DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Michael Hogard, RPN Chairperson Lisa Donnelly, RN Member Sylvia Douglas Public Member Lynn Hall, RN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO Emily Lawrence for College of Nurses of Ontario
- and -
RAYVIN SQUIRES Registration No. 0114413 Philip B. Abbink for Rayvin Squires Christopher Wirth, Independent Legal Counsel
Heard: September 3, 2024, via videoconference
DECISION AND REASONS
Publication Ban
By Order of the Discipline Panel dated September 3, 2024, pursuant to subsection s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, no one shall publish or broadcast the name(s) of the patient(s), or any information that could disclose the identity(ies) of the patient(s), referred to orally or in any documents presented at the Discipline hearing of Rayvin Squires.
This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on September 3, 2024.
The Allegations
College Counsel advised the Panel that the College was requesting leave to withdraw the allegation set out in paragraph #2 of the Notice of Hearing dated July 31, 2024. The Panel granted this request. The remaining allegations against Rayvin Squires (the “Member”) are as follows:
IT IS ALLEGED THAT:
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that while registered with the College of Nurses of Ontario as a Registered Nurse, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as follows:
while employed by Brant Community Healthcare System in Brantford, Ontario:
i. on or around March 17, 2019, you failed to report to the Inpatient Mental Health Unit to assist with patient care after being directed to do so given staffing shortages; and/or
ii. on or around August 24, 2020, during shift change, you
swung your hands in the face of your colleague, R.L.;
screamed in the face of your colleague R.L.;
loudly used profanities within earshot of patients, including words to the effect of “nothing’s fucking done”; and/or
slammed your hands on the desk; and/or
while employed by Homewood Health Centre in Guelph, Ontario:
i. on or around January 2021, you went on breaks from approximately 0500 to 0645 hours during your night shifts; and/or
ii. on or around February 4-5, 2021, you took a photograph of [the Patient]’s face on your personal cell phone without clinical purpose, showed the photograph to individuals outside of [the Patient]’s circle of care, and/or made comments to staff about [the Patient]’s appearance to the effect of “the patient looks like a pig”;
[Withdrawn];
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that while you were registered with the College of Nurses of Ontario as a Registered 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 on or around December 3 and 20, 2019, when you:
while employed by Brant Community Healthcare System in Brantford, Ontario:
i. on or around March 17, 2019, you failed to report to the Inpatient Mental Health Unit to assist with patient care after being directed to do so given staffing shortages; and/or
ii. on or around August 24, 2020, during shift change, you
swung your hands in the face of your colleague, R.L.;
screamed in the face of your colleague R.L.;
loudly used profanities within earshot of patients, including words to the effect of “nothing’s fucking done”; and/or
slammed your hands on the desk; and/or
while employed by Homewood Health Centre in Guelph, Ontario:
i. on or around January 2021, you went on a break from approximately 0500 to 0645 hours during your night shifts; and/or
ii. on or around February 4-5, 2021, you took a photograph of [the Patient]’s face on your personal cell phone without clinical purpose, showed the photograph to individuals outside of [the Patient]’s circle of care, and/or made comments to staff about [the Patient]’s appearance to the effect of “the patient looks like a pig”.
Member’s Plea
The Member admitted the allegations set out in paragraphs 1(a)(i), 1(a)(ii), 1(b)(i), 1(b)(ii), 3(a)(i), 3(a)(ii), 3(b)(i) and 3(b)(ii) in the Notice of Hearing. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admissions were voluntary, informed and unequivocal.
Agreed Statement of Facts
College Counsel and the Member’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which as amended reads, unedited and without exhibits mentioned therein, as follows:
THE MEMBER
- The Member initially registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on September 11, 2001.
BRANT COMMUNITY HEALTHCARE SYSTEM
On September 27, 2007, the Member began working at Brant Community Healthcare System (“Brant”) as a full-time RN on its mental health crisis team.
Brant is a 374-bed hospital in Brantford, Ontario and a regional centre for healthcare. Among other things, Brant has an Emergency Room (“ER”) and a Mental Health Inpatient Unit (the “MH Unit”). The Member worked in both the ER and the MH Unit.
Brant terminated the Member’s employment on August 28, 2020 as a result of the incidents that are described below.
HOMEWOOD HEALTH CENTRE
On October 26, 2020, the Member began working as an RN at the Homewood Health Centre (“Homewood”).
Homewood is a 350-bed psychiatric hospital. Homewood staff are contracted to operate the emergency mental health services at Guelph General Hospital (“GGH”). The GGH Emergency Department (“ED”) houses Homewood’s Short Stay Assessment Unit (the “Unit” or “SSAU”) which has 4 beds. The SSAU is a locked psychiatric unit for acutely unwell patients. The Member worked in the ED and SSAU, rotating between 12-hour night shifts and 12-hour days shifts that ran from 7 to 7.
On March 27, 2021, the Member resigned as a result of the incidents that are described below.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
March 16-17, 2019 Shift at Brant
On or around March 16, 2019, the Member was working in the ER at Brant.
The MH Unit is to have at least three nurses on duty at all times. Sometime before 20:00 on March 16, the Leader-On-Call advised the Member that the MH Unit would be understaffed starting at 23:00. Accordingly, the Leader-On-Call advised the Member to complete the work that she was doing in the ER and then report to the MH Unit by no later than 01:00.
The Member did not report to the MH Unit as she was directed. During the shift, the Member attended at the MH Unit, but only when she needed to have a patient from the ER admitted.
The Member’s failure to attend the MH Unit as directed resulted in the MH Unit having fewer staff than was required that evening. Starting at 23:00 on March 16, there were only two nurses working on the unit.
The MH Unit had very high acuity that evening and, as a result of the Member’s failure to attend, the Unit had a nurse-to-patient ratio of only 1:9. Patients on the unit included two patients who were experiencing mania, one patient who could not be medicated, and two elderly patients who either had catheters or were incontinent. The MH Unit also had one severely intoxicated patient who attempted to harm himself that evening and had to be moved to seclusion. Only with the assistance of police, security guards, and nurses from other units was the patient was eventually placed in restraints.
The two nurses who were assigned to the MH Unit that night filed reports of unsafe working conditions.
If the Member were to testify, she would say that she understood that the Leader-On-Call’s instructions to mean that the Member was only to report to the MH Unit if her workload in the ER permitted her to do so. However, the Member acknowledges and admits that she did not document providing any care to any patients in the ER after 02:37 on March 17, 2020.
The Member admits that she did not take any steps to determine if she should remain in the ER or attend the MH Unit given the units’ relative acuities. The Member did not speak to the MH Unit staff about the unit’s capacity or staffing needs. Notwithstanding that the Leader-On-Call had informed the Member that the MH Unit would be understaffed starting at 23:00, the Member did not speak to either of the Leader-On-Call, the ER Charge nurse, or anyone else to discuss how she could prioritize the relative needs of the ER and MH Unit.
If the Member were to testify, she would state that she spoke with the nurses on the MH Unit, who did not express to her that she had to stay or come back urgently, and did not tell her about the Unit’s acuity at the time. If the Member were to testify, she would acknowledge that, regardless of her knowledge about the Unit’s acuity, she should have reported to the MH Unit as directed, and at the very least that she should have communicated with her colleagues about where she was most needed. She regrets not having done so.
August 24, 2020 Shift at Brant
At approximately 19:00 on August 24, 2020, the Member arrived at Brant for her scheduled night shift. Two RNs, R.L. (“RN Colleague A”) and C.W. (“RN Colleague B”) had worked the day shift and were in the nursing office when the Member arrived.
Shortly after she arrived at the nursing office, the Member began waiving her hands in front of RN Colleague A’s face, saying words to the effect of “move, I want that chair.” RN Colleague A moved as the Member requested.
The Member then sat down, pulled up her schedule on a nursing office computer, printed it, and told RN Colleague B to go get her printed schedule from the nursing station. When RN Colleague B returned and advised the Member that the schedule had not printed, the Member became angry and loudly said “fuck.”
Shortly thereafter, RN Colleague A and RN Colleague B began to give report to the Member and informed her that six patients had been admitted to the Unit with no bed. The Member called the staffing department to ask if she would be receiving any additional help that evening. While on the phone, the Member continued yelling and swearing, saying “fuck” loudly and repeatedly.
After the Member got off the phone, she continued yelling at her two RN colleagues. The Member accused them of not having done anything during their shifts, saying words to the effect of “nothing’s fucking done.” When her RN colleagues tried to explain what they had done during their shift, the Member pulled down the face mask that she was wearing and began screaming in RN Colleague A’s face.
The Member later asked her RN colleagues where her clipboard was. When RN Colleague A pointed to the clipboard that she believed belonged to the Member, the Member yelled words to the effect of “that’s not my fucking clipboard.” The interaction between the three nurses ended when the Member violently slammed her hands into the desk in the nursing office, screamed words to the effect of “I’m so fucking mad,” and rushed out of the office without receiving further report from either of her RN colleagues.
The Member was speaking so loudly during her interaction with her RN colleagues that patients in the ER waiting room would have overheard her during the above-described interactions.
Both RN Colleague A and RN Colleague B filed harassment reports with Brant following the incident. If RN Colleague A were to testify, she would state that she reported, and she felt, that the Member’s conduct made her fear for her safety and otherwise feel disrespected and embarrassed.
If the Member were to testify, she would state that she did not realize at the time that her comments would be audible outside the office. If the Member were to testify, she would acknowledge that she behaved inappropriately, and that she regrets having lost her composure during these events.
January 2021 Shifts at Homewood
The Member worked night shifts at Homewood in January 2021.
During a 12-hour shift, nurses are entitled to 1.5 hours of breaks. Nurses were supposed to take three breaks within the first eight hours: two 15-minute breaks and one 30-minute break. A nurse’s break times are specifically scheduled to ensure that patients receive assessments and care at appropriate times. They are also scheduled in coordination with the schedules of Homewood’s social workers, who can perform assessments when nurses are on break.
During several of these shifts in January 2021, the Member took extended breaks from approximately 05:00 to 06:45.
It was contrary to Hospital policy for a nurse for the Member to have taken a 1.75-hour break, and to do so near the conclusion of their shift.
When the Member returned from her extended breaks, she was not aware of what had happened on the Unit during her break. Accordingly, the Member was not able to assist the other nurses with whom she was working to give report during shift change, which occurred at 7:00 each day.
If the Member were to testify, she would say that she believed taking a longer break during a night shift was common practice, although she acknowledges that would not have been the evidence of other potential witnesses. The Member would also testify that when she was working a longer 16 hour shift, she was allotted more rest periods, such that her break time would have been longer. She does, however, acknowledge the concerns raised about her lack of communication with colleagues regarding her whereabouts and in the context of shift changes.
February 4-5, 2021 Shifts at Homewood
On February 4, 2021, [ ] (the “Patient”) attended the GGH ED suffering from nasal cellulitis. The Patient reported that she had contracted her infection while she was consuming “hot rails” of crystal methamphetamine intranasally. The Patient ’s infection was severe and caused her nostrils to become so inflamed that they were almost swollen shut.
The Member attended the GGH ED to assess the Patient. The Member told the Patient that she had never seen anyone with such an extreme case of nasal cellulitis and asked the Patient if she could take a photo of her condition. The Member then took a photo of the Patient using her personal cell phone (the “Photo”). The Photo showed the lower portion of the Patient ’s face, including her swollen nostrils.
The Member did not have a clinical purpose taking the Photo.
If the Member were to testify, she would say that the Patient consented to her taking the Photo. However, the Member did not document having received consent from the Patient to take the Photo.
If a nurse at Homewood needs to take a photograph of a patient for a clinical purpose, it was Homewood’s policy that nurses were required to use a phone or camera that was owned and maintained by Homewood. Nurses were also required to upload any photo that they took of a patient to the patient’s chart with a note explaining for what purpose the photo had been taken.
Contrary to this policy, the Member also did not document having taken the Photo, nor did she include a copy of the Photo in the Patient ’s chart.
After taking the Photo, the Member returned to the Unit and showed it to some of the nurses and security guards who were working there at the time. The Member did not have any clinical reason for showing the Photo to her coworkers.
When the Member shared the Photo with her coworkers, she identified that the Photo was of the patient whom she had just seen in the GGH ED for a consult. The Member repeatedly exclaimed that the Patient ’s nose looked like a “pig’s snout” because of her swollen nostrils.
During the shift, the Member showed the Photo to one of her colleagues, who was an RN. When the Member showed this colleague the Photo, the colleague informed the Member that she should not have taken a photo of the Patient, in particular because the Patient was vulnerable as a result of being “high on meth.” The colleague advised the Member to delete the Photo. The Member did not delete the Photo and returned home that day with the Photo on her personal phone.
When the Member returned to work on the Unit on February 5, 2021, she showed the Photo to several other colleagues, an RN, an RPN, and a security guard. When the Member showed the Photo to the RN on that shift, the Member explained that the Photo was of a patient whom she had saw in the ED the night prior and remarked that the patient’s face was “messed up” as a result of her drug use. The RN colleague informed the Member that she was not supposed to take photos of patients. The Member did not have any clinical reason showing the Photo to her co-workers on this shift.
If the Member were to testify, she would say that she deeply regrets her behaviour with respect to this client, and the picture. She acknowledges that this was a vulnerable client in a difficult situation, and she regrets the impact of her conduct on this client, and her colleagues.
CNO STANDARDS OF PRACTICE
Code of Conduct
- CNO’s Code of Conduct is a standard of practice describing the accountabilities all Ontario nurses have to the public. The Code of Conduct consists of six principles including:
Nurses respect the dignity of patients and treat them as individuals;
Nurses work together to promote patient well-being;
Nurses maintain patients’ trust by providing safe and competent care;
Nurses work respectfully with colleagues to best meet patients’ needs;
Nurses act with integrity to maintain patients’ trust; and
Nurses maintain public confidence in the nursing profession.
With respect to the principle requiring nurses to respect the dignity of patients and treat them as individuals, CNO’s Code of Conduct provides that: nurses treat patients with care and compassion; nurses take steps to maintain patients’ privacy; and that nursing care is not judgmental.
With respect to the principle requiring nurses to maintain patients’ trust by providing safe and competent care, CNO’s Code of Conduct provides that nurses: respond and are available to patients when working; seek advice and collaborate with the health care team to uphold safe patient care; maintain complete, accurate and timely documentation in their practice; and are accountable to, and practice under, relevant laws and CNO’s standards of practice.
With respect to the principle requiring nurses to work respectfully with colleagues to best meet patients’ needs, CNO’s Code of Conduct provides that nurses are professional with colleagues and treat them with respect and that nurses collaborate and communicate with colleagues in a clear, effective, and professional way.
With respect to the principle requiring nurses to act with integrity to maintain patients’ trust, CNO’s Code of Conduct provides that nurses protect the privacy and confidentiality of patients’ personal health information and that nurses maintain professional boundaries with patients.
With respect to the principle requiring nurses to maintain public confidence in the nursing profession, CNO’s Code of Conduct provides that nurses are accountable for their own actions and decisions.
Attached as Exhibit “A” is a copy of CNO’s Code of Conduct that was in force at the time of the incidents described herein.
Professional Standards
CNO’s Professional Standards, Revised 2002 (“Professional Standards”) provides an overall framework for the practice of nursing and a link with other standards, guidelines, and competencies developed by CNO. It includes seven broad standard statements pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership, and relationships.
CNO’s Professional Standards provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring that their practice and conduct meets the legislative requirements and the standards of the profession. Nurses are responsible for their actions, the consequences of those actions, and for conducting themselves in ways that promote respect for the profession. Nurses demonstrate this standard by actions such as seeking assistance appropriately and in a timely manner and ensuring practice is consistent with CNO’s standards of practice and guidelines as well as legislation.
CNO’s Professional Standards provides, in relation to the relationship standard, that nurses establish and maintain respectful, collaborative, therapeutic, and professional relationships and that professional relationships are based on trust and respect, and result in improved client care. In professional relationships, nurses demonstrate this standard by actions such as: role-modelling positive collegial relationships; using a wide range of communication and interpersonal skills to effectively establish and maintain collegial relationships; demonstrating knowledge of and respect for each other's roles, knowledge, expertise and unique contribution to the health care team; and demonstrating effective conflict-resolution skills,
Attached as Exhibit “B” is a copy of CNO’s Professional Standards that was in force at the time of the incidents described herein.
Therapeutic Nurse-Client Relationship
CNO’s TNCR Standard contains four standard statements which describe nurses’ accountabilities with respect to therapeutic communication, client-centred care, maintaining boundaries and protecting the patient from abuse.
CNO’s TNCR Standard provides, in relation to therapeutic communication, that nurses use a wide range of effective communication strategies and interpersonal skills to appropriately establish, maintain, re-establish and terminate the nurse-client relationship. Nurses demonstrate this standard by actions such as informing the client that information will be shared with the health care team and identifying the general composition of the health care team.
CNO’s TNCR Standard provides, in relation to client-centred care, that nurses work with the client to ensure that all professional behaviours and actions meet the therapeutic needs of the client. Nurses demonstrate this standard by actions such as demonstrating sensitivity and respect for the client's choices, which have grown from the client's individual values and beliefs.
CNO’s TNCR Standard also provides guidance for nurses who are considering whether a particular activity or behaviour is appropriate within the context of the nurse-client relationship. The standard prescribes that nurses should abstain from behaviours that do not meet a clearly identified need of the client or that are not consistent with the role of nurses in the setting. If a nurse decides that a particular activity or behaviour is appropriate in within the context of the nurse-client relation, the standard prescribes they should proceed with the behaviour and document it.
atiAttached as Exhibit “C” is a copy of CNO’s TNCR Standard that was in force at the time of the incidents described herein.
Confidentiality and Privacy - Personal Health Information
CNO’s Confidentiality and Privacy - Personal Health Information standard (“Privacy Standard”) 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.
CNO’s Privacy Standard defines personal health information as any identifying information about clients that is in verbal, written or electronic form. This includes information collected by nurses during the course of therapeutic nurse-client relationships. Clients do not have to be named for information to be considered personal health information. Information is “identifying” if a person can be recognized, or when it can be combined with other information to identify a person.
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 personal health information that is needed to provide care;
d) Not discussing client information with colleagues or the client in public places such as elevators, cafeterias and hallways;
e) Denying people who are not part of the health care team access to personal health information;
f) Ensuring that explicit consent has been obtained to keep a client’s personal health information in the home and documenting that consent;
g) Not accessing information for which there is no professional purpose; and
h) Safeguarding the security of computerized, printed or electronically displayed or stored information against theft, loss, unauthorized access or use, disclosure, copying, modification or disposal.
- Attached as Exhibit “D” is a copy of CNO’s Privacy Standard which was in force at the time of the incidents.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1(a)(i) and (ii), and (b)(i) and (ii) of the Notice of Hearing 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 38 above.
In particular, the Member admits and acknowledges that she contravened CNO’s Code of Conduct, and Professional Standards when she:
a) failed to report to the MH Unit to assist with patient care after being directed to do so given staffing shortages and without determining how best to prioritize her work in the ER and this direction to report to the MH Unit;
b) swung her hands in the face of her colleague, screamed in the face of her colleague, loudly used profanities within earshot of patients, including words to the effect of “nothing’s fucking done,” and slammed her hands on the desk of the nursing station in anger in front of her colleagues;
c) took extended breaks during her shifts at Homewood between 05:00 and 06:45;
- The Member also admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards, TNCR Standard, and Privacy Standard when she:
a) took the Photo of the Patient’s face on her personal cell phone without clinical purpose, showed the Photo to individuals outside of the Patient’s circle of care, including security guards and nursing staff on the subsequent shift, and made comments to staff about the Patient ’s appearance to the effect of “the patient looks like a pig”.
The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3 (a)(i) and (ii), and (b)(i) and (ii) of the Notice of Hearing, and in particular that her conduct was dishonourable and unprofessional, as described in paragraphs 8 to 38 above. The Member admits that the conduct was unprofessional in that it breached the standards of practice, and was dishonourable in that the Member knew or ought to have known that her conduct was unacceptable and fell well below the standards of the profession.
CNO seeks leave to withdraw Allegation 2.
Decision
The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities based upon clear, cogent and convincing evidence.
Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1(a)(i), 1(a)(ii), 1(b)(i), 1(b)(ii), (3)(a)(i), 3(a)(ii), 3(b)(i) and 3(b)(ii) of the Notice of Hearing. As to allegations #(3)(a)(i), 3(a)(ii), 3(b)(i) and 3(b)(ii), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be dishonourable and unprofessional.
Reasons for Decision
The Panel considered the Agreed Statement of Facts and the Member’s plea and finds that this evidence supports findings of professional misconduct as alleged in the Notice of Hearing.
Allegation #1(a)(i) in the Notice of Hearing is supported by paragraphs 8 - 16, 43 - 58 and 63 - 65 in the Agreed Statement of Facts. The Member admitted to this allegation. On March 16, 2019, while employed as a Registered Nurse (“RN”) at Brant Community Healthcare System (“Brant”), the Leader-On-Call advised the Member that the Mental Health Unit (“MH Unit”) would be understaffed at 23:00 and the Member was to report to the MH Unit no later than 01:00. The Member did not report to the MH Unit as directed. While the Member may have thought that the Leader-On-Call’s instructions meant that she was only to report to the MH Unit if her workload in the ER permitted her to do so, the Member admitted that she did not document providing any care to any patients in the ER after 02:37 on March 17, 2019.
The Panel finds that the Member failed to meet the College’s Code of Conduct when she failed to follow direction from the Leader-On-Call, prioritize care and assist colleagues on another unit. The Member did not promote the behaviour of nurses working together to ensure the well-being of patients. The Member failed to meet the Professional Standards by showing a lack of respect for her colleagues. The Member knew or ought to have known she was needed on an understaffed unit.
Allegation #1(a)(ii) in the Notice of Hearing is supported by paragraphs 17 - 25, 43 - 58 and 63 - 65 in the Agreed Statement of Facts. The Member admitted to this allegation. On August 24, 2020, while working at Brant, the Member began waving her hands in front of RN Colleague A’s face, saying words to the effect of “move, I want that chair”. The Member also pulled up her schedule on a nursing office computer and told RN Colleague B to go get her printed schedule from the nursing station. When RN Colleague B returned and advised the Member that the schedule had not printed, the Member became angry and loudly said, “fuck”. During reports from RN Colleague A and RN Colleague B, when the Member was informed of the six patients that had been admitted to the Unit with no beds, the Member called the staffing department to ask if she was receiving any additional help that evening. While on the phone, the Member continued yelling and swearing, saying “fuck” loudly and repeatedly. After the Member got off the phone, she continued yelling at her two RN colleagues, saying words to the effect of “nothing’s fucking done,” “that's not my fucking clipboard,” “I’m so fucking mad,” and rushed out of the office without receiving further reports from either of her RN colleagues. The Member at one point pulled down her face mask and began screaming in RN Colleague A’s face.
The Panel finds that the Member breached the Code of Conduct and the Professional Standards by behaving unprofessionally towards her colleagues and communicating in an unprofessional manner. Her conduct did not promote professionalism with her colleagues, or therapeutic relationships with patients as she engaged in unprofessional interactions within earshot of patients. The Member knew or should have known that her interactions may have been overheard by patients and her behavior was unacceptable.
Allegation #1(b)(i) in the Notice of Hearing is supported by paragraphs 26 - 31, 43 - 58 and 63 - 65 in the Agreed Statement of Facts. The Member admitted to this allegation. The Member worked night shifts at Homewood Health Centre (“Homewood”) in January 2021. During each 12-hour shift, nurses are entitled to 1.5 hours of breaks, and are expected to take three breaks within the first eight hours: two 15-minute breaks and one 30-minute break. Break times are scheduled to ensure that patients receive assessments and care at appropriate times. The Member took extended breaks from 05:00 to 06:45. The Member’s practice of taking a 1.75-hour break near the conclusion of the shift was contrary to Hospital policy. When the Member returned from her extended breaks, she was not aware of what had happened on the Unit and was not able to assist the other nurses with whom she was working to give reports during shift change.
The Panel finds that the Member breached the Code of Conduct and the Professional Standards by taking extended breaks, showing a lack of respect for working relationships with her colleagues. Taking extended breaks near the end of the shift was against Hospital policy. It rendered the Member unable to assist colleagues to give reports during shift change.
Allegation #1(b)(ii) in the Notice of Hearing is supported by paragraphs 32 - 42 and 59 - 65 in the Agreed Statement of Facts. The Member admitted to this allegation. On February 4, 2021, while the Member was working at Homewood, [ ] (the “Patient”) attended the GGH ER suffering from nasal cellulitis. The Member told the Patient that she had never seen anyone with such an extreme case of nasal cellulitis and asked the Patient if she could take a photo of her condition. The Member took a photo of the Patient using her personal cell phone (the “Photo”). The Member did not have a clinical purpose for taking the Photo. The Member did not document having received consent from the Patient to take the Photo or follow Homewood’s policy that required the use of a phone or camera that was owned and maintained by Homewood. The policy required nurses to upload any photos that they took of a patient to the patient’s chart with a note explaining the purpose for which the photo was taken. The Member did not document having taken the Photo, nor did she include a copy of the Photo in the Patient’s chart. After taking the Photo, the Member showed the Photo to some of the nurses and a security guard. The Member did not have any clinical reason for showing the Photo to her coworkers. When sharing the Photo, the Member repeatedly exclaimed that the Patient’s nose looked like a “pig’s snout” because of her swollen nostrils. The Member showed the Photo to two colleagues who informed the Member that she should not have taken a photo of the Patient, because the Patient was vulnerable. The Member was advised to delete the Photo, and the Member did not do so.
The Member failed to uphold the Code of Conduct, the Professional Standards and the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard) by not maintaining the Patient’s privacy, as well as being judgemental about the Patient’s appearance. The Confidentiality and Privacy - Personal Health Information Standard was breached when the Member took the Photo without a clinical reason and shared the Photo with members of the health care team and outside the circle of care. Nurses are expected to uphold, demonstrate and maintain the standards of the profession.
Allegations #3(a)(i), #3(a)(ii), #3(b)(i) and #3(b)(ii) in the Notice of Hearing are supported by paragraphs 9 - 42 and 66 in the Agreed Statement of Facts. The Member admitted to these allegations. The Panel finds that the Member’s conduct in taking the Photo of a vulnerable patient, not following Hospital policy regarding photos and break times, failing to follow direction from the Leader-on-Call to assist colleagues on another unit, sharing the Photo and making inappropriate comments was clearly 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, the TNCR Standard and the Confidentiality and Privacy - Personal Health Information Standard.
The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral and ethical failing through the sharing of the Photo of the Patient and then making inappropriate comments. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional.
Penalty
College Counsel and the Member’s Counsel advised that a Joint Submission on Order had been agreed upon and requested that the Panel make the following order:
Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for 3 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:
a) The Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at the Member’s own expense and within 6 months from the date that this Order becomes final. If the Expert determines that a greater number of sessions are required, the Expert will advise CNO regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date that this Order becomes final. To comply, the Member is required to ensure that:
i. The Expert has expertise in nursing regulation and has been approved by CNO in advance of the meeting;
ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of:
1. the Panel’s Order, 2. the Notice of Hearing, 3. the Agreed Statement of Facts, 4. this Joint Submission on Order, and 5. if available, a copy of the Panel’s Decision and Reasons;iii. Before the first meeting, the Member reviews the following CNO publications and completes the associated Reflective Questionnaires, online learning modules and decision tools (where applicable):
1. Code of Conduct, 2. Therapeutic Nurse-Client Relationship Standard, and 3. Confidentiality and Privacy – Personal Health Information;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. Before the first meeting, the Member reviews Circle of Care: Sharing Personal Health Information for Health-Care Purposes, as released by the Information and Privacy Commissioner of Ontario;
vi. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires and Nurses’ Workbook;
vii. 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;viii. Within 30 days after the Member has completed the final session, the Member will confirm that the Expert forwards their report to CNO, in which the Expert will confirm:
1. the dates that 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;ix. If the Member does not comply with any one or more of the requirements above, the Expert may cancel the sessions scheduled, even if that results in the Member breaching a term, condition or limitation on the Member’s certificate of registration;
b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify the Member’s employers of the decision. To comply, the Member is required to:
i. 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;
ii. Inform any employer of the decision prior to commencing or prior to resuming employment in any nursing position;
iii. Provide the Member’s employer(s) with a copy of:
1. the Panel’s Order, 2. the Notice of Hearing, 3. the Agreed Statement of Facts, 4. this Joint Submission on Order, and 5. a copy of the Panel’s Decision and Reasons, once available;iv. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any nursing position, the employer(s) forward(s) a report to CNO, in which it will confirm:
1. that they received a copy of the required documents, and 2. that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession.All documents delivered by the Member to CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.
College Submissions on Penalty
College Counsel made submissions which included the following.
College Counsel submitted that the proposed penalty is appropriate in light of the Panel’s findings of misconduct. College Counsel reminded the Panel that the foremost duty when considering the appropriate penalty is public protection. College Counsel submitted that the Panel is obliged to accept the Joint Submission on Order unless doing so brings the administration of justice into disrepute.
College Counsel submitted that public protection is achieved through specific deterrence of the Member, general deterrence which includes the membership at large and where applicable rehabilitation and remediation of the Member. College Counsel submitted that the proposed penalty meets these objectives. College Counsel submitted that when the Panel is trying to meet these objectives, it should review the aggravating and mitigating circumstances of this case.
The aggravating factors in this case were:
The serious nature of the conduct – it involved a vulnerable patient;
The Member’s conduct displayed a lack of respect and compassion;
The Member’s description of the Patient’s appearance was judgemental;
The Member did not follow direction or policy;
The Member took extended breaks; and
The Member did not display professional behaviour or promote professional working relationships with colleagues.
The mitigating factors in this case were:
The Member has no prior discipline history with the College; and
The Member has expressed remorse and taken responsibility and accountability throughout the College’s process by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College.
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. Pedzinski (Discipline Committee, 2020): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. It involved a member leaving shift early. The penalty included an oral reprimand, a one-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert, and 12 months of employer notification.
CNO v. Cruz (Discipline Committee, 2023): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. It involved a member taking photographs of a vulnerable patient and posting the photographs on a departmental WhatsApp group. 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.
CNO v. Proulx (Discipline Committee, 2019): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. It involved a member taking a video on her cell phone of a client in a behavioural state and sharing it through a social media application. The penalty included an oral reprimand, a five-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and 18 months of employer notification. The longer suspension was related to the member providing false information on her resume when applying for employment.
Member’s Submissions on Penalty
The Member’s Counsel agreed with the College’s submissions. The Member’s Counsel submitted that the Member has taken accountability for her actions, which is evident in her plea. The Member has insight into her behaviour. The Member misunderstood the direction given to her by the Leader-On-Call. The Member is remorseful for her behavior towards her colleagues and for taking the Photo.
Penalty Decision
The Panel accepted the Joint Submission on Order and made the order requested.
Reasons for Penalty Decision
There is a high threshold for departing from a Joint Submission on Order established by the Supreme Court of Canada in R. v. Anthony-Cook, 2016 SCC 43. Departing from a joint submission would require a finding that the proposed penalty would bring the administration of justice into disrepute or is otherwise contrary to the public interest.
The Panel concluded that the proposed penalty is not contrary to the public interest and does not bring the administration of justice into disrepute.
The Panel concluded that the proposed penalty is reasonable and in the public interest. It promotes public confidence in the ability of the College to regulate nurses.
The Panel finds that the proposed penalty satisfies the penalty goals of specific and general deterrence, rehabilitation and remediation, and public protection.
The proposed penalty provides for general deterrence through the 3-month suspension of the Member’s certificate of registration, which will deter the membership at large, reinforcing that this type of conduct will not be tolerated.
The proposed penalty provides for specific deterrence through the oral reprimand and the 3-month suspension of the Member’s certificate of registration, which will deter the Member from repeating this type of conduct.
The proposed penalty provides for remediation and rehabilitation through a minimum of 2 meetings with a Regulatory Expert, which will allow the Member to further reflect on her conduct and ensure that this conduct will not be repeated in the future.
Overall, the public is protected through the 12 months of employer notification as there will be employer oversight on the Member’s return to practice.
The Panel acknowledges that the Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility, which is a mitigating factor.
The proposed penalty also falls within the range of penalties imposed in previous decisions of the Discipline Committee in similar circumstances.
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.