College of Nurses of Ontario v. Guetaba, 2025 CanLII 73597

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Tyler Hands, RN Chairperson Lynda Carpenter Public Member Sam Jennings, RPN Member Sandra Larmour Public Member Ahamad Mohammed, RPN Member

BETWEEN:

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

• and - )

BERNARD KOUDJO GUETABA ) NO REPRESENTATION for Registration No. AB826640 ) Bernard Koudjo Guetaba

) KIMBERLEY ISHMAEL ) Independent Legal Counsel

) Heard: February 11, 2025, ) via videoconference

DECISION AND REASONS

Publication Ban

By Order of the Discipline Panel dated February 11, 2025, 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 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 Bernard Koudjo Guetaba.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on February 11, 2025.

The Allegations

The allegations against Bernard Koudjo Guetaba (the “Member”) as stated in the Notice of Hearing dated January 6, 2025 are as follows:

IT IS ALLEGED THAT:

1. You 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 practising as a Registered Practical Nurse at Chartwell Rideau Place in Ottawa, Ontario, you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession in that:

a) between on or about January 2018 and January 2019, you falsified patient records by altering the dates on which care plans and assessments had been completed for patients including, but not limited to:

i. [A];

ii. [B];

iii. [C]; and/or

iv. [D];

2. You committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(14) of Ontario Regulation 799/93, in that while practising as a Registered Practical Nurse at Chartwell Rideau Place in Ottawa, Ontario, you falsified records relating to your practice as follows:

a) between on or about January 2018 and January 2019, you falsified patient records by altering the dates on which care plans and assessments had been completed for patients including, but not limited to:

i. [A];

ii. [B];

iii. [C]; and/or

iv. [D];

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(15) of Ontario Regulation 799/93, in that, in that while practising as a Registered Practical Nurse at Chartwell Rideau Place in Ottawa, Ontario, you signed or issued, in your professional capacity, a document that you knew, or ought to have known contained a false or misleading statement in that:

a) between on or about January 2018 and January 2019, you falsified patient records by altering the dates on which care plans and assessments had been completed for patients including, but not limited to:

i. [A];

ii. [B];

iii. [C]; and/or

iv. [D];

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

a) between on or about January 2018 and January 2019, you falsified patient records by altering the dates on which care plans and assessments had been completed for patients including, but not limited to:

i. [A];

ii. [B];

iii. [C]; and/or

iv. [D]

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a)(i), (ii), (iii), (iv), 2(a)(i), (ii), (iii), (iv), 3(a)(i), (ii), (iii), (iv) and 4(a)(i), (ii), (iii) and (iv) 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 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

1. Bernard Koudjo Guetaba (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on March 12, 2012.

2. The Member has no prior disciplinary findings with CNO.

3. The Member was employed as the Health and Wellness Manager at Chartwell Rideau Place in Ottawa, Ontario (the “Facility”) from March 2017 until his termination on March 20, 2019 in relation to the incidents described below.

THE FACILITY

4. The Facility was a retirement home in Ottawa, Ontario. It has since permanently closed.

5. The Member typically worked Monday to Friday, 8 am to 4 pm. The Member also worked weekends every 6 weeks and was regularly on call.

6. The Retirement Homes Act, SO 2010, c 11, required that the Facility assess and develop a care plan for each patient at the beginning of their residency. The Act also required that each patient be reassessed, and the care plan revised at least every six months or at other intervals, such as when the patient’s care needs changed, their goals had been met, or the care set out in the plan had not been effective.

7. As the Health and Wellness Manager, the Member was responsible for ensuring that each patient’s care plan was up to date, either by conducting the assessments and drafting the care plans himself, or by assigning their completion to nurses under his supervision.

8. At the time of the incidents below, the Facility maintained all care plans by hardcopy documentation. Care plans were typically stored in the nursing station, in a binder along with all other current care plans.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

9. On February 27, 2019, a regional Chartwell nurse attended the Facility to conduct a routine audit of the Facility’s documentation. During this audit, the regional nurse discovered expired care plans that had been altered to revise the dates of the plans. These care plans were altered using white-out, in some cases, and, in others, by editing the existing dates on the care plans by hand.

10. The Facility conducted an investigation which identified changes made to a number of care plans and associated documentation. The Member was required to and did sign in his capacity as Manager all of the documents identified by the Facility, even where the original document had been drafted by another nurse. The altered documents included but were not limited to:

a. Assessments and a care plan for Patient [ ] (“Patient A”), in which the documentation had been whited out and altered by hand to change the date completed and consented to by the patient to November 30, 2018;

b. A care plan for Patient [ ] (“Patient B”), in which the documentation had been both whited out and altered by hand to change the date completed and consented to by the patient from January 22, 2017, to January 22, 2018, and January 22, 2019;

c. Assessments and a care plan for Patient [ ] (“Patient C”), in which the documentation had been whited out and altered by hand to change the dates completed and consented to by the patient to January 19 and January 22, 2019;

d. Assessments and a care plan for Patient [ ] (“Patient D”), in which the documentation had been altered by hand to change the date completed and consented to by the patient, from June 28, 2018, to January 28, 2019.

11. When asked by the Facility to explain the alterations, the Member initially stated that he did not know how they came about. However, the Member later admitted to having altered the care plans and assessments, although the Member claimed to have done so for his own personal research purposes. Nevertheless, the Member admits that it is never appropriate to alter patient documentation.

CNO STANDARDS OF PRACTICE

12. 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.

Code of Conduct

13. 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.

14. CNO’s Code of Conduct is a standard of practice describing the accountabilities all Ontario nurses have to the public. It includes six broad principles relating to the dignity of patients, promotion of patient well-being, maintenance of patient trust, working respectfully with colleagues, acting with integrity, and maintaining public confidence in the nursing profession.

15. 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 are accountable to, and practice under, relevant laws and CNO’s standards of practice.

16. With respect to the principle requiring nurses to maintain confidence in the nursing profession, CNO’s Code of Conduct provides that nurses are accountable for their own actions and decisions and that nurses respect the property of their patients and employers.

17. 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

18. CNO’s Professional Standards provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by CNO. It includes seven broad standard statements pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership and relationships.

19. CNO’s Professional Standards provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring their practice and conduct meets the legislative requirements and the 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. Nurses demonstrate this standard by actions such as ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation.

20. CNO’s Professional Standards provides, in relation to the ethics standard, that nurses act with integrity, honesty, and professionalism in all dealings with the client and other health care team members. Nurses demonstrate this standard by actions such as identifying ethical issues and communicating them to the health care team.

21. Attached as Exhibit “B” is a copy of CNO’s Professional Standards that was in force at the time of the incidents described herein.

Ethics

22. CNO’s Ethics Standard describes ethical values that are important to the nursing profession in Ontario including patient well-being, patient choice, privacy and confidentiality, respect for life, maintaining commitments, truthfulness and fairness.

23. CNO’s Ethics Standard provides, in relation to maintaining commitments, that nurses have a commitment to the nursing profession and being a member of the profession 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, conduct themselves in a manner that reflects well on the profession, and to participate in and promote the growth of the profession.

24. CNO’s Ethics Standard also provides, in relation to truthfulness, that truthfulness means speaking and acting without intending to deceive.

25. Attached as Exhibit “C” is a copy of CNO’s Ethics Standard that was in force at the time of the incidents described herein.

Documentation

26. CNO’s Documentation standard requires that documentation reflects all aspects of the nursing process including assessment, planning, intervention (independent and collaborative) and evaluation.

27. In accordance with the Documentation Standard, nurses are accountable for ensuring their documentation of client care is accurate, timely and complete. A nurse meets the standard by demonstrating compliance with various indicators, including, inter alia: documenting the date and time that care was provided and when it was recorded; and indicating when an entry is late as defined by organizational policies; and correcting errors while ensuring that the original information remains visible/retrievable.

28. Attached as Exhibit “D” is a copy of CNO’s Documentation Standard that was in force at the time of the incidents described herein.

29. The Member admits and acknowledges that he contravened CNO’s Code of Conduct, Professional Standards, Ethics Standard, and Documentation Standard.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

30. The Member admits that he committed the acts of professional misconduct as alleged in paragraph 1(a)(i), (ii), (iii), and (iv) of the Notice of Hearing, in that he contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 4-29 above.

31. The Member admits that he committed the acts of professional misconduct as alleged in paragraph 2(a)(i), (ii), (iii), and (iv) of the Notice of Hearing, in that he altered documentation to falsify the dates of having conducted assessments and/or completed care plans, as described in paragraphs 4-29 above.

32. The Member admits that he committed the acts of professional misconduct as alleged in paragraph 3(a)(i), (ii), (iii), and (iv) of the Notice of Hearing, in that he signed or issued, in his professional capacity, a document that he knew or ought to have known contained a false or misleading statement, as described in paragraphs 4-29 above.

33. The Member admits that he committed the acts of professional misconduct as alleged in paragraph 4 (a)(i), (ii), (iii), and (iv) of the Notice of Hearing and, in particular, that he engaged in conduct that would reasonably be regarded by members of the profession as dishonourable and unprofessional, as described in paragraphs 4-29 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), (ii), (iii), (iv), 2(a)(i), (ii), (iii), (iv), 3(a)(i), (ii), (iii), (iv) and 4(a)(i), (ii), (iii) and (iv) of the Notice of Hearing. As to allegations #4(a)(i), (ii), (iii) and (iv), 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.

Allegations #1(a)(i), (ii), (iii) and (iv) in the Notice of Hearing are supported by paragraphs 4 to 29 and 30 in the Agreed Statement of Facts. The evidence demonstrated and the Member admitted that while employed as the Health and Wellness Manager at Chartwell Rideau (the “Facility”) he committed an act of professional misconduct in that he contravened the standards of practice of the profession when he repeatedly falsified patient records by altering the dates on which care plans and assessments had been completed. This directly contravened the standards of practice of the profession, including the Code of Conduct, the Professional Standards, the Ethics Standard, and the Documentation Standard, and undermines the integrity of nursing documentation.

Allegations #2(a)(i), (ii), (iii) and (iv) are supported by paragraphs 4 to 29 and 31 in the Agreed Statement of Facts. The Panel found and the Member admitted that he committed an act of professional misconduct in that he knowingly falsified records related to patient care when he altered documentation to falsify the dates of having conducted assessments and/or completed care plans, representing a failure to maintain accurate and truthful documentation.

Allegations #3(a)(i), (ii), (iii) and (iv) are supported by paragraphs 4 to 29 and 32 in the Agreed Statement of Facts. The Panel found and the Member admitted that he committed an act of profession misconduct in that he signed or issued, in his professional capacity, documents that he knew or ought to have known contained false or misleading information, which breached the ethical and professional obligations required of a nurse.

Allegations #4(a)(i), (ii), (iii) and (iv) are supported by paragraphs 4 to 29 and 33 in the Agreed Statement of Facts. The Panel found that the Member’s conduct of altering patient records and failing to take immediate accountability was relevant to the practice of nursing and was unprofessional as it demonstrated a serious and persistent disregard for his professional obligations by contravening the Code of Conduct, the Professional Standards, the Ethics Standard and the Documentation Standard.

The Panel also finds that the Member’s conduct was dishonourable. The deliberate falsification of documentation demonstrated an element of dishonesty and deceit, which directly impacts the integrity of the nursing profession. Documentation is a fundamental aspect of nursing practice, ensuring continuity of care and patient safety. By altering records, the Member compromised patient care and misled colleagues, violating the trust placed in nursing professionals.

The submissions to the Panel confirmed that such conduct is inconsistent with professional expectations and is regarded as both dishonourable and unprofessional. The Member exhibited a disregard for his professional obligations, and as a regulated professional, he knew or ought to have known that his conduct fell well below the standards of a professional.

Penalty

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

1. Requiring the Member to appear before the Panel to be orally 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 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.

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 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:

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. Code of Conduct, and

2. Documentation;

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) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify their 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.

iii. 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;

iv. Provide their 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;

v. Only practise nursing for an employer who agrees to, and does, forward a report to CNO within 14 days of the commencement or resumption of the Member’s employment in any nursing position, confirming:

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

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

3. that they agree to perform 3 random spot audits of the Member’s documentation practice at the following intervals over a 12 month and provide a report to CNO regarding the Member’s practice after each audit:

a. the first audit shall take place within four months from the date the Member begins or resumes employment with the employer,

b. the second audit shall take place within eight months from the date the Member begins or resumes employment with the employer,

c. the third audit shall take place within 12 months from the dated the Member begins or resumes employment with the employer;

vi. The audits shall, on each occasion, involve reviewing a random selection of at least five of the Member’s charts to ensure they meet both CNO and employer standards.

c) The Member shall not practice independently in the community for a period of 12 months from the date the Member returns to the active practice of nursing.

4. 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 regarding the aggravating and mitigating factors in this case, emphasizing the importance of balancing the need for public protection, maintaining public confidence in the profession, and ensuring that the penalty serves as a deterrent for both the Member and the broader nursing community.

The aggravating factors in this case include the repeated nature of the misconduct over a significant period and the potential risk to patient safety due to falsified documentation. Documentation is essential for communication among healthcare professionals, and inaccuracies compromise patient care. Additionally, the Member initially failed to take accountability for his conduct.

The mitigating factors in this case include the Member’s cooperation with the College, his admission to the allegations and taking responsibility for his actions by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College, and that the Member has no prior disciplinary history with the College, all of which were considered in determining an appropriate penalty to propose before the Panel.

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. Ventenilla (Discipline Committee 2022): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member falsified documentation by recording visits that had not taken place, which led to the facility billing for services that were never provided. The misconduct resulted in financial misrepresentation and a breach of trust. The penalty included an oral reprimand, a three-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert, 12 months of employer notification and six months of no independent practice in the community. While there was an element of financial misconduct in this case, the falsification of records mirrors the concerns in the case before this Panel, making it a relevant comparison.

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 implement required fall prevention interventions and failed to accurately document assessments and interventions. The misconduct included multiple instances of failing to document properly, which compromised patient safety. 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 three random spot audits of the member’s documentation. The extended employer notification period highlights the seriousness of documentation-related offenses and the need for oversight to ensure compliance with the standards of practice of the profession.

CNO v. O’Connor (Discipline Committee 2022): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member signed a prescription without physician authorization and provided wound care without consulting a physician. The member also failed to properly maintain documentation related to patient care. This case involved elements of practicing outside of the nursing scope and falsification of records. 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. Although the nature of the misconduct slightly differs, this case underscores the importance of maintaining accurate and honest documentation in nursing practice.

These cases establish consistency in disciplinary actions and reinforce that the proposed penalty meets the objectives of general deterrence, specific deterrence, and rehabilitation, ensuring public protection and confidence in the College’s self-regulation.

Member’s Submissions on Penalty

The Member indicated that he agreed with the College’s submissions.

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 a two-month suspension of the Member’s certificate of registration and an oral reprimand, sending a clear message to other members of the profession that this type of conduct will not be tolerated. The public nature of the penalty ensures that other members are aware of the consequences of similar actions. This serves to reinforce the importance of maintaining accurate documentation and acting with integrity in professional practice. The disciplinary action demonstrates that the College takes such conduct seriously, thereby discouraging other members from engaging in similar misconduct.

The proposed penalty provides for specific deterrence as the penalty directly discourages the Member from repeating this conduct by imposing a two-month suspension of the Member’s certificate of registration and through the oral reprimand. The suspension serves as a direct consequence for the misconduct, ensuring that the Member fully understands the severity of his actions. The oral reprimand reinforces the expectation of professional integrity and accountability. Together, these measures act as strong deterrents, encouraging the Member to uphold the standards of practice of the profession moving forward.

The proposed penalty provides for remediation and rehabilitation through a minimum of two meetings with a Regulatory Expert, 12 months of employer notification and three random spot audits of the Member’s documentation. These measures provide the Member with the necessary guidance and oversight to understand the impact of his actions and develop the skills required to prevent future occurrences. The Regulatory Expert meetings offer structured education and training, while the employer notification and spot audits ensure on-the-job learning with direct supervision. These steps facilitate the Member’s professional growth and reinforce adherence to ethical standards.

Overall, the public is protected because the penalty meets the overarching goals of regulatory proceedings by protecting the public, maintaining public confidence in the College’s ability to self-regulate, and ensuring professional accountability. The 12 months of employer notification, three random spot audits of the Member’s documents and 12 months of no independent practice in the community provide public protection. This penalty reassures the public that regulatory standards are upheld, reinforcing trust in the profession and in the College’s ability to oversee its members. Documentation is a critical component of nursing practice, ensuring proper communication among care team members. By addressing these concerns through the suspension, oral reprimand, and remedial measures, the penalty ensures that the Member is held accountable, and that similar conduct is deterred in the future.

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, Tyler Hands, RN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.