DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL

Michael Hogard, RPN Chairperson Lalitha Poonasamy Public Member Dayna Porco, RPN Member Sherry Szucsko-Bedard, RN Member

BETWEEN

COLLEGE OF NURSES OF ONTARIO ) JEAN-CLAUDE KILLEY for ) College of Nurses of Ontario

• and - )

GEORGE IRA IDZENGA ) NO REPRESENTATION for REGISTRATION NO. IH01085 ) George Ira Idzenga ) PATRICIA HARPER ) Independent Legal Counsel ) Heard: December 17 & 18, 2024 ) via videoconference

DECISION AND REASONS

Publication Ban

By Order of the Discipline Panel dated December 17, 2024, pursuant to subsection s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, no one shall disclose, 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 at the Discipline hearing of George Ira Idzenga.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) commencing on December 17, 2024.

The Member’s Non-Attendance at the Hearing

As George Ira Idzenga (the “Member”) was not present at the start time of the hearing, the hearing recessed for fifteen minutes to allow time for the Member to appear. Upon reconvening, the Panel noted that the Member was still not in attendance.

College Counsel provided the Panel with evidence that the Member had been sent the Notice of Hearing on November 13, 2024 by way of an affidavit from Alexandra Covriga, Prosecutions Clerk, affirmed November 19, 2024 and marked as Exhibit #2, confirming that she sent correspondence, which included the Notice of Hearing, as well as previous documents sent to the Member by the College that included a Memo re: Hearing Procedures for Self-Represented Members, the Discipline Committee Rules, Discipline Committee Guidelines and the Memo re: Issuance of Summonses, on November 13, 2024 to the Member via a SharePoint link to the Member’s last known email address on the College Register.

Pursuant to College By-law 44.2, members of the College are required to complete annually and return to the College, a form containing information including the member’s home address, primary telephone number and primary email address checked personally by the member on a regular basis.

College Counsel provided the Panel with evidence that the Member had been served with the Notice of Hearing on November 21, 2024 by way of an affidavit from David Florek, Process Server, sworn November 22, 2024 and marked as Exhibit #3, confirming that he served the Member with a letter dated November 21, 2024 from Jean-Claude Killey, College Counsel, which included the Notice of Hearing, as well as previous documents sent to the Member by the College that included the College’s disclosure materials, Code of Conduct, Professional Standards, revised 2002 and Practice Standards: Therapeutic Nurse-Client Relationship Standard, revised 2006 to the Member’s last known address on the College Register.

The Panel was satisfied that the Member had received adequate notice of the time, place and purpose of the hearing and of the fact that if he did not attend, the hearing may proceed in his absence. Accordingly, the Panel decided to proceed with the hearing in the Member’s absence under the authority of sections 6(5)(d) and 7(3) of the Statutory Powers Procedure Act, R.S.O. 1990, c. S.22 (the “SPPA”). The Panel notes that the videoconference line remained open until the end of the hearing and the Member did not join the hearing before its conclusion.

The Allegations

The allegations against the Member as stated in the Notice of Hearing dated November 7, 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 Maplewood OMNI Health Care in Brighton, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, and in particular:

a. on or about December 20, 2019, you grabbed [the Patient] by the shoulder, and/or turned her around, and/or forcefully directed her away from another patient;

b. on or about December 20, 2019, you said to [the Patient] words to the effect of “then maybe next time you will listen to me” and/or “next time you won’t do that” and/or “good, I don’t care”; and/or

c. on or about October 16, 2019, you administered Fluzone QIV to approximately four patients, when Fluzone High-Dose had been ordered;

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

a. on or about December 20, 2019, you grabbed [the Patient] by the shoulder, and/or turned her around, and/or forcefully directed her away from another patient; and/or

b. on or about December 20, 2019, you said to [the Patient] words to the effect of “then maybe next time you will listen to me” and/or “next time you won’t do that” and/or “good, I don’t care”; 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 Maplewood OMNI Health Care in Brighton, 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, and in particular:

a. on or about December 20, 2019, you grabbed [the Patient] by the shoulder, and/or turned her around, and/or forcefully directed her away from another patient;

b. on or about December 20, 2019, you said to [the Patient] words to the effect of “then maybe next time you will listen to me” and/or “next time you won’t do that” and/or “good, I don’t care”; and/or

c. on or about October 16, 2019, you administered Fluzone QIV to approximately four patients, when Fluzone High-Dose had been ordered.

Member’s Plea

Given that the Member was not present and was not represented, he was deemed to have denied the allegations in the Notice of Hearing. The hearing proceeded on the basis that the College bore the onus of proving the allegations in the Notice of Hearing against the Member.

Overview

The Member was a Registered Practical Nurse (“RPN”) employed at Maplewood OMNI Health Care (the “Facility”) in Brighton, Ontario from the early 2000s until 2021, when he took a leave of absence. Currently, the Member’s certificate of registration has expired. At the time of the alleged incidents, the Member was working full-time on the evening shift. During this shift, the Member was part of a team that included a Registered Nurse (“RN”) and five Personal Support Workers (“PSW”). The Facility is a 49-bed long-term care (“LTC”) home, providing 24-hour care for vulnerable patients.

In order to determine whether or not the Member committed acts of professional misconduct as set out in paragraphs #1(a), (b), (c), #2(a), (b) and #3(a), (b) and (c) of the Notice of Hearing, the Panel addressed the following issues:

1. Did the Member contravene a standard of practice of the profession or fail to meet the standards of practice of the profession by grabbing, forcefully directing and/or aggressively speaking with [the Patient]?

2. Did the Member contravene a standard of practice of the profession or fail to meet the standards of practice of the profession by administering Fluzone QIV to approximately four patients, when Fluzone High Dose had been ordered?

3. Did the Member physically, verbally and/or emotionally abuse [the Patient] by grabbing, forcefully directing her and aggressively speaking to her?

4. Did the Member engage in conduct that would reasonably be regarded by members of the profession to be disgraceful, dishonourable and/or unprofessional in his treatment of [the Patient] and in administering the incorrect flu vaccination to approximately four patients?

The Panel found the Member to have committed professional misconduct by failing to meet the standards of practice when providing care to [the Patient], by physically, emotionally and verbally abusing [the Patient] and by administering the incorrect flu vaccination to approximately four patients. The Panel also found the Member engaged in conduct that members of the profession would regard as disgraceful, dishonourable and unprofessional.

The Evidence

The Panel received nine exhibits from the College and heard testimony from four witnesses.

Witness #1 - Rachel Corkery (“Ms. Corkery”)

Ms. Corkery, the Administrator of the Facility, testified that the Facility had 49 beds and provided 24-hour care to vulnerable patients. The Facility also employed a Director of Nursing, who was a Registered Nurse. Ms. Corkery explained that the Member worked at the Facility from the early 2000s until 2021, when he took a leave of absence. The Member returned his keys, so Ms. Corkery understood he would not be returning. She then outlined the staffing structure, noting that during the Member’s shifts, the evening team included one RN and five PSWs.

When asked about the flu vaccination incident, Ms. Corkery testified that she was aware of it. She explained that the nurse who came in the day after the incident found that patients aged 65 and over had been given the flu vaccine intended for the general population instead of the high-dose vaccine. Ms. Corkery testified that when the Member was questioned about the error, he deflected responsibility, stating that other RNs should have informed him about the different vaccines. She emphasized that the physician’s orders were clearly documented. Ms. Corkery identified Exhibit #5 as the Critical Incident Report, which was submitted to the Ministry due to the Member’s medication error.

Ms. Corkery further testified that this was not the first year that two different flu vaccines had been used. She identified Exhibit #6 as a Self-Reflective Practice (“SRP”) form the Member completed after the error. Ms. Corkery explained that the Director of Nursing would have met with the Member and the Member would have filled out the SRP form afterward. Exhibit #6 documented that the Member stated he followed the lead of the RN and that communication between shifts would be key to preventing similar errors in the future. Ms. Corkery noted that the Member’s responses on the SRP form showed a lack of ownership and accountability for the medication administration error.

College Counsel then questioned Ms. Corkery about the incident from December 20, 2019, in which the Member allegedly grabbed a patient forcefully and used words such as, “Then maybe next time you will listen to me,” and “Good, I don’t care.” Ms. Corkery testified that she was involved in the investigation of the incident, which resulted in a three-day suspension for the Member.

When asked for her overall impression of the Member, Ms. Corkery described him as someone who “skirted accountability.” She stated that he consistently shifted blame to others, demonstrated a lack of professionalism, and failed to take responsibility in multiple incidents.

Witness #2 - Linda O’Hara (“Ms. O’Hara”)

Ms. O’Hara, a RPN with 33 years of experience as a staff nurse at the Facility, testified that she remembered the Member. She explained that the Member administered the flu vaccine intended for patients under 65 years of age to those over 65. Ms. O’Hara identified Exhibit #8 as the Witness Report she had prepared to document the medication error. She confirmed that after the incident, she spoke with the Member, who responded by saying, “No one told me" and “Bob did it too.”

Ms. O’Hara went on to explain that a vial was found in the refrigerator with the Member’s handwriting on it, which led to the discovery that the flu vaccinations had been drawn from the vial rather than from the pre-filled syringes. She testified that there had been two different flu vaccines for some time, though she could not recall the exact date. Ms. O’Hara clarified for the Panel that the flu vaccine for patients over 65 was provided in pre-filled syringes, while the vaccine for those under 65 was in the vial. Both types of vaccine were clearly labeled to indicate their intended use.

Witness #3 - Tracy Moorewood (“Ms. Moorewood”)

Ms. Moorewood, the Manager of Nutritional Care and Environmental Services at the Facility, has worked at the Facility for 32 years. She testified that she remembered the incident involving [the Patient] on December 20, 2019. Ms. Moorewood explained that she was in her office a few doors down from the dining room with her door open during the supper hour when she heard yelling and crying. She heard [the Patient] saying something like, “George did it, he hurt my arm.” While she did not witness the event, Ms. Moorewood stated that she heard the Member say something along the lines of, “Next time you’ll listen to me,” and when the patient refused to eat her supper, the Member responded with, “Good, I don’t care.”

Ms. Moorewood testified that she knew [the Patient] well; she had Down syndrome, was affectionate, and was very emotional, often yelling out. She explained that she became involved to calm the patient and made her a sandwich to eat. When asked whether the Member’s comments surprised her, Ms. Moorewood replied, “No.” She testified that the Member was often unkind to patients he did not like and tended to escalate situations when patients became upset.

Witness #4 - Amanda Nerpin (“Ms. Nerpin”)

Ms. Nerpin was employed as a PSW at the Facility in December 2019, having worked there since July 2014. When asked by College Counsel if she recalled the Member, she confirmed that she worked with him a few days a week for several years. Ms. Nerpin testified that she remembered [the Patient] coming up the hallway and that she saw the Member grabbing [the Patient] by the shoulders, spinning her around and start pushing her away while [the Patient] was pushing a wheelchair. She described the Member as being aggressive and frustrated when interacting with [the Patient], who she characterized as cheerful and always eager to help. After witnessing the incident, Ms. Nerpin reported it to management, which subsequently launched an investigation. When College Counsel asked Ms. Nerpin about her impression of the Member’s response, she stated that his actions were inappropriate and emphasized that no one should put their hands on another person, regardless of the situation.

Final Submissions

College Counsel reminded the Panel that the College bears the onus of satisfying the Panel, on a balance of probabilities, that the Member engaged in professional misconduct as alleged in the Notice of Hearing. College Counsel submitted that the documentary evidence, the testimony of the witnesses and the affidavit evidence clearly established that it was more probable than not that the Member had committed the acts of professional misconduct as alleged in the Notice of Hearing. With respect to witness testimony, the evidence adduced regarding the incident was straightforward and to the point. The Member acknowledged the medication error allegation by documenting it on the Medication Incident - SRP form (Exhibit #6), where he stated, “this is the first time I ever heard of two types of vaccine entering Maplewood at the same time.” This statement indicates that the Member was unaware of the need to distinguish between flu vaccinations for individuals under 65 years of age and those over 65 years of age.

Regarding the allegations of verbal, physical, and emotional abuse towards [the Patient], the Panel heard testimony from two witnesses who directly observed the December 20, 2019, incident, either through sight or hearing. College Counsel further argued that the facts presented by these witnesses were well established.

College Counsel submitted that the Member violated the Code of Conduct by failing to advocate for the patients under his care and by not taking responsibility for any of the allegations set out in the Notice of Hearing. The Member also failed to meet the Therapeutic Nurse-Client Relationship (“TNCR”) Standard when he verbally, physically, and emotionally abused [the Patient]. Additionally, the Member failed to meet the Medication Standard by not properly assessing and administering the correct medication to approximately four patients, and he demonstrated no accountability for the error.

College Counsel further submitted that if the Panel determines the Member abused [the Patient], this conduct would reasonably be regarded by members of the profession as dishonourable, disgraceful, and unprofessional. Regarding the medication error, College Counsel submitted that if the Panel accepts that this allegation was proven, it should be characterized as unprofessional, as it was not a recurring issue, and the Member did not attempt to conceal the error once it was identified.

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), #2(a), (b) and #3(a), (b) and (c) in the Notice of Hearing. With respect to allegations #2(a) and (b), the Panel finds that the Member physically, verbally and emotionally abused a patient. With respect to allegations #3(a) and (b), 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. With respect to allegation #3(c), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be unprofessional.

Reasons for Decision

The Panel considered and accepted the testimony of the witnesses, the documentary evidence and the submissions from College Counsel and finds that the evidence supports the findings of professional misconduct as alleged in the Notice of Hearing.

In assessing the credibility of witnesses, the Panel considered the following factors from the Divisional Court Decision of Re Pitts and Director of Family Benefits Branch of the Ministry of Community & Social Services, where relevant:

(a) the witness’s appearance and demeanor;

(b) the witness’s opportunity to observe;

(c) the witness’s capacity to remember;

(d) the probability or reasonability of the evidence;

(e) the internal consistency or inconsistency of the evidence;

(f) the external consistency or inconsistency of the evidence; and

(g) the witness’s interest in the outcome of the case.

The Panel also understood that it can accept all, part or none of a witness’s testimony and that minor discrepancies between the evidence of different witnesses does not necessarily discredit their evidence.

The Panel assessed all four witnesses and found them to be credible in their testimony regarding their knowledge of the events related to the allegations.

Ms. Corkery’s testimony was clear and convincing. She identified when she did not know the answer to a question, had good recall of the two incidents and had no interest in the outcome as the Member no longer worked at the Facility.

Ms. O'Hara had a good recollection of the medication incident, her testimony was consistent with the documentary evidence, and she had no interest in the outcome of the hearing.

Ms. Moorehead’s testimony was clear and concise. As an eyewitness to the incident on December 20, 2019, she provided direct evidence of the event. Ms. Moorehead had no personal interest in the outcome of the hearing.

Ms. Nerpin's testimony was straightforward and to the point. The Panel deemed her credible, as she was an eyewitness to the incident on December 20, 2019, and her evidence was based on firsthand knowledge. Additionally, Ms. Nerpin had no personal interest in the outcome of the hearing.

Allegations #1(a) and (b)

The Panel heard testimony from two eyewitnesses regarding the incident with [the Patient] on December 20, 2019. Both Ms. Moorewood and Ms. Nerpin’s evidence was clear, cogent, and convincing. Despite approaching the situation from different perspectives, both witnesses’ testimony was factually consistent. Ms. Moorewood testified based on what she heard, describing how the Member spoke to [the Patient] and the patient’s emotional response, which included crying and being upset. In contrast, Ms. Nerpin witnessed the interaction directly, describing the Member grabbing and shoving [the Patient], with the patient reacting in the same way as described by Ms. Moorewood, crying and upset. While Ms. Nerpin could not recall the exact words the Member used, she noted that the Member sounded frustrated and aggressive. The Member breached the TNCR Standard by grabbing, shoving, and speaking aggressively to [the Patient].

Allegation #1(c)

The Member acknowledged his conduct related to this allegation by completing the Medication Incident - SRP form (Exhibit #6), in which he stated, “registered staff should have told evening registered staff about the two different types of vaccine.” This self-reflection confirms that the Member administered the incorrect flu vaccination to patients. Ms. O’Hara testified that she completed the Witness Report (Exhibit #8) after learning that the Member had administered the wrong flu vaccination. This was discovered when a nurse noticed that a flu vaccination vial in the refrigerator had the Member’s handwriting on it, even though the Member should have used pre-filled syringes not the vial when administering the high-dose vaccine to individuals over 65 years of age. The Member failed to meet the Medication Standard by administering the incorrect flu vaccination to approximately four patients and failing to take responsibility for the error. Exhibits #5, #6 and #8 clearly document the error in flu vaccination administration by two witnesses and the Member himself.

The incidents outlined in allegations #1(a), (b) and (c), along with the evidence provided, demonstrate that the Member contravened the relevant standards which constitutes professional misconduct.

Allegations #2(a) and (b)

The Panel finds the Member abused [the Patient] verbally, physically and emotionally when he grabbed her by the shoulder and forcefully directed her away from another patient; spoke aggressively to her with words such as “good I don’t care” which in turn made [the Patient] cry and become emotionally upset as testified to by two eyewitnesses. The Panel heard from the two witnesses that the Member was speaking aggressively, and the words spoken were insensitive and sarcastic. Physical abuse includes, using force and handling a client in a rough manner. The Panel heard from one witness who saw the interaction directly and she testified that the Member grabbed and pushed [the Patient] away. The Panel finds that the Member’s conduct constituted verbal, physical and emotional abuse as defined in subsection 1(7) of Ontario Regulation 799/93.

Allegations #3(a) and (b)

The Panel finds that the Member’s conduct was relevant to the practice of nursing and would reasonably be regarded by members of the profession to be disgraceful, dishonourable and unprofessional.

It was unprofessional as it demonstrated a serious and persistent disregard for his professional obligations in breaching the Code of Conduct, the Professional Standards and the TNCR Standard.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing when he physically, emotionally and verbally abused [the Patient] who he was supposed to be caring for. The Member knew or ought to have known that his conduct was unacceptable and fell below the standards of a professional and that as a nurse any abuse of a patient is not acceptable.

Finally, the Panel finds that the Member’s conduct brings disgrace to the profession. Nurses must provide safe care and environment with those they care for. The Member’s conduct brought shame on himself and by extension to the entire profession. The Panel finds that the Member’s behaviour is disgraceful in nature and would reasonably be regarded as such by the nursing profession and the general public.

Allegation #3(c)

The Panel finds that the Member’s conduct was relevant to the practice of nursing and would reasonably be regarded by members of the profession to be unprofessional. It was unprofessional as it demonstrated a serious and persistent disregard for his professional obligations in breaching the Medication Standard. The Member knew or ought to have known his actions were unacceptable when he administered the incorrect flu vaccination to four patients and took no accountability for his actions when he reflected upon the event.

Penalty

Penalty Submissions

College Counsel submitted that, in view of the Panel’s findings of professional misconduct, it should make an order as follows:

1. Requiring George Ira Idzenga (“the Member”) to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.

2. Directing the Executive Director to suspend the Member’s certificate of registration for 5 months. This suspension shall take effect from the date that 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, and

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

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

1. Code of Conduct,

2. Therapeutic Nurse-Client Relationship Standard, and

3. Medication Standard

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

v. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Practice Reflection Worksheets and Nurses’ Workbook;

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

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

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

3. strategies for preventing the misconduct from recurring,

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

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

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

1. the dates the Member attended the sessions,

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

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

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

viii. If the Member does not comply with any 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 18 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, and

3. 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; and

3. 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 Counsel submitted that there are no mitigating factors to consider due to the Member not attending the hearing and therefore there was no evidence of him taking accountability or being amenable to remediation or rehabilitation.

The proposed penalty would achieve public protection as the Member is not eligible to practice nursing since his certificate of registration was expired. In the future, if the Member did return to nursing despite his not accepting responsibility, he would still receive the oral reprimand and have to attend a minimum of two meetings with a Regulatory Expert.

The proposed penalty provides for general deterrence through the five-month suspension of the Member’s certificate of registration, which signals to the profession what kind of a penalty they can expect for this kind of conduct.

The proposed penalty provides for specific deterrence through the oral reprimand and the five-month suspension of the Member’s certificate of registration, which will send a message to the Member that this type of conduct is unacceptable.

The proposed penalty provides for remediation and rehabilitation through a minimum of two meetings with a Regulatory Expert and review of the College’s publications, which will assist the Member with returning to ethical nursing practice if he chooses to do so.

Overall, the public is protected through the 18 months of employer notification, should the Member return to practice, which will help assure the public that the College is capable of self-governing, addresses matters, and does not sweep things under the rug.

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. Goy (Discipline Committee, 2021): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member made inappropriate comments and physically, verbally and emotionally abused several vulnerable patients. The member was found to have committed an act of professional misconduct. The penalty included an oral reprimand, a five-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, 12 months of employer notification and 12 months of no independent practice in the community.

CNO v. Paraon (Discipline Committee, 2022): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member physically restrained a patient in a wheelchair and failed to appropriately monitor and assess the patient while restrained. The member was found to have physically and emotionally abused the patient. 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.

CNO v. Halupa (Discipline Committee, 2024): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member kicked a patient three times and threw a backpack at a patient. The member was found to have committed an act of professional misconduct and of physically and emotionally abusing a patient. The penalty included an oral reprimand, a four-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and 12 months of employer notification.

CNO v. Hall (Discipline Committee, 2024): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member yelled aggressively at one patient on more than one occasion and was overheard by a colleague saying “I could fucking kill him” in reference to another patient. The member was found to have committed an act of professional misconduct and of verbally, emotionally and physically abusing a patient. The penalty included an oral reprimand, a two-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert and 12 months of employer notification.

College Counsel submitted that the penalty in the case before this Panel is on the higher end of the range when reviewing penalties of misconduct of this nature, but acceptance is an important mitigating factor and, in this case, the Member failed to acknowledge any error.

Penalty Decision

The Panel accepts the College’s Submission on Order and accordingly orders:

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

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

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

a) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at the Member’s own expense and within 6 months from the date the Member obtains an active certificate of registration in a practicing class. If the Expert determines that a greater number of sessions are required, the Expert will advise CNO regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date the Member obtains an active certificate of registration in a practicing class. To comply, the Member is required to ensure that:

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

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

1. the Panel’s Order,

2. the Notice of Hearing, and

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

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

1. Code of Conduct,

2. Therapeutic Nurse-Client Relationship Standard, and

3. Medication Standard

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

v. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Practice Reflection Worksheets and Nurses’ Workbook;

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

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

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

3. strategies for preventing the misconduct from recurring,

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

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

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

1. the dates the Member attended the sessions,

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

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

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

viii. If the Member does not comply with any 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 18 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, and

3. 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; and

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

Reasons for Penalty Decision

Having concluded that the Member physically, emotionally and verbally abused [the Patient] and administered the incorrect flu vaccination to approximately four patients, the Panel considered that public protection is paramount to any penalty imposed upon a member. The proposed penalty accomplishes this objective while communicating to the membership at large that this type of conduct will not be tolerated. Physical, verbal and emotional abuse is clearly unprofessional and contrary to the expectations of patients, employers and the public. This type of egregious conduct is disgraceful, dishonourable and unprofessional which shames the Member and the profession.

The Panel’s primary concern is public protection, which is achieved in these circumstances by the Member having an expired certificate of registration, a five-month suspension that will come into effect if the Member chooses to reapply for his certificate of registration, as well as the 18 months of employer notification, should the Member return to practice. Rehabilitation and remediation plans are in place in the event the Member decides to reapply for his certificate of registration.

This penalty achieves general deterrence through the five-month suspension, which will send a strong message to members of the profession that there are serious consequences for any type of abuse of patients/clients, and failure to meet the Medication Standards. The penalty achieves specific deterrence through the oral reprimand and the five-month suspension of the Member’s certificate of registration, which will send a message to the Member that this type of conduct is unacceptable.

The Member chose not to participate in this process. He has offered no explanation and has shown no insight into his conduct or behaviour. As a result, the Panel has no mitigating factors to consider.

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

I, 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.