College of Nurses of Ontario v. Sarah Emmanuel, 2025 ONCNO 82637

Discipline Committee of the College of Nurses of Ontario

PANEL: Tanya Dion, RN Chairperson Mary MacNeil, RN Member Carly Gilchrist, RPN Member Sylvia Douglas Public Member Randall Burke Public Member

BETWEEN:

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

• and -

SARAH EMMANUEL Registration No. AH101750 GRANT FERGUSON for Sarah Emmanuel ELYSE SUNSHINE Independent Legal Counsel

Heard: May 28, 2025 via videoconference

DECISION AND REASONS

Publication Ban

By Order of the Discipline Panel dated May 28, 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 names of the patients, or any information that identifies or may tend to identify patients and/or their personal health information, referred to orally or in any documents presented at the Discipline hearing of Sarah Emmanuel.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on May 28, 2025.

The Allegations

The allegations against Sarah Emmanuel (the “Member”) as stated in the Notice of Hearing dated April 1, 2025 are as follows:

IT IS ALLEGED THAT:

1. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that, on November 24 to 25, 2021, while working as a Registered Practical Nurse at the Scarborough Health Network – Birchmount Site, in Scarborough, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession as follows:

a. you environmentally restrained [the Patient] when it was not necessary to do so and/or used a restraint that was not the least restraint required;

b. you environmentally restrained [the Patient] without having obtained a physician’s order to do so;

c. you failed to document the environmental restraint of [the Patient] and/or to document a reason for the environmental restraint of [the Patient];

d. you failed to conduct adequate monitoring, observation, and/or assessments of [the Patient] while he was environmentally restrained; and/or

e. you failed to document and/or accurately document your monitoring, observation and/or assessments of [the Patient] while he was environmentally restrained;

2. You have committed an act of professional misconduct as provided by subsection 51(1)(c) 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 November 24 to 25, 2021, while working as a Registered Practical Nurse at the Scarborough Health Network – Birchmount Site, in Scarborough, Ontario, you failed to keep records as required, as follows:

a. you failed to document the environmental restraint of [the Patient] and/or to document a reason for the environmental restraint of [the Patient]; and/or

b. you failed to document and/or accurately document your monitoring, observation and/or assessments of [the Patient] while he was environmentally restrained;

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, on November 24 to 25, 2021, while working as a Registered Practical Nurse at the Scarborough Health Network – Birchmount Site, in Scarborough, Ontario, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional, as follows:

a. you environmentally restrained [the Patient] when it was not necessary to do so and/or used a restraint that was not the least restraint required;

b. you environmentally restrained [the Patient] without having obtained a physician’s order to do so;

c. you failed to document the environmental restraint of [the Patient] and/or to document a reason for the environmental restraint of [the Patient];

d. you failed to conduct adequate monitoring, observation, and/or assessments of [the Patient] while he was environmentally restrained; and/or

e. you failed to document and/or accurately document your monitoring, observation and/or assessments of [the Patient] while he was environmentally restrained.

Member’s Plea

The Member admitted to the allegations set out in paragraphs 1(a) - (e), 2(a) - (b), and 3(a) - (e) 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 referenced therein, as follows:

THE MEMBER

1. Sarah Emmanuel (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on October 16, 2018.

2. From September 20, 2017 to January 20, 2022, the Member was employed part-time at Scarborough Health Network – Birchmount Campus in Scarborough, Ontario (the “Facility”). The Member’s employment was terminated as a result of the incidents described below.

3. At the time of the incidents, the Member’s name was “Maimuna Kassim Garba”.

THE FACILITY

4. While employed at the Facility, the Member worked 12-hour night shifts from 1930 to 0730 on Unit 3C, which is a mental health unit (the “Unit”). Patients on the Unit typically have conditions such as depression, psychosis, and schizophrenia. Nursing duties for these patients include conducting mental status assessments, following up on treatment orders, administering medication, redirecting patients, and assisting patients with activities of daily living, where required.

5. During night shifts, the Unit had three nurses working simultaneously. The Unit is located in the Facility adjacent to the Psychiatric Intensive Care Unit (“PICU”). During night shifts, two nurses are on duty in the PICU. If extra support is ever required in either the Unit or the PICU, nurses from the adjacent unit are expected to be available to assist each other.

FACILITY POLICIES

Facility’s Restraint Policy

6. The Facility’s Mental Health-Least Restraint for Mental Health Patients policy (the “Restraint Policy”), in force at the time of the incidents, lists three types of restraint: environmental restraint, chemical restraint, and mechanical restraint. Environmental restraint can involve confinement to the patient’s room.

7. Restraint, in general, is defined as a method of last resort reserved for emergency situations in which the patient has lost control and demonstrates behaviour that indicates a risk of bodily harm to self or others. The Restraint Policy, reproduces the Mental Health Act 2002, in part, which states:

“restrain means to place under control when necessary to prevent serious bodily harm to the patient or to another person by the minimal use of […] force […] as is reasonable having regard to the physical and mental condition of the patient.”

8. The Restraint Policy outlines the process for determining the need for restraining patients, which includes, but is not limited to, the following:

• The assigned nurse and Most Responsible Physician (“MPR”), when available, must determine the level of risk the patient presents to self and/or others prior to implementing restraints. The decision must be made once all the non-restraining methods have been considered and/or attempted with no success.

• Assigned nurse, in consultation with co-nurses, may decide to use environmental restraints for a brief time period as a less intrusive method of restraint. Assigned nurse will be responsible to maintain clinical monitoring of the patient. There should be clear documentation of the reason and effects of environmental restraint. The MRP/on-call physician should be informed within 24 hours.

• Every patient requiring any kind of restraints must have documented evidence of interprofessional plan of care.

• A physician’s order must specify the type of restraint and specific behaviours requiring use of restraint.

• The ordering physician/MRP/on-call psychiatrist must assess the patient face to face within 24 hours.

• The assigned nurse must assess and document the patient’s readiness to discontinue restraints at least every hour.

9. The Restraint Policy also sets out that patients in environmental restraints must be clinically monitored as follows:

• Close observation must be maintained to monitor patient activity. Assigned nurse must continue to interact with patient explaining the reason. There must be documented evidence that patient was explained and offered alternatives to restraint.

• Patient must be offered fluids at least every 2 hours and/or as needed or requested by patient.

• Patient must be allowed to use bathroom when needed, if possible, or alternatively, must be provided with a urinal or bedpan.

10. The Restraint Policy requires that the following documentation be completed, for all mental health patients in restraints:

• Progress note indicating all interventions and strategies used to de-escalate the patient before using chemical, environmental or mechanical restraint.

• The rationale for the use of chemical, environmental or mechanical restraint.

• The type of restraint initiated with the date and time of initiation.

• Behavioural criteria and goals for discontinuation of environmental or mechanical restraint and documentation that this plan is reviewed with patient.

• Record the patient’s perspective on behaviour leading to the use of least restraint.

• Review any relevant medical problems and the presence of any physical limitations.

• Notification and subsequent discussions with the patient or substitute decision maker and family regarding the need for restraint or seclusion and their response to their use.

• Information provided to patient/family members/substitute decision maker about types and purpose of use of restraints.

• The patient’s response to the use of the restraint, therapeutic support and counselling interventions.

• De-restraining assessments and interventions to be documented every two hours.

• Least restraints observation nursing record will be completed for all Mental Health Patients in environmental or mechanical restraints.

• Assigned nurse must continue to interact with patient explaining the reason. There must be documented evidence that patient was explained and offered alternatives to restraint.

The Facility’s Observation Policy

11. The Facility’s Levels of Observation for Mental Health Patients policy (the “Observation Policy”), in force at the time of the incidents, lists four levels of observation: routine observation, close observation, continuous observation, and constant observation.

12. The Observation Policy states that “routine observation” is the minimum standard for all patients. Routine observation requires “direct monitoring of the patient once per hour with documentation on the hourly rounding sheet…”

13. “Close observation” is defined as the direct monitoring of the patient once every 15 minutes with documented evidence of the patient’s location on the Periodic Observation Form. The Observation Policy states that close observation may be implemented one of four ways:

• every patient admitted to 3B or 3C mental health units, on a Form 1, is placed on close observation for the first 72 hours;

• every patient who is transferred from the PICU to 3C or 3B is placed on close observation for the first 24 hours, following which a physician’s order is required either to continue or discontinue close observation;

• a physician may order close observation for any patient at any time - the order must state the reason for close observation and a physician’s order is required to discontinue the close observation; and

• a nurse may implement close observation, provided they document the reason for the close observation and a physician’s order is not required to discontinue the close observation.

14. “Continuous observation” is defined as one-to-one monitoring of one patient by one nurse.

15. “Constant observation” is defined as increased observation for patients in the PICU.

16. The Unit’s nursing station has one large monitor on which surveillance feeds from patient rooms can be viewed as part of a grid. The screens are small, and nurses could not view patients unless they were close to the screens. Reviewing CCTV footage is not a replacement for physical rounding and does not provide adequate supervision to constitute “direct monitoring”.

THE PATIENT

17. The Patient was an 85-year-old man who had recently been admitted to the Facility for a psychiatric assessment after exhibiting symptoms of dementia.

18. On November 14, 2021, the following was documented in the Patient’s chart: “continue to redirect and use the least restraint policy, i.e.: attempt to manage wandering with redirection. May require PICU if this proves too challenging.”

19. On the night shift of November 29-30, 2021, the Member was assigned to provide care to the Patient. The Patient did not have any restraint orders on or before the Member’s shift on November 29-30, 2021.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

20. Beginning at around 1930 on November 29, 2021, the Patient began wandering the hallway immediately outside of his room, which was directly across from the nursing station. He occasionally interacted with other patients, who were also in the hallway outside the nursing station. He was not agitated or aggressive.

21. At 1930, the Member documented receiving transfer of accountability of the Patient. The Member also documented conducting an extensive assessment of the patient, including suicidality, skin integrity, and continence, among other things.

22. At 2013, the Member entered a note which read: “TOA accepted at 1930hr, patient walking around the [unit], calm and cooperative, patient said he had a good day. No concerned [sic], alert to person.”

23. At 2200, the Member documented that the Patient was walking around the Unit, socializing, ate a snack, and was compliant with medication. The Member noted she would continue to monitor.

24. At 2201, the Member administered medications to the Patient in his room. At about 2208, the Member left the Patient’s room, closing the door behind her. She entered the nursing station and obtained the key for the Patient’s room. She returned to the door to the Patient’s room, locking it, with the Patient inside.

25. The Patient was environmentally restrained to his room for approximately 9 hours. Over the course of his confinement in his room, the Patient can be seen on video surveillance approaching the door on numerous occasions. The Patient periodically slept throughout the night, although he had periods of wakefulness as well.

26. The Member environmentally restrained the Patient when it was not necessary to do so and used a restraint that was not the least restraint required. The Member also failed to document the environmental restraint and failed to document a reason for applying the environmental restraint.

27. While the Patient was environmentally restrained, the Member failed to conduct adequate monitoring, observation and assessments of the Patient. The Member also failed to document and/or accurately document the limited monitoring, observation and/or assessments she conducted while the Patient was restrained as detailed below.

28. The Member’s next documentation was at 0305. The Member documented that the Patient had slept between midnight and 0300 and that he was now awake, walking in his room, when “writer did q15 round.” At around this time, the Member walked by the Patient’s room and glanced towards his door. She did not approach his door or otherwise directly monitor the Patient.

29. During the course of the Patient’s confinement in his room, the Member approached the door to his room on only two occasions, shortly after locking the door to his room at 2201 and then again at around 0620 the following morning.

30. Throughout the night, the Member spent the majority of her time in the nursing station or on break. The Member did not directly monitor the Patient from the nursing station. If the Member were to testify, she would state that she did monitor the Patient through CCTV footage visible at the nursing station, although the Member admits that this does not constitute direct monitoring.

31. At 0650, the Member documented that the Patient had slept for another 4 hours and was currently awake although the Member did not directly monitor the Patient at or around that time.

32. On the morning of November 30, 2021, the Member’s supervisor arrived early on the Unit. As the Member’s supervisor walked the Unit, he observed that the Patient was locked in his room. This commenced the Facility’s investigation of the Member’s restraint of the Patient.

33. The monitoring sheets, “Periodic Observation Record”, which were completed by hand, indicate that the majority of the Q15 checks were completed by the Member’s colleagues throughout her shift. The Member documented having completed Q15 checks on the “Periodic Observation Record” on three occasions throughout her shift, at 2100 to 2200 hrs, 2345 hrs to 0030 hrs, and 0445 hrs to 0730 hrs. However, the Member did not complete any of these checks by direct observation as documented or required by the Observation Policy.

CNO STANDARDS

Code of Conduct

34. 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 pertaining to respecting the dignity of patients and treat them as individuals, working together to promote patient well-being, maintaining patients’ trust by providing safe and competent care, working respectfully with colleagues to best meet patients’ needs, acting with integrity to maintain patients’ trust and maintaining public confidence in the nursing profession.

35. CNO’s Code of Conduct 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.

36. CNO’s Code of Conduct further provides, in relation to the principle requiring nurses to maintain patients’ trust by providing safe and competent care, that nurses:

• recognize and work within the limits of their knowledge, skill and judgment and their legal scope of practice;

• seek advice and collaborate with the health care team to uphold safe patient care;

• maintain complete, accurate and timely documentation in their practice; and

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

37. CNO’s Code of Conduct also 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.

38. Attached as Exhibit “A” is a copy of CNO’s Code of Conduct that was in force at the time of the incidents.

Professional Standards

39. 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 pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership and relationships.

40. 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:

• providing, facilitating, advocating and promoting the best possible care for [patients];

• advocating on behalf of [patients];

• seeking assistance appropriately and in a timely manner;

• ensuring practice is consistent with CNO’s standards of practice and guidelines as well as legislation; and

• taking action in situations in which [patient] safety and well-being are compromised.

41. CNO’s Professional Standards further provides, in relation to the knowledge application standard, nurses demonstrate this standard by actions such as recognizing limits of practice and consulting appropriately.

42. In addition, CNO’s Professional Standards provides, in relation to the leadership standard, that all nurses, regardless of their position have opportunities for leadership. Nurses demonstrate this standard by actions such as:

• role-modelling professional values, beliefs and attributes; and

• collaborating with [patients] and the health care team to provide professional practice that respects the rights of [patients].

43. CNO’s Professional Standards also provides, in relation to the relationship standard and the therapeutic nurse-patient relationship, that nurses demonstrate this standard by demonstrating respect and empathy for, and interest in patients and recognizing the potential for patient abuse.

44. Attached as Exhibit “B” is a copy of CNO’s Professional Standards that was in force at the time of the incidents and has since been retired.

Therapeutic Nurse-Client Relationship

45. 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.

46. The TNCR Standard further provides that at the core of nursing is the therapeutic nurse-patient relationship and nurses establish and maintain this key relationship by using nursing knowledge and skills, as well as applying caring attitudes and behaviours.

47. The TNCR Standard provides, in relation to patient-centred care, that nurses work with the patient to ensure that all professional behaviours and actions meet the therapeutic needs of the patient. Nurses meet the standard by:

• gaining an understanding of the [patient’s] abilities, limitations and needs related to his/her health condition and the [patient’s] needs for nursing care or services; and

• recognizing that the [patient’s] well-being is affected by the nurse’s ability to effectively establish and maintain a therapeutic relationship.

48. Attached as Exhibit “C” is a copy of CNO’s TNCR Standard that was in force at the time of the incidents.

Documentation

49. CNO’s Documentation Standard includes three standard statements and indicators pertaining to communication, accountability and security.

50. CNO’s Documentation standard provides in relation to communication, that nurses ensure that documentation presents an accurate, clear and comprehensive picture of the patient’s needs, the nurse’s interventions and the patient’s outcomes. Nurses meet the standard by actions such as ensuring documentation is a complete record of nursing care provided and reflects all aspects of the nursing process, including assessment, planning, intervention (independent and collaborative) and evaluation.

51. CNO’s Documentation standard further provides, in relation to accountability, that nurses are accountable for ensuring their documentation of patient care is accurate, timely and complete. Nurses meet the standards by actions such as:

• documenting in a timely manner and completing documentation during, or as soon as possible after, the care or event; and

• documenting the date and time that care was provided and when it was recorded.

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

Decisions About Procedures and Authority

53. CNO’s Decisions About Procedures and Authority Standard outlines the expectations of nurses when determining if they have the authority to perform a procedure, if it is appropriate for them to perform a particular procedure, and if they are competent to perform the procedure. CNO’s Decisions About Procedures and Authority Standard indicates that a procedure, for the purpose of the standard, includes controlled acts and non-controlled act procedures, as well as actions, activities and/or measures that nurses use in the course of providing patient care.

54. CNO’s Decisions About Procedures and Authority Standard includes four standards statements pertaining to appropriate healthcare provider, authority, competence and managing outcomes.

55. CNO’s Decisions About Procedures and Authority Standard provides, in relation to the appropriate healthcare provider standard, that nurses must consider each situation to determine if the performance of a particular action or measure promotes safe patient care, and if it is appropriate for a nurse to perform. Nurses meet this standard by:

• ensuring that the rationale for taking the action or measure is based on achieving the best outcomes for the [patient];

• determining whether the action or measure fits within a professional nursing role (e.g., requires nursing assessment, health teaching, counselling, discharge planning); and

• ensuring that practice setting policies support the nurse in taking the action or measure.

56. CNO’s Decisions About Procedures and Authority Standard further provides, in relation to the authority standard, that nurses ensure they have the proper authority before taking actions or measures. Nurses meet the standard by:

• knowing the scope of practice of nursing, the legislated authority and what the practice setting has approved as a nurse’s role and responsibilities;

• knowing when specific direction for [patient] care is required in the form of orders, directives, protocols or recommendations;

• obtaining direct [patient] orders or implementing directives appropriately; and

• ensuring that [patient] records reflect the actions or measures that were taken.

57. CNO’s Decisions About Procedures and Authority Standard also provides, in relation to the competence standard, that nurses ensure that they are competent in both the cognitive and technical aspects of an action or measure prior to taking it. Nurses meet this standard by:

• determining the appropriateness of the action or measure for the specific client in a specific situation; and

• communicating with other health care team members as necessary for safe, effective and ethical [patient] care.

58. Attached as Exhibit “E” is a copy of CNO’s Decisions About Procedures and Authority Standard that was in force at the time of the incidents.

Contravention of CNO Standards

59. The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards, TNCR Standard and Decisions about Procedures and Authority Standard when she:

• environmentally restrained the Patient when it was not necessary to do so and used a restraint that was not the least restraint required;

• environmentally restrained the Patient without having obtained a physician’s order to do so; and

• failed to conduct adequate monitoring, observation, and/or assessments of the Patient while he was environmentally restrained.

60. The Member further admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards, Documentation Standard and Decisions about Procedures and Authority Standard when she:

• failed to document the environmental restraint of the Patient and failed to document a reason for the environmental restraint of the Patient; and

• failed to document and/or accurately document her monitoring, observation and/or assessments of the Patient while he was environmentally restrained.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

61. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1 (a), (b), (c), (d) and (e) 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 to 60 above.

62. 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 4 to 33, 36, 40, 49 to 52, 56, and 60 above.

63. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3 (a), (b), (c), (d) and (e) of the Notice of Hearing, and in particular her conduct was dishonourable and unprofessional, as described in paragraphs 4 to 60 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) - (e), 2(a) - (b), 3(a) - (e) of the Notice of Hearing. As to allegations 3(a), (b), (c), (d), (e), 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), (b), (c), (d) and (e) in the Notice of Hearing, which relate to the Member’s contravention of standards, are supported by paragraphs 4 - 61 in the Agreed Statement of Facts. During the night shift of November 29-30, 2021, the Member cared for an 85-year-old patient with dementia. Early in the shift, the Patient was noted as wandering the hall but was calm, cooperative and showed no indication of being a risk. Despite this, the Member locked the Patient in his room for about nine hours overnight without physician’s orders or documentation of rationale. The Member also failed to monitor or check on the Patient adequately during this period. The Member violated the Patient’s trust to be cared for competently, respectfully, with care and compassion and without abusing her power as a caregiver. The Member did not document the restraint or the rationale for restraining the Patient in his room. The Member also failed to appropriately monitor, assess and accurately document care for the Patient overnight. The Member’s conduct breached the Facility’s restraint policies as well as the College’s Code of Conduct, the Professional Standards, the TNCR Standard, the Documentation Standard and the Decisions About Procedures and Authority Standard.

Allegations #2(a) and (b) in the Notice of Hearing, which relate to a failure to keep required records, are supported by paragraphs 4 - 33, 36, 40, 49-52, 56, 60 and 62 in the Agreed Statement of Facts. The Member did not document the Patient’s environmental restraint nor a rationale for it. Additionally, the Member did not document and did not accurately document the monitoring, observation, or assessment of the Patient as required. The Member recorded that q15 checks were performed, but these were not conducted through direct observation as required by the Facility Observation policy.

Allegations #3(a), (b), (c), (d) and (e), which relate to the Member engaging in conduct that would reasonably be regarded as disgraceful, dishonourable or unprofessional, are supported by paragraphs 4 - 60 and 63 in the Agreed Statement of Facts. The Panel finds that restraining a calm and cooperative patient for nine hours without proper clinical justification was relevant to the practice of nursing and was unprofessional, as it demonstrated a serious and persistent disregard for the Member’s professional obligations. The restraint was neither necessary nor minimal. Additionally, the Member left the Patient unattended for about 9 hours. The Panel also finds the Member's conduct was dishonourable, demonstrating an element of dishonesty and deceit. She falsely documented 'q15 round' checks, demonstrating an element of moral failing. The Member knew or ought to have known that her conduct was unacceptable and fell well below the standards of a professional.

Penalty

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

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 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,

2. Therapeutic Nurse-Client Relationship,

3. Documentation,

4. Scope of Practice, and

5. Understanding Restraints: https://cno.org/standards-learning/educational-tools/understanding-restraints;

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 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.

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

College Submissions on Penalty

College Counsel submitted that the proposed penalty is appropriate as it meets the overarching goals of penalty, it reflects both aggravating and mitigating factors in the case and is consistent with prior decisions of this Discipline Committee.

The proposed penalty would specifically deter this Member from engaging in this kind of conduct again through the reprimand, which will signal disapproval of the conduct. The suspension will deter this Member and other members of the profession from engaging in this type of conduct because it will signal that conduct of this nature is not acceptable and will be dealt with seriously. The proposed terms, conditions and limitations on the Member’s certificate of registration will rehabilitate the Member by providing her with an opportunity to learn and reflect and will also protect the public.

The aggravating factors in this case were:

• The Patient was an extremely vulnerable, elderly man who was also showing signs of dementia;

• Failing to directly monitor a patient experiencing dementia for approximately nine hours posed a significant risk to the Patient; and

• The Member’s conduct showed a fundamental breach of trust and disrespect for the Patient and his right to have some agency oversee his care.

The mitigating factors in this case were:

• The Member has no prior disciplinary history with the College;

• The Member has cooperated with the College throughout the proceedings and by agreeing to the resolution has helped the College preserve resources, avoiding a contested hearing; and

• The Member has expressed remorse, taken accountability and shown insight into her conduct.

Counsel submitted the following cases to the Panel, which demonstrate that the proposed penalty falls within the range of similar cases from this Discipline Committee: CNO v Paraon (2022 135822 (ON CNO)), CNO v. Mollanedjad (2021 154456 (ON CNO)), and CNO v. Farah (2021 120364 (ON CNO)).

Member’s Submissions on Penalty

The Member’s Counsel made submissions in agreement 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 the three-month suspension of the Member's certificate of registration as well as the terms, conditions and limitations on the Member's certificate. This sends a clear message to the profession and the public that conduct of this nature is unacceptable and will be viewed seriously.

The proposed penalty provides for specific deterrence through the three-month suspension of the Member's certificate of registration. This will demonstrate to the Member that her conduct is not acceptable. Additionally, the oral reprimand will help the Member gain insight about how her conduct is viewed by nursing colleagues and the public, emphasizing its inappropriateness and the serious consequences that can result.

The proposed penalty provides for remediation and rehabilitation through the two meetings with a Regulatory Expert and the review of the College's publications. These requirements will help the Member reflect and learn, deepening her understanding of her misconduct to ensure that this conduct is not repeated.

Overall, the public is protected through the 12 months of employer notification which will provide additional oversight on the Member’s practice.

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

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

I, Tanya Dion, 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.