College of Nurses of Ontario v. Natasha Perry, 2024 CanLII 150617

minicounsel

PANEL: Michael Hogard, RPN Chairperson Sylvia Douglas Public Member Tammy Hedge, RPN Member Jane Hess, RN Member Sandra Larmour Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) ALYSHA SHORE for ) College of Nurses of Ontario

and - ) NATASHA PERRY ) NIITI SIMMONDS for Registration No. 14041592 ) Natasha Perry ) PATRICIA HARPER ) Independent Legal Counsel ) Heard: November 12, 2024, ) via videoconference

Publication Ban

By Order of the Discipline Panel dated November 12, 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 their identities, referred to orally or in any documents presented at the Discipline hearing of Natasha Perry.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on November 12, 2024.

The Allegations

College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs 1(a)(i), 1(a)(ii), 1(c), 2(a), 2(c), 3(a)(i), 3(a)(ii) and 3(c) of the Notice of Hearing dated September 26, 2024. The Panel granted this request. The remaining allegations against Natasha Perry (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 practicing as a Registered Nurse at Headwaters Health Care Centre in Orangeville, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as follows:

a. on, about or around January 28, 2022, you:

i. [withdrawn];

ii. [withdrawn];

iii. closed the door to Patient [A]’s room and held the exterior handle of the door shut for approximately 45 seconds to 1 minute while the Patient tried to exit the room; and/or

iv. said to Patient [A] in a raised tone of voice, while holding the Patient’s door shut, “No! You’re not coming out! You can’t come out!” or words to that effect, when the Patient attempted to open the door and exit the room;

b. on, about or around February 25-26, 2022, you approached Patient [B], while he was speaking with the Charge Nurse, and spoke to him in a raised tone of voice and used inappropriate language, including when you said to the Patient “you aren’t telling the whole truth. You are a dick” or words to that effect; and/or

c. [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(7) of Ontario Regulation 799/93, in that while you were employed as a Registered Nurse at Headwaters Health Care Centre in Orangeville, Ontario, you abused patients verbally, physically, and/or emotionally as follows:

a. [withdrawn];

c. [withdrawn]; and/or

You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that while you were practicing as a Registered Nurse at Headwaters Health Care Centre in Orangeville, 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 as disgraceful, dishonourable or unprofessional as follows:

a. on, about or around January 28, 2022, you:

i. [withdrawn];

ii. [withdrawn];

iii. closed the door to Patient [A]’s room and held the exterior handle of the door shut for approximately 45 seconds to 1 minute while the Patient tried to exit the room; and/or

c. [withdrawn].

Member’s Plea

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

Agreed Statement of Facts

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

THE MEMBER

Natasha Perry (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on May 8, 2014.
The Member was employed at Headwaters Health Care Centre in Orangeville, Ontario (the “Facility”) from November 16, 2015 until March 17, 2022. The Member later resigned from the Facility in relation to these incidents.
The Member has no prior CNO disciplinary history.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Patient A

Patient A was admitted to the Facility after a fall that caused major trauma to her head. She had difficulty with her memory, was hard of hearing, and at the time of the incident she also had COVID-19.
On or about January 28, 2022, Patient A was isolating in her room due to COVID-19. Patient A exited her room repeatedly and staff directed her back to her room on each occasion. All attempts to direct her back to her room were successful and did not require escalated interventions. This behaviour recurred throughout the morning.
At one point, however, when Patient A exited her room and approached the nursing station, the Member held the Patient’s arm and directed her back to her room. The Member then held Patient A’s door closed for approximately one minute.
Patient A attempted to open the door, and the Member said “you cannot come out; you have to stay in your room” in a raised tone of voice. After approximately one minute, the Patient stopped trying to exit her room and the Member let go of the door handle.
The incident was witnessed by a Registered Practical Nurse (“RPN”) at the Facility (“Colleague A”). During the interaction between the Member and Patient A, Colleague A was at the nursing station near Patient A’s room. According to Colleague A, the Member’s conduct was unprofessional.
The incident was also overheard by another staff member at the Facility (“Colleague B”). According to Colleague B, the Member spoke to Patient A inappropriately. At one point, Colleague B told the Member to stop.
Following the incident, Colleague A reported the incident to the Facility.
If the Member were to testify, she would say that Patient A’s room door was not latching fully and there was a gap between the door and the door frame, so she held it closed.
If the Member were to testify, she would explain that this incident took place in the peak of the fifth wave of the COVID-19 pandemic and Patient A was unable to comply with isolation precautions such as masking. If the Member were to testify the Member would say that she communicated to Patient A that she needed to remain isolated in her room due to COVID-19 precautions in effect. The Member would say that she was speaking loudly with Patient A due to the Member’s donning of a surgical mask, which muffled her voice. The Member would testify that she had not yet had an opportunity to locate a N95 mask and was making best efforts to comply with infection prevention and control policies. The Member would also say that she was speaking loudly in her communication due to Patient A’s partial loss of hearing but recognizes this was not received or experienced by Patient A in that way. The Member acknowledges that she handled the situation inappropriately, regardless of the circumstances.

Patient B

On February 24, 2022, Patient B was admitted to the Facility with extreme abdominal pain and was diagnosed with acute pancreatitis.
On February 26, 2022, Patient B’s care was assigned to an RPN at the Facility (“Colleague C”).
After a number of heightened exchanges with Colleague C, Patient B approached the nursing station to voice a complaint about Colleague C to the Charge Nurse (“Colleague D”), another RN at the Facility.
Colleague D led Patient B away from the nursing station and into a nearby corridor in an attempt to de-escalate the situation. According to Colleague D, the Member, who was not involved in the conversation, came over to where she and Patient B were standing and inappropriately communicated to Patient B, including by saying to him, “you aren’t telling the whole truth. You are a dick”, or words to that effect. Patient B’s behaviour escalated again. Patient B felt shamed by the interaction with the Member.
If the Member were to testify, she would say that Patient B had been difficult for the nurses to deal with throughout the day. The Member would say she believed Patient B was exaggerating when he approached the nursing station to complain about Colleague C. The Member would say she said to Patient B, “it didn’t happen that way” or “it isn’t true”, or words to that effect. If the Member were to testify, she would state that she felt she had built a positive rapport with Patient B during the previous shifts, and her intent was to use a light-hearted tone. The Member would state that she said “what a doink” to another colleague after Patient B was led away from the nursing station. If the Member were to testify, she would explain that she sincerely regrets her comments and that they contributed to Patient B feeling shamed.
The Member acknowledges that her conduct was unacceptable, regardless of these circumstances or the exact words used.

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:

Nurses respect the dignity of patients and treat them as individuals;
Nurses work together to promote patient well-being;
Nurses maintain patients’ trust by providing safe and competent care;
Nurses work respectfully with colleagues to best meet patients’ needs;
Nurses act with integrity to maintain patients’ trust; and
Nurses maintain public confidence in the nursing profession.

CNO’s Code of Conduct further provides, in relation to the principle requiring nurses to respect the dignity of patients and treat them as individuals, that nurses treat patients with care and compassion, and take steps to maintain patients’ dignity in the physical space where they are receiving care.
CNO’s Code of Conduct further provides, in relation to the principle requiring nurses to maintain public confidence in the nursing profession, that nurses are accountable for their own actions and decisions.
Attached as Exhibit “A” is a copy of CNO’s Code of Conduct in force at the time of the Incident.

Professional Standards

CNO’s Professional Standards provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by CNO. It includes seven broad standard statements and indicators that illustrate how the standard may be demonstrated pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership and relationships.
CNO’s Professional Standards further provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring their practice and conduct meets the legislative requirements and the standards of the profession. Nurses are responsible for their actions and the consequences of those actions as well as for conducting themselves in ways that promote respect for the profession.
CNO’s Professional Standards further provides, in relation to the relationships standard statement and the therapeutic nurse-patient relationship, that nurses are expected to demonstrate empathy and caring in all relationships with patients, families and significant others and it is the responsibility of the nurse to establish and maintain the therapeutic relationship. Nurses demonstrate this standard by, among other actions:

a. demonstrating respect and empathy for, and interest in clients;

b. ensuring [the patient’s] needs remain the focus of nurse-[patient] relationships;

c. recognizing the potential for [patient] abuse; and

d. preventing abuse when possible.

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

Therapeutic Nurse-Client Relationship Standard

CNO’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) contains four standard statements which describe nurses’ accountabilities with respect to therapeutic communication, patient-centred care, maintaining boundaries and protecting the patient from abuse. The TNCR Standard provides that the nurse-patient relationship is built on trust, respect, empathy, professional intimacy and requires the appropriate use of power inherent in the care provider’s role.
CNO’s TNCR Standard provides, in relation to therapeutic communication, that nurses meet this standard by, among other acts:

a. being aware of her/his verbal and non-verbal communication style and how [patients] might perceive it;

b. modifying communication style, as necessary, to meet the needs of the [patient] (for example, to accommodate a different language, literacy level, developmental stage or cognitive status); and

c. recognizing that all behaviour has meaning and seeking to understand the cause of a [patient’s] unusual comment, attitude or behaviour.

CNO’s TNCR Standard also requires nurses to refrain from exhibiting physical, verbal, and non-verbal behaviours toward a client that demonstrate disrespect for the client and/or are perceived by the client and/or others as abusive.
Attached as Exhibit “C” is a copy of CNO’s TNCR Standard in force at the time of the incidents.
The Member admits and acknowledges that in engaging in the conduct described above she breached CNO’s Code of Conduct, the Professional Standards, and the TNCR Standard.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

The Member admits that she committed the act of professional misconduct as alleged in paragraph 1(a)(iii), 1(a)(iv), and 1(b) of the Notice of Hearing in that she contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 4-31 above.
The Member admits that she committed the act of professional misconduct as alleged in paragraph 2(b) of the Notice of Hearing in that she abused a patient verbally and/or emotionally, as described in paragraphs 13-31 above.
The Member admits that she committed the act of professional misconduct as alleged in paragraph 3(a)(iii), 3(a)(iv), and 3(b) of the Notice of Hearing in that she 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 and unprofessional, as described in paragraphs 4-31 above.

OTHER

With the leave of the Panel of the Discipline Committee, CNO withdraws the remaining allegations in the Notice of Hearing, which are paragraphs 1(a)(i), 1(a)(ii), 1(c), 2(a), 2(c), 3(a)(i), 3(a)(ii), and 3(c) of the Notice of Hearing.

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)(iii), 1(a)(iv), 1(b), 2(b), 3(a)(iii), 3(a)(iv) and 3(b) of the Notice of Hearing. With respect to allegation #2(b), the Panel finds that the Member abused a patient verbally and emotionally. With respect to allegations #3(a)(iii), #3(a)(iv) and #3(b), the Panel finds that the Member’s conduct would reasonably be regarded by members of the profession to be disgraceful, 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.

Allegations #1(a)(iii), #1(a)(iv) and #1(b) in the Notice of Hearing are supported by paragraphs 4-32 in the Agreed Statement of Facts. The Member admitted that while employed as a Registered Nurse (“RN”) at Headwaters Health Care Centre (the “Facility”) she committed an act of professional misconduct in that she contravened a standard of practice of the profession or failed to meet the standards of practice of the profession when she held Patient A’s door closed for approximately one minute to keep Patient A in her room and spoke to Patient A in a raised voice, telling her that she cannot come out and to stay in her room when Patient A attempted to open the door. The Member also admitted that she interrupted a conversation between Patient B and a Charge Nurse (“Colleague D”) and spoke to Patient B in a raised tone of voice and used inappropriate language.

The Member’s conduct contravened the Code of Conduct, specifically that nurses respect the dignity of patients, maintain patients’ trust by providing safe and competent care, act with integrity to maintain patients’ trust and maintain public confidence in the nursing profession. The Member also contravened the Professional Standards and the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”), specifically the prevention of abuse. The Member’s conduct breached the requirement set out in the Professional Standards to demonstrate respect and empathy for patients, and to ensure that patient needs remain the focus of the nurse-patient relationship. The Member’s conduct breached the TNCR Standard, which requires nurses to be aware of how verbal and non-verbal communication styles may be perceived by patients, and to modify communication styles as necessary to meet the needs of the patient.

Allegation #2(b) in the Notice of Hearing is supported by paragraphs 13-31 and 33 in the Agreed Statement of Facts. The Member admitted that she committed an act of professional misconduct in that she abused Patient B verbally and/or emotionally when she interrupted Colleague D attempting to de-escalate a situation with Patient B, and inappropriately communicated to Patient B by saying to him, “you aren’t telling the whole truth, You are a dick”, or words to that effect which escalated Patient B’s behaviour and made him feel shamed by the interaction.

Allegations #3(a)(iii), #3(a)(iv) and #3(b) in the Notice of Hearing are supported by paragraphs 4-31 and 34 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct was relevant to the practice of nursing and was unprofessional, as it demonstrated a serious and persistent disregard for her professional obligations in contravening the Code of Conduct, the Professional Standards and the TNCR Standard.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing, as the Member knew or ought to have known that her conduct was unacceptable and fell well below the standards of a professional.

Finally, the Panel finds that the Member’s conduct was disgraceful as it shames the Member and by extension the profession. The conduct casts serious doubt on the Member’s moral fitness and inherent ability to discharge the higher obligations the public expects professionals to meet.

Penalty

College Counsel and the Member’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 2 months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in a practicing class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend 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 meetings;

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

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;

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

Code of Conduct,
Therapeutic Nurse-Client Relationship, and
One is One too Many;

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:

the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;

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:

the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into the Member’s behaviour;

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

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

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

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

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

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;

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

that they received a copy of the required documents, and
that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession.
All documents delivered by the Member to CNO, the Expert, or the 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 two patients involved were vulnerable, with one patient suffering from an acute illness and the other patient was elderly and living with dementia;
The Member’s conduct breached the trust of patients in the health care system;
The Member’s conduct involved verbal and emotional abuse; and,
The Member’s conduct discredited her and the profession as a whole.

The mitigating factors in this case were:

The Member has no prior disciplinary history with the College;
The Member has taken responsibility and expressed remorse by admitting to her conduct and entering into an Agreed Statement of Facts and a Joint Submission on Order with the College;
The incidents were isolated and brief; and
There were additional stresses on the health care system at this time due to the challenges presented by COVID-19.

College Counsel reviewed the following cases with the Panel, which demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee:

CNO v. Fu (Discipline Committee, 2020): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member verbally, physically and emotionally abused a vulnerable, elderly patient. The penalty included an oral reprimand, a two-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and nine months of employer notification.

CNO v. Moore (Discipline Committee, 2021): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member verbally and emotionally abused a vulnerable, elderly patient. The penalty included an oral reprimand, a two-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and nine months of employer notification.

Member’s Submissions on Penalty

The Member’s Counsel made submissions which included the following:

The Member’s Counsel highlighted that the Member had admitted to the allegations from the outset of this process, taken responsibility for her conduct and demonstrated remorse by entering into an Agreed Statement of Facts and a Joint Submission on Order, and noted that the Member has no prior disciplinary history with the College.

The Member’s Counsel submitted the following additional mitigating factors for the Panel’s consideration:

There was no evidence of any lasting harm or injury to the patients affected; and,
The Member’s conduct did not involve physical abuse.

Penalty Decision

The Panel accepted the Joint Submission on Order and made the order requested.

Reasons for Penalty Decision

There is a high threshold for departing from a Joint Submission on Order established by the Supreme Court of Canada in R. v. Anthony-Cook, 2016 SCC 43. Departing from a joint submission would require a finding that the proposed penalty would bring the administration of justice into disrepute or is otherwise contrary to the public interest.

The Panel concluded that the proposed penalty is not contrary to the public interest and does not bring the administration of justice into disrepute.

The Panel concluded that the proposed penalty is reasonable and in the public interest. It promotes public confidence in the ability of the College to regulate nurses.

The Panel finds that the proposed penalty satisfies the penalty goals of specific and general deterrence, rehabilitation and remediation, and public protection.

The proposed penalty provides for general deterrence through the two-month suspension of the Member’s certificate of registration, which demonstrates to the membership that this type of conduct will be taken seriously.

The proposed penalty provides for specific deterrence through the oral reprimand and the two-month suspension of the Member’s certificate of registration, which sends a clear message to the Member that this type of conduct will not be tolerated.

The proposed penalty provides for remediation and rehabilitation through a minimum of two meetings with a Regulatory Expert and the remedial course work. This will give the Member an opportunity for reflection and to develop insight into her actions and how her conduct failed to meet the standards of practice, and to guide the Member towards improvements to her practice going forward.

Overall, the public is protected through the 12 months of employer notification and because the penalty as a whole addresses all the principles of penalty orders, which will ensure that the Member returns to her practice safely.

The Panel acknowledges that the Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility, which is a mitigating factor.

The penalty is in line with the range of what has been ordered in previous similar cases.

I, Michael Hogard, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.