the end of March 2020, the Hospital audited the charts of all Covid-19 patients for appropriateness of access by staff members.

31. As a result of the audit, the Hospital identified that on March 26, 2020 at 2035, the Member accessed Patient [E]’s patient chart from “BG01500”, a computer that is located in Unit B2 of the Hospital, where the Member was assigned to work on that date.

32. Patient [E] was not a patient of Unit B2, at that time or ever. The Member was not part of Patient [E]’s circle of care.

33. The Member admits that she had no clinical reason to access Patient [E]’s chart and did not have consent or authorization to do so. As a result, the Member admits that she breached Patient [E]’s privacy by inappropriately accessing their chart.

The Facility – Narcotics Incidents

34. The Facility used AcuDose, an automated dispensing machine, to track medication withdrawals. AcuDose records the identity of the nurse withdrawing medications, the date and time of the withdrawal, the type and quantity of medication, and the patient for whom the medication was withdrawn.

35. On December 10, 2021, staff at the Facility generated an AcuDose “override” report, as part of their standard auditing of the Facility’s narcotics dispensing systems. This report shows the dates, times, and dosages for withdrawals in which a nurse used an override code to access and withdraw narcotics from the system. Override codes permit a nurse to access narcotics without entering the details of a patient or an order.

36. The AcuDose report demonstrated that between November and December 2021, when she was no longer working in a nursing role, the Member withdrew controlled substances on a number of occasions.

37. The Facility initiated an investigation. The Facility also notified the Hamilton Police, who opened a criminal investigation.

38. The Facility’s AcuDose records demonstrate that on more than 100 occasions between August and December 2021, the Member withdrew narcotics from the Facility’s AcuDose system at a time when she was working shifts as a Porter and therefore not assigned to the care of patients nor permitted to withdraw or administer medications. The Member withdrew hydromorphone in both 2mg/mL and 10mg/mL concentrations.

Criminal Charges and Finding of Guilt

39. On January 7, 2022, the Member was arrested and charged by the Hamilton Police Service with the following charges:

(a) that between August 17 and December 9, 2021, the Member unlawfully stole hydromorphone valued under $5,000 which was the property of the Facility, contrary to s. 334 (b) of the Criminal Code; and

(b) that the Member unlawfully converted a secure drug dispensing code to a use not authorized for, in breach of trust, for her own personal profit and with an intent to defraud, contrary to s. 336 of the Criminal Code.

40. The Member was released on bail with conditions, including that she notify police if she moved, that she have no contact with some employees of the Facility, and that she not go within 100 metres of the Facility. The Member also gave an undertaking to appear in court on February 24, 2022.

41. The Member did not report to CNO that she had been charged with criminal offences, nor did she report to CNO the conditions of her bail or her undertaking to appear in court.

42. On October 31, 2022, the Member pleaded guilty to theft under $5,000, contrary to section 334 (b) of the Criminal Code. The second count, criminal breach of trust, was withdrawn. The Member was given a suspended sentence of 12 months’ probation. As part of the Member’s guilty plea, the Member admitted that between August 17 and December 9, 2021 she accessed the Facility’s AcuDose machine and dispensed hydromorphone on 183 different occasions for her personal use, without a physician’s order, by using her own unique access code to override the system.

43. The Member did not report to CNO that she had been found guilty of a criminal offence.

CNO STANDARDS

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

Code of Conduct

45. 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; and

(f) Nurses maintain public confidence in the nursing profession.

46. CNO’s Code of Conduct provides, in relation to the principle requiring nurses to maintain patients’ trust by providing safe and competent care, that nurses are accountable to, and practice under, relevant laws and CNO’s standards of practice.

47. CNO’s Code of Conduct provides, in relation to the principle requiring nurses to act with integrity to maintain patients’ trust, that nurses protect the privacy and confidentiality of patients’ personal health information.

48. CNO’s Code of Conduct also 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.

49. In order to meet the Code of Conduct, nurses must:

(a) Maintain complete, accurate, and timely documentation;

(b) Respect the property of their patients and employers;

(c) Take accountability for their own actions and decisions, without jeopardizing patient safety and the quality of care; and

(d) Ceasing to practice when impaired and maintaining overall health and fitness if they believe their health affects their ability to practice safely.

50. 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

51. 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.

52. 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 actions such as ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation.

53. CNO’s Professional Standards further provides, in relation to the ethics standard, that ethical nursing care means promoting the values of patient well-being, assuring privacy and confidentiality, maintaining commitments, respecting truthfulness and ensuring fairness in the use of resources.

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

Confidentiality and Privacy: Personal Health Information

55. CNO’s Confidentiality and Privacy - Personal Health Information standard (“Privacy Standard”) largely incorporates the Personal Health Information Protection Act, 2004. The Privacy Standard provides that nurses have ethical and legal responsibilities to maintain the confidentiality and privacy of patient health information obtained while providing care. It requires that personal health information be kept confidential and secure. Nurses comply with the Privacy Standard by:

(a) Seeking information about issues of privacy and confidentiality of personal health information;

(b) Maintaining confidentiality of [patients’] personal health information with members of the healthcare team, who are also required to maintain confidentiality, including information that is documented or stored electronically;

(c) Collecting only information that is needed to provide care;

(d) Accessing information for her/his [patients] only and not accessing information for which there is no professional purpose; and

(e) Safeguarding the security of computerized, printed or electronically displayed or stored information against theft, loss, unauthorized access or use, disclosure, copying, modification, or disposal.

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

57. The Member admits and acknowledges that she contravened CNO’s Code of Conduct and Professional Standards when she misappropriated narcotics from the Hospital and the Facility.

58. The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards, and Privacy Standard when she accessed the patient chart of a patient of the Hospital who was not in her circle of care.

59. The Member further admits and acknowledges that she contravened CNO’s Code of Conduct and Professional Standards when she failed to report to CNO that she had been charged with criminal offences, had agreed to conditions of bail and an undertaking, and/or when she pleaded guilty to a criminal offence.

SUITABILITY TO PRACTISE

60. Section 51(1)(a) of the Health Professions Procedural Code (Schedule 2 to the Regulated Health Professions Act, 1991, S.O. 1991 c. 18), provides that a panel shall find that a member has committed an act of professional misconduct if the member has been found guilty of an offence that is relevant to the member’s suitability to practise.

61. CNO’s Reference Document Professional Conduct: Professional Misconduct, provides guidance on section 51(1)(a) of the Health Professions Procedure Code and states:

A finding of guilt for an offence that is relevant to the nurse’s suitability to practise is behaviour that is considered harmful to the public, places the public’s safety in jeopardy or threatens the trust the public needs to have in a nurse.

62. CNO’s Reference Document Professional Conduct: Professional Misconduct, further states that examples of convictions that have been found relevant to a nurse’s suitability to practise include assault, theft, trafficking of illicit drugs, and conspiring to commit any of those offences.

63. A copy of CNO’s Reference Document Professional Conduct: Professional Misconduct is attached as Exhibit “D”.

64. The Member admits and acknowledges that the finding of guilt for one count of theft is relevant to her suitability to practice.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

Admissions to Allegations in NOH #1

65. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a), 1(b), (c), and 1(d) of NOH #1 in that she contravened a standard of practice of the profession or failed to meet the standard of practice of the profession, as described in paragraphs 8 to 64 above.

66. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 2(a) of NOH #1 in that she misappropriated property from her workplace and/or patients, as described in paragraphs 8 to 27 and 34 to 38 above.

67. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3(a) and (b) of NOH #1 in that she failed to keep records as required, as described in paragraphs 8 to 27 and 34 to 38 above.

68. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 4(a) of NOH #1 in that she falsified records related to her practice, as described in paragraphs 8 to 27 and 34 to 38 above.

69. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 5(a) of NOH #1 in that she signed a document in her professional capacity that she knew or ought to have known contained a false or misleading statement, as described in paragraphs 8 to 27 and 34 to 38 above.

70. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 6(a), 6(b), 6(c), and 6(d) NOH #1 and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 8 to 64 above.

Admissions to Allegations in NOH #2

71. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1(a) of NOH #2 in that she was found guilty of an offence relevant to her suitability to practise, as described in paragraphs 39 to 43 and 60 to 64 above.

72. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 2(a) of NOH #2 in that she contravened a standard of practice of the profession or failed to meet the standard of practice of the profession, as described in paragraphs 34 to 38 above.

73. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3(a) of NOH #2 in that she misappropriated property from a patient or workplace, as described in paragraphs 34 to 42 above.

74. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 4(a)(i), 4(b)(i)1, and 4(b)(i)2 of NOH #2 and, in particular, that she contravened a term, condition or limitation on her certificate when she failed to report criminal charges and findings of guilt to CNO as required by section 1.5(1)1.(i) and (ii) of Ontario Regulation 275/94 of the Nursing Act, 1991, as described in paragraphs 39 to 43 above.

75. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 5(a)(i), 5(b)(i), 5(b)(ii)1, and 5(b)(ii)2 of NOH #2 and, in particular, that she failed to report criminal charges, findings of guilt, and information about a bail condition or restrictions imposed in connection with a charge to CNO as required by sections 85.6.1 and 85.6.4 of the Health Professions Procedural Code, as described in paragraphs 39 to 43 above.

76. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 6(a), 6(b), 6(c)(i), 6(c)(ii)1, 6(c)(ii)2, and 6(c)(iii) of the Notice of Hearing and, in particular, that she engaged in conduct that would reasonably be regarded by members of the profession as disgraceful, dishonourable and unprofessional, as described in paragraphs 34 to 54 and 57 to 64 above.

College’s Submissions on Liability

College Counsel asked the Panel to accept the Member’s admissions to all the allegations as set out in paragraphs 65 to 76 of the Agreed Statement of Facts and, on the basis of those facts and admissions, make findings of professional misconduct with respect to the allegations in Notice of Hearing #1 and Notice of Hearing #2. College Counsel submitted that the Panel had taken the Member’s plea and conducted a verbal plea inquiry. The Member’s plea was voluntary.

Member’s Submissions on Liability

The Member made no submissions on liability.

Decision

The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities based upon clear, cogent and convincing evidence.

Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1(a), (b), (c), (d), 2(a), 3(a), (b), 4(a), 5(a) and 6(a), (b), (c) and (d) in the Notice of Hearing #1. As to allegations #6(a), (b), (c) and (d), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonourable and unprofessional.

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), 2(a), 3(a), 4(a)(i), (b)(i)(1), (2), 5(a)(i), (b)(i), (b)(ii)(1), (2) and 6(a),(b), (c)(i), (c)(ii)(1), (2) and (c)(iii) in the Notice of Hearing #2. As to allegations #6(a), (b), (c)(i), (c)(ii)(1), (2) and (c)(iii), 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

Notice of Hearing #1

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 #1.

Allegations #1(a), (b), (c) and (d) in the Notice of Hearing #1 are supported by paragraphs 8 – 59 and 65 in the Agreed Statement of Facts. The Member admitted and the Panel finds that between March 8, 2020 and April 12, 2020, while employed at Brant Community Healthcare System (the “Hospital”), she not only took narcotics prescribed to seven patients for her own personal use, but falsified documents in the process. The Member also admitted to accessing a patient’s personal health record or health information without any clinical reason during that same time. This constitutes a breach of the College’s Confidentiality and Privacy – Personal Health Information Standard. The Member’s conduct contravened multiple other College standards. The College’s Code of Conduct and the Professional Standards require nurses to act with integrity, protect the privacy of patients, and maintain complete, accurate documents. The Member breached both these standards.

Allegation #2(a) in the Notice of Hearing #1 is supported by paragraphs 8 - 27, 34 - 38 and 66 in the Agreed Statement of Facts. The Member admitted and the Panel finds that she committed an act of professional misconduct when she misappropriated property from the Hospital by stealing hydromorphone injectables and a tablet from seven patients at the Hospital where she worked.

Allegations #3(a) and (b) in the Notice of Hearing #1 are supported by paragraphs 8 - 27, 34 - 38 and 67 in the Agreed Statement of Facts. The Member admitted and the Panel finds that she committed an act of professional misconduct when she failed to keep accurate records as required. The Member acknowledged that she was aware the documentation was inaccurate when she falsified witness signatures on the narcotic disposal forms and failed to properly document the narcotic administration to patients.

Allegation #4(a) in the Notice of Hearing #1 is supported by paragraphs 8 - 27, 34 - 38 and 68 in the Agreed Statement of Facts. The Member admitted and the Panel finds that she committed an act of professional misconduct when she falsified records at the Hospital. The Member admitted to falsifying witness signatures on the narcotic disposal forms when she took patient narcotics for her own use.

Allegation #5(a) in the Notice of Hearing #1 is supported by paragraphs 8 - 27, 34 - 38 and 69 in the Agreed Statement of Facts. The Member admitted and the Panel finds that she committed an act of professional misconduct when she signed a document in her professional capacity that she knew contained false information. The Member admitted to falsifying narcotics disposal forms then signed them in her professional capacity as if she was administering the narcotics to patients.

Allegations #6(a), (b), (c) and (d) in the Notice of Hearing #1 are supported by paragraphs 8 - 64 and 70 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 Confidentiality and Privacy – Personal Health Information Standard. The Panel finds that the Member’s actions in misappropriating medication intended for patients, falsifying records related to medication administration, forging witness signatures on narcotic disposal forms, breaching a patient’s privacy by inappropriately accessing their personal health information, and signing a document she knew to be inaccurate in her professional capacity reflect a significant and ongoing disregard for her professional obligations and responsibilities.

The Panel also finds that the Member’s conduct was dishonourable as it demonstrated an element of moral failing, dishonesty and deceit when she used her position to steal medications. The Member knew or ought to have known that stealing patient medications for her own benefit and concealing the theft was unacceptable and fell below the standards of a professional.

Notice of Hearing #2

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 #2.

Allegation #1(a) in the Notice of Hearing #2 is supported by paragraphs 39 - 43, 60 - 64 and 71 in the Agreed Statement of Facts. The Member admitted and the Panel finds that while employed at St. Joseph’s Healthcare Hamilton (the “Facility”) she committed an act of professional misconduct in that she was found guilty on October 31, 2022, of an offence that is relevant to her suitability to practise, namely, theft under $5,000.00 in relation to her misappropriation of narcotics from the Facility.

Allegation #2(a) in the Notice of Hearing #2 is supported by paragraphs 34 - 38 and 72 in the Agreed Statement of Facts. The Panel finds and the Member admitted that she contravened a standard of practice of the profession or failed to meet the required standards of practice when she misappropriated narcotics from the Facility for her personal use between September 8, 2021 and December 10, 2021. The College’s Professional Standards emphasize that nurses must uphold ethical principles and promote patient well-being.

Allegation #3(a) in the Notice of Hearing #2 is supported by paragraphs 34 - 42 and 73 in the Agreed Statement of Facts. The Panel finds and the Member admitted that she committed an act of professional misconduct when she misappropriated property from a patient or workplace when she took narcotics from the Facility for her personal use between September 8, 2021 and December 10, 2021.

Allegations #4(a)(i) and (b)(i)1 and 2 in the Notice of Hearing #2 are supported by paragraphs 39 - 43 and 74 in the Agreed Statement of Facts. On January 7, 2022, the Member was arrested and charged by the Hamilton Police Service with theft under $5,000.00, contrary to s. 334 (b) of the Criminal Code, and breach of trust with an intent to defraud contrary to s. 336 of the Criminal Code, related to stealing hydromorphone from the Facility between August 17, 2021 and December 9, 2021. On October 31, 2022, the Member pleaded guilty to theft under $5,000.00 and the breach of trust charge was withdrawn. The Member admitted that she did not report the charge or finding of guilt to the College. This constituted professional misconduct as set out in s. 1(18) of Ontario Regulation 799/93 made under the Nursing Act, 1991. It was a condition of the Member’s certificate of registration that she report findings of guilt for any criminal offence and any current proceeding in respect of any offence in accordance with s. 1.4(1) (1)(i) and (iv) of Ontario Regulation 275/94 under the Nursing Act, 1991, and she failed to do so.

Allegations #5(a)(i), (b)(i), (ii)1 and (ii)2 in the Notice of Hearing #2 are supported by paragraphs 39 - 43 and 75 in the Agreed Statement of Facts. The Member admitted and the Panel finds that she failed to report to the College that she was charged with an offence, as well as any bail conditions or other restrictions imposed upon her in connection with the charge. As set out above, on January 7, 2022, the Member was arrested and charged with two offences contrary to the Criminal Code. She was released on bail with conditions, including that she would have no contact with employees of the Facility or go within 100 metres of the Facility. The Member also gave an undertaking to appear in court on February 24, 2022.

Section 85.6.1 of the Health Professions Procedural Code required the Member to report to the College that she had been found guilty of an offence as soon as reasonably practicable, and s. 85.6.4 required the Member to report any criminal charges and information about her bail conditions or any other restrictions in connection with the charges. The Member did not report to the College the conditions of her bail or undertaking to appear in court, which constitutes professional misconduct as set out in s. 1(19) of Ontario Regulation 799/93.

Allegations #6(a), (b), (c)(i), (ii)1, 2 and (iii) in the Notice of Hearing #2 are supported by paragraphs 34 - 54, 57 - 64 and 76 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct was relevant to the practice of nursing as she contravened the standards of practice of the profession and was found guilty of offences relevant to her suitability to practise. The Member’s finding of guilt related to the misappropriation of narcotics from a healthcare facility is an offence relevant to her suitability to practise and occurred in the course of her work as a nurse. It was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations in contravening the Code of Conduct and the Professional Standards.

The Panel also finds that the Member’s conduct was dishonourable as it demonstrated an element of moral failing, dishonesty and deceit when she used her position to steal medications. The Member knew or ought to have known that stealing medications from the Facility for her own benefit was unacceptable and fell below the standards of a professional.

Finally, the Panel finds that the Member’s conduct was disgraceful as it shames the Member and by extension the profession. The Member failed to disclose to the Executive Director of the College the details of her findings of guilt, criminal charges and bail conditions. Nurses are expected to uphold and demonstrate the standards of the profession in their practice. By stealing narcotics from the Facility, the Member discredited herself and the profession and, breached the expectations set out in the standards. The Member’s conduct 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 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 three months of the date that this Order becomes final.

College Submissions on Penalty

College Counsel made submissions which included the following:

College Counsel submitted that the Joint Submission on Order also provides in Appendix “A” an undertaking and agreement by the Member for the Member’s permanent resignation as a member of the College effective December 2, 2024 (the “Undertaking”). Pursuant to this Undertaking, the Member undertakes, acknowledges and agrees to:

a) Permanently resign as a member of the College, effective from the date that the Order made by the Discipline Committee in accordance with the Joint Submission on Order becomes final;

b) Not apply for membership with the College as a Registered Nurse or Registered Practical Nurse at any time in the future;

c) Agree that the public portion of the College’s Register will indefinitely reflect that the Member entered into an Undertaking with the Executive Director to permanently resign as a member of the College as part of an agreed resolution of allegations of professional misconduct;

d) No longer have a right to the issuance or reinstatement of a Certificate of Registration from the College;

e) No longer have a right to use the title “Nurse”, “Registered Nurse”, “Registered Practical Nurse”, “RN”, “RPN” or a variation, an abbreviation or an equivalent in another language;

f) No longer have a right to hold herself out as a Nurse, Registered Nurse, Registered Practical Nurse or as a person who is qualified to practise in Ontario as a Nurse, Registered Nurse or Registered Practical Nurse;

g) No longer have a right to engage in the practice of nursing in any capacity; and

h) Agree the College is authorized to and may, in its sole discretion, provide a copy of the Undertaking and/or its terms to a governing body that regulates nursing in Canada or elsewhere in response to an inquiry or otherwise.

College Counsel submitted that the Member’s permanent resignation allows for a limited penalty with no need for terms, conditions and limitations or suspension of the Member’s certificate of registration.

College Counsel submitted that the objectives of specific and general deterrence are met through the Member’s permanent resignation, the oral reprimand and her commitment not to apply for membership with the College in the future. College Counsel submitted that this penalty shows other members of the profession at large that the College takes this behaviour, as well as the protection of the public, seriously.

College Counsel further submitted that the aggravating factors in this case were:

• The duration of the Member’s misconduct, which was repeated over an extended period of time; and
• The Member’s conduct posed a potential risk of harm to patients when she stole narcotics intended for patient use. Her actions violated the trust between herself and the patients.

The mitigating factors in this case were:

• The Member cooperated with the College, accepted accountability for her conduct and entered into an Agreed Statement of Facts and a Joint Submission on Order with the College;
• The Member had no prior discipline history with the College; and
• The Member had a substance abuse condition at the time of the events.

College Counsel submitted that since the Member has undertaken to permanently resign her certificate of registration and never reapply for membership with the College, the penalty order does not need to consider remediation and rehabilitation.

Overall, the public is protected because the Member has agreed to an undertaking to not apply for membership with the College as a registered nurse or registered practical nurse at any time in the future.

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. Demme (Discipline Committee, 2020): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. This case was similar to the case before this Panel in that it involved misappropriating narcotics and items from a workplace, falsifying records and inappropriate access to a patient’s personal health information. The member was found guilty of criminal charges related to these incidents. The member acknowledged suffering from a substance use disorder. The member also signed an undertaking to permanently resign as a member of the College. The penalty was an oral reprimand. which is identical to the penalty proposed in the case before this Panel.

CNO v. O’Kell-Ayers (Discipline Committee, 2021): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. This case was similar to the case before this Panel in that it involved misappropriating narcotics and items from a workplace, falsifying records and failing to keep accurate records. The member signed an undertaking to permanently resign as a member of the College. The penalty was an oral reprimand, which is identical to the penalty proposed in the case before this Panel.

Member’s Submissions on Penalty

The Member made no submissions on penalty.

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.

In this case, because the Member has undertaken to permanently resign, the oral reprimand is a sufficient penalty and no other specific deterrence is required.

General deterrence is also addressed as the Panel concluded had the Member’s situation been different and no Undertaking given, the Panel would have ordered a suspension, and terms, conditions and limitations on the Member’s certificate of registration which would have been in line with previous penalties.

Furthermore, because of the Member’s resignation, it is not necessary to consider remediation and rehabilitation in determining the appropriate penalty.

Finally, the penalty of an oral reprimand only is appropriate because the public is already protected through the Member’s permanent resignation and the Undertaking to never apply for registration as a nurse in Ontario or engage in the practice of nursing in any capacity.

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, 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.