College of Nurses of Ontario v. Cowell, 2024 ONCNO 145649

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Carly Gilchrist, RPN Chairperson Sylvia Douglas Public Member Lalitha Poonasamy Public Member Susan Roger, RN Member Samuel Jennings, RPN Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) DOUGLAS MONTGOMERY for ) College of Nurses of Ontario

• and - )

LIA SUSAN COWELL ) CHRISTOPHER BRYDEN for Registration No. 9314394 ) Lia Susan Cowell ) KIMBERLEY ISHMAEL ) Independent Legal Counsel

) Heard: November 11, 2024, ) via videoconference

DECISION AND REASONS

Publication Ban

By Order of the Discipline Panel dated November 11, 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 their identities, referred to orally or in any documents presented at the Discipline hearing of Lia Susan Cowell.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on November 11, 2024.

The Allegations

The allegations against Lia Susan Cowell (the “Member”) as stated in the amended Notice of Hearing dated October 10, 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, in that, while registered as a Registered Nurse with the College of Nurses, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to the following incidents:

(a) On or about October 22 and 23, 2020, while employed at St. Thomas Elgin General Hospital in St. Thomas, Ontario, you provided inadequate care and/or inadequately documented the care you provided to Patient [A], in that:

i. You failed to ensure that the patient’s oxygen was continuously connected;

ii. You failed to complete and/or document vital signs check;

(b) On or about February 24, 2021, while employed at Hillside Manor in Stratford, Ontario,

i. You failed to administer a 1.5mg hydromorphone tablet to Patient [B] and/or documented that you had administered a 1.5mg hydromorphone tablet to Patient [B] that you had not administered;

ii. You failed to properly dispose and/or document the disposal of medication with respect to 1.5 mg of hydromorphone for Patient [B];

(c) On or about March 28, 2021, while employed at Hillside Manor in Stratford, Ontario,

i. You prepared medications for multiple patients at the same time and/or in advance of their administration;

ii. You left narcotic medications unattended in an unlocked drawer of a mobile nursing station;

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(13) of Ontario Regulation 799/93, in that, on or about February 24, 2021, while employed as a Registered Nurse at Hillside Manor in Stratford, Ontario, you failed to keep records as required with respect to the following incidents:

(a) You failed to properly document the administration of hydromorphone with respect to Patient [B];

(b) You failed to properly document the disposal of medication with respect to 1.5 mg of hydromorphone for Patient [B];

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 as a Registered Nurse with the College of Nurses, 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) On or about October 22 and 23, 2020, while employed at St. Thomas Elgin General Hospital in St. Thomas, Ontario, you provided inadequate care and/or inadequately documented the care you provided to Patient [A], in that:

i. You failed to ensure that the patient’s oxygen was continuously connected;

ii. You failed to complete and/or document vital signs check;

(b) On or about February 24, 2021, while employed at Hillside Manor in Stratford, Ontario,

i. You failed to administer a 1.5mg hydromorphone tablet to Patient [B] and/or documented that you had administered a 1.5mg hydromorphone tablet to Patient [B] that you had not administered;

ii. You failed to properly dispose and/or document the disposal of medication with respect to 1.5 mg of hydromorphone for Patient [B];

(c) On or about March 28, 2021, while employed at Hillside Manor in Stratford, Ontario,

i. You prepared medications for multiple patients at the same time and/or in advance of their administration; and/or

ii. You left narcotic medications unattended in an unlocked drawer of a mobile nursing station.

Member’s Plea

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

Agreed Statement of Facts

College Counsel and the Member’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited, as follows:

THE MEMBER

1. Lia Susan Cowell (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on April 12, 1993.

2. The Member was employed as an RN at Hillside Manor, a long-term care residence in Stratford, Ontario (the “Manor”), from July 1, 2019 to April, 2021.

3. The Member was subsequently employed on a part-time basis at St. Thomas-Elgin General Hospital in St. Thomas, Ontario (the “Hospital”) from September 1, 2020 to December 31, 2020. The Member worked in the Continuing Care Centre of the Hospital.

PRIOR HISTORY

4. On April 28, 2021, the ICRC directed the Member to complete remedial activities with respect to the Professional Standards, Medication and Documentation standards. The Member completed these activities on December 8, 2021.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Incident at the Hospital

5. The Member was assigned to the Continuing Care Centre at the Hospital (the “Unit”) for the 12-hour night shift between 1900 and 0700 on October 22 to 23, 2020. The Member was the only RN assigned to the complex continuing care patients in the Unit, along with one Registered Practical Nurse (“RPN”) and one Personal Support Worker (“PSW”).

6. Patient A had been recently diagnosed with multiple myeloma and was an existing patient of the Unit; however, she had been admitted to the ICU with hypotension. Patient A was transferred back to the complex continuing care section of the Unit shortly before to the start of the Member’s shift.

7. At the time of her transfer back to the Unit, Patient A’s chart noted the following: “O2 nasal prongs on @ 1L continuously.” On the Handoff/Transfer Report form, “O2 Tank” was checked off under Equipment Needs. The multidisciplinary record section of her chart also clearly noted that Patient A had just returned to the Unit from the ICU. If the Member were to testify, she would testify that during shift handoff the departing nurse did not advise the Member that Patient A had just returned from the ICU. The Member acknowledges, however, that it was her responsibility to review Patient A’s chart and to complete the Transfer of Accountability form to ensure she was apprised of the status of the patients under her care.

8. Under the Hospital’s Adult Assessment Standards, nurses must assess and document vital signs for each patient according to a physician’s order or unit-specific routines. At minimum, vital signs must be assessed once per shift unless a physician’s order or standard instructs otherwise. Patients who have been recently transferred from the ICU should have their vitals assessed every four hours, unless a physician orders otherwise. Nurses must also complete a comprehensive head-to-toe physical assessment on all their patients at a minimum of once per shift, within the first four hours of the shift’s start.

9. The PSW working that night communicated concerns about Patient A’s condition to the Member several times over the course of the night, as Patient A exhibited nausea, vomiting and diarrhoea, and had soiled the bed. In the PSW’s view, Patient A’s condition appeared to be deteriorating.

10. Despite this, over the course of her shift, the Member made one handwritten note in Patient A’s chart at 2210. This note stated that vomiting had been reported by the PSW, but that Patient A was sleeping when the Member checked on her. The Member’s note was written on the same page as the note recording Patient A’s recent transfer from the ICU and the need for supplemental oxygen. The Member made no other notes in Patient A’s chart.

11. During her shift, the Member did not document any of Patient A’s vital signs. The Member also failed to maintain the order for supplemental oxygen.

12. Another RN (the “RN Colleague”) was scheduled to take over from the Member in the morning. She arrived before her scheduled start at 0700 and was notified by the PSW that Patient A was very unwell. Upon checking Patient A, the RN Colleague noted that Patient A was not attached to her supplemental oxygen tank and that the Member had not completed the requisite Transfer of Accountability form.

13. If the Member were to testify, she would testify that Patient A removed the oxygen several times during her shift. The Member acknowledges, however, that it was her responsibility to ensure that Patient A’s oxygen was continuously connected.

14. The RN Colleague asked the PSW to take vitals which confirmed that Patient A was profoundly hypotensive, had a high heart rate, high respiratory rate, and had decreased levels of oxygenation. The RN Colleague called a rapid response and initiated treatment. By this time, the Member had left the unit. At no point had she offered to assist with Patient A’s care.

15. After the incident, the Member acknowledged that she ought to have completed appropriate vital signs assessments on Patient A but had not.

16. The Member’s employment ended on December 18, 2020.

Incidents at the Manor

Failing to administer, document and/or dispose of medication

17. On February 24, 2021, the Member was working a double shift at the Manor from 0600 to 2200. She was assigned to work as the floor RN on the second floor. As a floor RN, the Member’s duties included medication administration, resident assessment and communication with families.

18. Patient B was a resident of the second floor assigned to the Member’s care. Patient B had a physician’s order for hydromorphone. Over the course of the Member’s shift, Patient B was supposed to receive three 1.5mg hydromorphone tablets.

19. The Member dropped the hydromorphone tablet Patient B was supposed to receive around 1900.

20. When medication is wasted at the Manor, a nurse is required to immediately document the wastage in the medical administration record and dispose of it properly. Wastage must be witnessed by another staff member and discarded into biohazardous waste containers.

21. Instead of following the proper procedure for wastage, the Member documented that Patient B had received all his scheduled hydromorphone tablets during her shift at 1515, 1928 and 2101, but Patient B did not receive all three doses. The Member acknowledges that the documentation was incorrect in light of the wastage.

22. The Member completed a pharmacy reorder form for a hydromorphone tablet during her shift which stated that she had dropped a tablet, but failed to document any wastage of medication in the electronic medical record or have a witness sign for the wastage.

Pre-pouring medications and leaving narcotics unattended

23. The Manor’s medication procedures specify that medication will not be prepared in advance (a practice referred to as “pre-pouring”) under any circumstance. The correct procedures require nursing staff to acquire and then administer medications for one resident at a time. The Manor had previously spoken with the Member about not pre-pouring medications in January and early March 2021. In January 2021, the Member was asked to complete remediation on this topic by reviewing the Manor’s policies regarding medication administration and the CNO Medication standard. The Member signed-off on completing this review.

24. On March 28, 2021, the Member was again working an evening shift at the Manor as the second floor RN from 1600 to 2200. During her shift, around 1647, the Member removed several blister packs from the locked box in the bottom of the medication cart, which was parked near the nursing station. She then removed and placed pills from multiple blister packs into two small disposable paper cups without labelling the cups with the names of the drugs. The Member then put the two pre-poured cups of narcotics into an unlocked drawer and left the drugs unattended. The Member then administered the drugs from the paper cups.

25. Later in her shift, around 1947, the Member removed multiple blister packs from a locked drawer in the medication room and again placed pills from several blister packs into three separate unlabelled disposable paper cups. The Member carried the unlabelled cups with her during a medication pass for administration.

26. If the Member were to testify, she would testify that she pre-poured the medications due to a concern about the timely provision of medication in light of the number of patients and shortage of staff at the Facility. The Member would also testify that, to her knowledge, there were no reported or documented impacts on patients as a result of the Member pre-pouring the medications, but the Member acknowledges the potential for negative consequences on patient health as a result of pre-pouring.

27. The Member resigned her employment with the Manor on April 26, 2021.

CNO STANDARDS

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

Medication

29. CNO’s Medication standard describes nurses’ accountabilities when engaging in medication practices. This standard outlines three principles to promote public protection: authority, competence and safety.

30. The Medication standard provides, in relation to competence, that nurses meet the standard when they assess the appropriateness of their medication practice by considering the client, the medication and the environment.

31. In relation to safety, nurses meet the standard when they promote and/or implement the secure and appropriate storage, transportation and disposal of medication; take appropriate action to resolve or minimize the risk of harm to a client from a medication error or adverse reaction; and report medication errors, near misses or adverse reactions in a timely manner.

Documentation

32. CNO’s Documentation standard provides that nurses are accountable for ensuring their documentation of patient care is accurate, timely and complete. The standard further clarifies that a nurse meets the standard by ensuring that documentation presents an accurate, clear and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes.

Professional Standards

33. CNO’s Professional Standards provides that each nurse is accountable to the public and responsible for ensuring their conduct meets legislative requirements and the standards of practice of the profession. Nurses demonstrate this standard by role-modelling professional values, beliefs and attributes as well as maintaining and continually improving their knowledge and competency to practise. In particular, the Professional Standards directs nurses to take responsibility for errors when they occur, take appropriate action to maintain client safety, and use best-practice guidelines to address client needs.

Code of Conduct

34. The Code of Conduct articulates what Ontarians can expect of nurses in all practice settings. It aims to promote public confidence in the nursing profession through a principle-based accountability model.

35. Nurses have a commitment to the nursing profession. Being a member of CNO brings with it the respect and trust of the public. To continue to deserve this respect, nurses have a duty to uphold the standards of the profession by comporting themselves in a manner befitting their role. Nurses must behave in a way that reflects well on the membership and, importantly, must take accountability for their actions when their conduct falls below or contravenes an articulated standard. This is a critical element of self-regulation.

36. Members uphold this standard by, among other things, ensuring that they provide safe and competent care and act with integrity to maintain patients’ trust.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

37. The Member admits that her conduct breached CNO’s Documentation, Medication, Professional Standards and Code of Conduct standards of practice.

38. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a), (b), and (c) 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 5 to 37, above.

39. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2(a) and (b) of the Notice of Hearing in that she failed to keep records as required, as described in paragraphs 17 to 22, above.

40. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3(a), (b) and (c) of the Notice of Hearing, and in particular, that her conduct was unprofessional, as described in paragraphs 5 to 37 above.

Decision

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

Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1(a)(i), 1(a)(ii), 1(b)(i), 1(b)(ii), 1(c)(i), 1(c)(ii), 2(a), 2(b), 3(a)(i), 3(a)(ii), 3(b)(i), 3(b)(ii), 3(c)(i) and 3(c)(ii) of the Notice of Hearing. As to allegations #3(a)(i), #3(a)(ii), #3(b)(i), #3(b)(ii), #3(c)(i) and #3(c)(ii), 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 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 7, 8, 10 - 13 and 28 - 38 in the Agreed Statement of Facts. The Panel found and the Member admitted that while employed at St. Thomas-Elgin General Hospital (the “Hospital”) she committed an act of professional misconduct by contravening a standard of practice of the profession when she failed to properly assess the health status of Patient A when she overlooked the Transfer of Accountability form indicating the need for supplemental oxygen and failed to maintain the order for supplemental oxygen. The College’s Documentation Standard holds nurses accountable for ensuring their documentation of patient care is accurate, timely, and complete. Failing to note receipt of the Transfer of Accountability form and failing to document the assessment of a patient, including that all provider orders are implemented properly, is a departure from this professional standard.

Allegation #1(a)(ii) in the Notice of Hearing is supported by paragraphs 8 - 11, 14, 15, 28 - 32 and 37 - 38 in the Agreed Statement of Facts. The Panel found and the Member admitted that she committed an act of professional misconduct by contravening a standard of practice of the profession when she failed to complete and/or document vital signs checks for Patient A as per the Hospital’s Adult Assessment Standards. Patients transferred from the ICU are to have their vital signs assessed every four hours. The College’s Documentation Standard provides that nurses are accountable for ensuring their documentation is accurate, timely, and complete. The College’s Code of Conduct states that nurses must ensure they provide safe and competent care in a manner which maintains patient trust. Failure to assess or document vital signs assessments as per prescriber orders or facility standards is a departure from the College’s Documentation Standard and the Code of Conduct.

Allegation #1(b)(i) in the Notice of Hearing is supported by paragraph 21 and 28 - 38 in the Agreed Statement of Facts. The Panel found and the Member admitted that while employed at Hillside Manor (the “Manor”) she committed an act of professional misconduct by contravening a standard of practice of the profession when she documented that Patient B had received all scheduled doses of hydromorphone during her shift, however, Patient B had not received all three doses and that the medication documentation was incorrect. This conduct is a departure from the College’s Documentation Standard which requires nurses to document an accurate, clear, and comprehensive picture of the client’s needs, interventions, and outcomes.

Allegation #1(b)(ii) in the Notice of Hearing is supported by paragraphs 20, 22 and 28 - 38 in the Agreed Statement of Facts. The Panel found and the Member admitted that she committed an act of professional misconduct by contravening a standard of practice of the profession when she failed to correctly document medication wastage as per the Manor’s standards, as well as the College’s Documentation Standard and Medication Standard and failed to properly dispose of medication as per the Manor’s protocols. The College’s Documentation Standard calls for an accurate, clear, and comprehensive picture of the client’s needs, interventions, and outcomes. The College’s Medication Standard requires nurses to appropriately dispose of medications.

Allegation #1(c)(i) in the Notice of Hearing is supported by paragraphs 23 - 26 and 28 - 38 in the Agreed Statement of Facts. The Panel found and the Member admitted that she committed an act of professional misconduct by contravening a standard of practice of the profession when she pre-poured medications, including narcotics, placed them in an unlocked drawer, and left the medications unattended. The Member was previously instructed by the Manor to stop pre-pouring medications yet continued to do so. The Member admitted that she pre-poured medication out of concern for the timely administration of medication to patients within the Manor. The Member failed to meet the College’s Medication Standard, which required her to appropriately store and transport medications. The Member also failed to meet the College’s Professional Standards when she repeatedly pre-poured medications, which failed to maintain client safety and breached best practices with regards to medication storage and administration. The Member further failed to meet the College’s Professional Standards when she did not maintain continuing competency and knowledge with respect to medication safety by pre-pouring medication despite intervention by the Manor and the completion of remedial activities.

Allegation #1(c)(ii) in the Notice of Hearing is supported by paragraphs 24, 26 and 28 - 38 in the Agreed Statement of Facts. The Panel found and the Member admitted that she committed an act of professional misconduct by contravening a standard of practice of the profession when she left narcotics unattended in an unlocked drawer of a mobile nursing station. This contravened the College’s Medication Standard, which calls for secure and appropriate storage of medications.

Allegation #2(a) in the Notice of Hearing is supported by paragraphs 17 – 22 and 39 in the Agreed Statement of Facts. The Member admitted that she failed to properly document the administration of hydromorphone with respect to Patient B and thus failed to keep records as required.

Allegation #2(b) in the Notice of Hearing is supported by paragraphs 20, 22 and 39 in the Agreed Statement of Facts. The Member admitted that she failed to properly document the disposal of medication with respect to 1.5 mg of hydromorphone with respect to Patient B and thus failed to keep records as required.

Allegation #3(a)(i) in the Notice of Hearing is supported by paragraphs 7, 8, 10 - 13, 28 - 37 and 40 in the Agreed Statement of Facts. Allegation #3(a)(ii) in the Notice of Hearing is supported by paragraphs 8 - 11, 14, 15, 28 - 37 and 40 in the Agreed Statement of Facts. Allegation #3(b)(i) in the Notice of Hearing is supported by paragraph 21, 28 - 37 and 40 in the Agreed Statement of Facts. Allegation #3(b)(ii) in the Notice of Hearing is supported by paragraphs 20, 22, 28 - 37 and 40 in the Agreed Statement of Facts. Allegation #3(c)(i) in the Notice of Hearing is supported by paragraphs 23 - 26, 28 - 37 and 40 in the Agreed Statement of Facts. Allegation #3(c)(ii) is supported by paragraphs 24 - 26, 28 - 37 and 40 in the Agreed Statement of Facts.

With respect to allegations #3(a)(i), #3(a)(ii), #3(b)(i), #3(b)(ii), #3(c)(i) and #3(c)(ii), the Panel finds that the Member’s conduct in failing to provide and/or document adequate care with respect to Patient A, completing inaccurate and incomplete documentation regarding Patient B, and pre-pouring medication and leaving narcotics and/or other medications unattended was clearly relevant to the practice of nursing. The Panel finds that the Member’s conduct would be considered by members of the profession to be unprofessional as it demonstrated a serious and persistent disregard for her professional obligations in contravening the Medication Standard, the Documentation Standard, the Professional Standards and the Code of Conduct.

Penalty

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

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

2. Directing the Executive Director to suspend the Member’s certificate of registration for 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.

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 of this Order. 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 of this Order. To comply, the Member is required to ensure that:

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

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

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

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

1. Documentation,

2. Medication, and

3. Code of Conduct;

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

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

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

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

3. strategies for preventing the misconduct from recurring,

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

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

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

1. the dates the Member attended the sessions,

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

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

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

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

b) Within 6 months from the date that this Order becomes final, or a longer time period as approved by CNO, the Member shall successfully complete at the Member’s own expense the Essentials of Patient Safety course offered by George Brown College or another educational course approved by the regulatory expert, provided that the course is offered through an accredited Ontario institution; is a minimum of 20 hours duration; and is focused on patient safety, medication administration and/or documentation. The Member must pass the course. If the course is graded, the Member must receive a minimum passing grade of 65%. The Member must provide CNO with proof of enrolment, successful completion of the course and the specific grade received (if applicable).

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

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

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

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

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

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

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

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

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

d) For a period of at least 6 months and no longer than 9 months from the date this Order becomes final during which the Member is engaged continuously in the practice of nursing (i.e. not including the period during which the Member’s certificate of registration is suspended), the Member must meet with a Registered Nurse who is employed at the same employer as the Member and who is pre-approved by the Director (“Mentor”) to discuss her efforts to ensure that her care, medication administration and documentation are meeting the standards of practice of the profession. The Member must meet with the Mentor at such frequency as determined by the Mentor, but at least monthly. In order for the Mentor to be pre-approved by the Director, the Member must:

i. Provide the proposed mentor 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;

ii. Provide the Director with a copy of the proposed mentor’s résumé and a report confirming the following:

1. that the proposed mentor has received a copy of the documents identified in 3(d)(i), and

2. that the proposed mentor agrees to notify the Director and the Member’s employer immediately upon receipt of any information that the Member has breached the standards of practice of the profession.

iii. After the 6-month period identified in 3(d) above, the Mentor will determine whether additional meetings with the Member are required and will arrange those meetings as necessary during the 9-month period;

iv. The Mentor will advise the Director in writing when the meetings have ended.

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

College Submissions on Penalty

College Counsel made submissions which included the following.

The aggravating factors in this case were:

• The Member engaged in multiple incidents of misconduct over several shifts. While there was no evidence of patient harm, there was a significant risk of harm to patients;

• The Member had previously been directed to complete remedial activities by the ICRC with respect to the same practice standards; and

• The Member’s conduct at the Hospital with respect to Patient A was a “close call” which put the patient at great risk of harm; specifically, the Member failed to provide and document adequate care for Patient A.

The mitigating factors in this case were:

• The Member has accepted responsibility, expressed remorse, and cooperated with the College by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College.

The proposed penalty provides for general deterrence through the three-month suspension of the Member’s certificate of registration, which signals to members of the profession that this type of conduct will not be tolerated.

The proposed penalty provides for specific deterrence through the oral reprimand and the three-month suspension of the Member’s certificate of registration, which demonstrates to the Member the seriousness of her conduct.

The proposed penalty provides for remediation and rehabilitation through a minimum of two meetings with a Regulatory Expert, the completion of the Essentials of Patient Safety course (or a similar educational course), as well as the mentorship program. These activities will provide the Member with an opportunity to remediate these errors in the future, ensure workplace specific improvements, understand the impact of errors and omissions, and gain insight into the nature of her conduct.

The public is protected through the 12 months of employer notification, which adds employer oversight on the Member’s return to practice. Both the educational and mentorship components will improve the Member’s overall level of knowledge and competence which will further protect the public.

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. Parker (Discipline Committee, 2022): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. Similar to the case before this Panel, the member documented administering drugs when they were not in fact given. The member also failed to care for a patient as ordered by a prescriber when she failed to change a dressing on a patient’s foot. This conduct took place over a series of shifts and amounted to a breach of the Professional Standards. The penalty included an oral reprimand, a four-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, 12 months of employer notification, three random spot audits of the member’s documentation and 12 months of no independent practice in the community.

CNO v. Li (Discipline Committee, 2022): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member failed to document assessments on two patients: one related to a fall and another related to signs of deterioration. The conduct occurred over two shifts. The panel in this case made findings under the same three heads of misconduct at issue before this Panel: a breach of professional standards, failure to keep records as required, and disgraceful, dishonourable, or unprofessional conduct. The penalty ordered included an oral reprimand, a three-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, 18 months of employer notification and three random spot audits of the member’s documentation. In this case, the member had no prior disciplinary findings and accordingly did not result in the same remedial terms, conditions and limitations on the member’s certificate of registration sought before this Panel.

CNO v. Joseph (Discipline Committee, 2024): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. It included similar underlying facts and order sought in the case before this Panel. The member failed to regularly assess patients over five shifts, failed to escalate communication regarding a fall to the physician, and failed to document care or observations on six occasions. The member was found to have breached the College’s Professional Standards, failed to keep records as required, and the conduct was characterized as dishonourable and unprofessional.

The penalty included an oral reprimand, a three-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, 18 months of employer notification and four random spot audits of the member’s practice.

CNO v. Ubredi (Discipline Committee, 2024): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member failed to adequately document wasted medication, failed to document when an arterial line came out, failed to intervene with a prescribed intervention, failed to follow instructions, and failed to document a medication. The member was found to have breached the College’s Professional Standards, failed to keep records as required, and her conduct was found to be dishonourable and unprofessional. The penalty included an oral reprimand, a four-month suspension of the member’s certificate of registration, a minimum of two meetings with a Regulatory Expert, 12 months of employer notification, 12 months of mentorship, four random spots audits of the member’s charts and 12 months of no independent practice in the community. The mentorship aspect of the penalty is similar to what is proposed in the case before this Panel.

Member’s Submissions on Penalty

The Member’s Counsel asked the Panel to accept the Joint Submission on Order and submitted the following:

• The Member has many long years of service as a nurse;

• The Member is remorseful and contrite over these circumstances and the conduct before the Panel;

• The Member has been cooperative with the College by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College; and

• The Member is committed to benefitting from the remedial elements of the Joint Submission on Order to prevent these types of incidents from occurring in the future.

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 three-month suspension of the Member’s certificate of registration. This will signal to all nurses that the Member’s conduct was serious in nature, unacceptable, and will not be tolerated.

The proposed penalty provides for specific deterrence through the oral reprimand and the three-month suspension of the Member’s certificate of registration. The oral reprimand is an opportunity for the Member to hear from her nursing peers and members of the public and provides her an opportunity to understand how her conduct is perceived. The suspension of the Member’s certificate of registration is an opportunity for the Member to reflect on the standards of the profession, complete her remedial and rehabilitative activities and gain overall insight into her actions.

The proposed penalty provides for remediation and rehabilitation through a minimum of two meetings with a Regulatory Expert, completion of an Essentials of Patient Safety course at an accredited Ontario institution (or another educational course approved by the Regulatory Expert), and a six to nine month formal mentorship relationship with a nursing peer.

Overall, the public is protected through the Essentials of Patient Safety educational requirement as it will improve the Member’s knowledge and competence regarding safe nursing practice, 12 months of employer notification to act as oversight on the Member’s conduct, the mentorship relationship with a nursing peer, which will allow for a personalized approach to improving the Member’s practice, as well as more direct oversight of the Member’s conduct, the two meetings with a Regulatory Expert which will allow the Member to reconcile her conduct against the professional standards and improve her understanding of her responsibilities and obligations as a nurse. The three-month suspension will further protect the public by allowing the Member to pause her practice, gain deeper understanding of her misconduct, and understand the severity of harm that could have been foisted on the patients who trusted her with their treatment and care.

The Panel recognizes the serious nature of this misconduct. It is the expectation that all nurses uphold the standards of the profession while prioritizing patient safety. The Panel also 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, Carly Gilchrist, 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.