College of Nurses of Ontario v. Sanqui-Penaflor, 2025 ONCNO 82642

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Sherry Szucsko-Bedard, RN Chairperson Jane Hess, RN Member Sandra Larmour Public Member Ahamad Mohammed, RPN Member Patricia Pilon Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) JEFFREY FEINER for ) College of Nurses of Ontario

• and - ) MARIBEL SANQUI-PENAFLOR ) CARINA LENTSCH for Registration No. 08335438 ) Maribel Sanqui-Penaflor ) ELYSE SUNSHINE ) Independent Legal Counsel ) Heard: June 2, 2025 ) via videoconference

DECISION AND REASONS

Publication Ban

By Order of the Discipline Panel dated June 2, 2025 pursuant to subsection s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, no one shall publish or broadcast the name of the patient, or any information that could disclose their identity referred to orally or in any documents presented at the Discipline hearing of Maribel Sanqui-Penaflor.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on June 2, 2025.

The Allegations

The allegations against Maribel Sanqui-Penaflor (the “Member”) as stated in the Notice of Hearing dated April 25, 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 while you were employed as a Registered Nurse at Waypoint Centre for Mental Health in Penetanguishene, Ontario (the “Facility”), you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to the following incidents:

a. On or about September 13, 2022, with respect to Patient 1:

i. You disregarded an order that Patient 1, who had tested positive for COVID-19 and was symptomatic, be permitted to rest in her room;

ii. You engaged in an improper and/or unnecessary verbal and physical altercation with Patient 1 when you said words to the effect of:

1. “This is ridiculous”;

2. “Get up”;

3. “You are lazy”;

4. “I can’t believe you ate in your bedroom”; and/or

5. “If you want [a] snack you need to get up, no way you are eating in your room, no one eats in their room, get up”;

iii. You complained within the presence of Patient 1 and at least once Facility colleague that you had “wasted [your efforts] for the past two years” as a result of Patient 1 not getting out of bed;

iv. You removed Patient 1’s blanket from her bed in an aggressive manner;

v. On one or more occasions, you pulled Patient 1 by the leg, turned her body, and aggressively pulled on her leg in an attempt to remove her from her bed; and/or

vi. You tipped Patient 1’s mattress in an attempt to rouse her from her bed.

2. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(7) of Ontario Regulation 799/93, in that while you were employed as a Registered Nurse at the Facility, you verbally, physically, and/or emotionally abused a patient with respect to the following incident:

a. On or about September 13, 2022, with respect to Patient 1:

i. You engaged in an improper and/or unnecessary verbal and physical altercation with Patient 1 when you said words to the effect of:

1. “This is ridiculous”;

2. “Get up”;

3. “You are lazy”;

4. “I can’t believe you ate in your bedroom”; and/or

5. “If you want [a] snack you need to get up, no way you are eating in your room, no one eats in their room, get up”;

ii. You complained within the presence of Patient 1 and at least one Facility colleague that you had “wasted [your efforts] for the past two years” as a result of Patient 1 not getting out of bed;

iii. You removed Patient 1’s blanket from her bed in an aggressive manner;

iv. On one or more occasions, you pulled Patient 1 by the leg, turned her body, and aggressively pulled on her leg in an attempt to remove her from her bed; and/or

v. You tipped Patient 1’s mattress in an attempt to rouse her from her bed.

3. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that while you were employed as a Registered Nurse at the Facility, 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 with respect to the following incidents:

a. On or about September 13, 2022, with respect to Patient 1:

i. You disregarded an order that Patient 1, who had tested positive for COVID-19 and was symptomatic, be permitted to rest in her room;

ii. You engaged in an improper and/or unnecessary verbal and physical altercation with Patient 1 when you said words to the effect of:

1. “This is ridiculous”;

2. “Get up”;

3. “You are lazy”;

4. “I can’t believe you ate in your bedroom”; and/or

5. “If you want [a] snack you need to get up, no way you are eating in your room, no one eats in their room, get up”;

iii. You complained within the presence of Patient 1 and at least one Facility colleague that you had “wasted [your efforts] for the past two years” as a result of Patient 1 not getting out of bed;

iv. You removed Patient 1’s blanket from her bed in an aggressive manner;

v. On one or more occasions, you pulled Patient 1 by the leg, turned her body, and aggressively pulled on her leg in an attempt to remove her from her bed; and/or

vi. You tipped Patient 1’s mattress in an attempt to rouse her from her bed.

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a)(i) – (vi), 2(a)(i) – (v), and 3(a)(i) – (vi) 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 the exhibits referenced therein, as follows:

THE MEMBER

1. Maribel Sanqui-Penaflor (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse (“RN”) on July 20, 2004.

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

THE FACILITY

3. The Member was employed as a full-time RN in the Bayview Program for Dual Diagnosis (the “Bayview Program” or “Unit”) at the Waypoint Centre for Mental Health Care in Penetanguishene, Ontario (the “Facility”) at the time of the incidents described below.

4. The Facility is a 315-bed specialty mental health hospital that provides a range of acute and long-term psychiatric inpatient and outpatient services.

5. The Bayview Program is an inpatient program that is a specialty care program that provides services to up to 20 inpatients with developmental disability and mental health care needs. The Bayview Program includes a locked unit called the Extra Care Area (the “ECA”) that is designated for patients who exhibit aggressive behaviours. Patients of the Unit who require 1:1 level care have a designated primary nurse assigned to them.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Patient 1

6. The incidents occurred during the evening shift of September 13, 2022, while the Member was providing nursing care to Patient 1.

7. Patient 1 was [ ] years old at the relevant time. She has a severe intellectual disability and autism, is non-verbal and blind as a result of her history of engaging in severe self-injurious behaviours (SIB). Patient 1 was also known to engage in other problematic behaviours, including compulsive ritualistic behaviours of varying patterns and screaming.

8. Patient 1 was initially admitted to the Facility in January 2020. She was transferred to the Bayview Program in February 2020, where she was initially placed in the ECA and required the use of a helmet and Pinel restraints to protect her from self-harm.

9. The Member was first assigned as Patient 1’s primary nurse in or around March 2020. The Member provided ongoing 1:1 nursing care to Patient 1 throughout her stay in the ECA.

10. Patient 1 successfully transitioned out of Pinel restraints by early April 2021. Thereafter, Patient 1 no longer required the use of hard restraints and was moved into the regular inpatient area on the Unit.

11. At the time of the incidents, Patient 1 received 1:1 nursing care throughout the day shift and 2:1 care during the night shift, and the Member continued to provide nursing care to Patient 1 as assigned.

Recovery Plan of Care

12. While on the Unit, Patient 1 was supported with therapeutic and behavioural supports aimed to enable her to achieve the term goal of being discharged to the community with appropriate supports in place. Patient 1 had a schedule of activities during the day, including getting up, using the bathroom, eating breakfast, doing exercises, such as going on daily walks before mealtimes. Patient 1 was prompted and encouraged to but not forced to engage in these activities.

13. Patient 1 had a Recovery Plan of Care (RPOC) in place that was updated from time-to-time, which defined the therapeutic goals for the patient and described the behavioural interventions to achieve those goals, including for example, encouraging Patient 1 to be physically active and awake, and taking her for walks before each meal, at least twice a day.

14. When engaging with Patient 1 for her daily routine, staff were to use several prompts to cue the patient that it is time to get up and go for a walk. Prompts included turning on the lights, removing the blanket, and verbally cueing the patient to go on a “walk first” before a meal, without using any punitive words, threats or force.

15. Staff were not to physically assist Patient 1 to get up when prompting her to take walks – only verbal cues were to be relied upon.

16. The RPOC also emphasized the importance of not rushing Patient 1 in a transition and allowing the patient time to process the request and comply on her own time.

COVID-19 Outbreak

17. In or around August 2022, the Facility experienced an outbreak of COVID-19. As a result, the daily routine of outside walks for Patient 1 were put on hold. Patient 1 started presenting with symptoms of COVID-19 on September 5, 2022, and was placed on isolation in accordance with IPAC directions.

18. On September 9, 2022, Program staff were notified that the Facility was no longer required to seclude patients due to COVID-19 symptoms or positive results. However, for all patients that were either symptomatic or had tested positive for COVID-19, staff were instructed to attempt to have the patients isolate in their rooms, which included providing meals to them in their rooms. Patient 1 remained symptomatic for COVID-19, but had not yet tested positive, and was no longer required to remain in isolation.

Incidents of September 13, 2022

19. On September 13, 2022, the Member attended for her scheduled night shift on the Unit starting at 19:00hrs and was assigned to Patient 1.

20. At the beginning of her shift, the Member received a report from the charge nurse and was informed that Patient 1 had tested positive for COVID-19, there was a change to her routine, and the physician made an order allowing Patient 1 to rest in her room as the patient was symptomatic.

21. Prior to the Member’s arrival on the Unit, Patient 1 had been resting in her room since after her afternoon snack and had accepted supper in her room, despite being encouraged to attend the dining area.

22. After speaking to the charge nurse, the Member attended the patient’s room and assumed responsibility for Patient 1 from Colleague A, the Registered Practical Nurse (“RPN”) assigned to Patient 1 prior to the Member’s shift.

23. Colleague B, a Personal Care Attendant (“PCA”) who was working on the Unit at the time and seated in the hallway across from Patient 1’s room, observed the following incidents:

a. Upon arriving at Patient 1’s room, the Member was visibly upset, saying “this is ridiculous” and went over and turned on the light in Patient 1’s room and stood in the doorway and yelled “get up, you are lazy I cannot believe you ate in your bedroom” or words to that effect;

b. The Member then walked over and ripped Patient 1’s blanket off the patient and yelling loudly “get up”, grabbed the patient by the leg, turned her body, and tipped her mattress in an attempt to remove her from the bed. Patient 1 started coming off the mattress and started screaming and crying “no, no, no”;

c. The Member then left Patient 1’s bedside, returned to the doorway, and stated “I am not wasting the past two years” or words to that effect; and

d. While at the wow computer near the door, the Member yelled at Patient 1 who was sitting up on her bed “if you want [a] snack you need to get up, no way you are eating in your room, no one eats in their room, get up” or words to that effect.

24. Colleague B perceived the Member’s actions towards Patient 1 as rude and forceful and her tone of voice as inappropriate.

25. Colleague A also overheard and observed the Member’s interactions with Patient 1 and felt that the Member’s tone of voice and actions were not right, and “not therapeutic”.

26. If the Member were to testify, she would say that she acknowledges that her tone of voice came across as aggressive and inappropriate. She would say that while she does not recall certain things about the incident, such as calling the Patient “lazy” or stating “no way you are eating in your room; no one eats in their room, get up”, she acknowledges that any shaming or judgmental language of this nature is inappropriate for a nurse to use when speaking to a patient.

27. If the Member were to testify, she would further say in regard to her removing Patient 1’s blanket covering from the bed, that while this was an acceptable cue to use and part of the normal routine for Patient 1 as per the RPOC, she acknowledges that she did so in an unacceptably abrupt or rough manner.

28. If the Member were to testify, she would further say that she does not recall engaging with Patient 1 in the aggressive manner as described by Colleague B; however, she acknowledges that physically sliding or pulling the patient’s legs or moving the patient out of her bed, tipping the patient’s mattress, or using physical force in any way to prompt Patient 1 to get out of bed, was contrary to the RPOC, and inappropriate and unacceptable conduct.

29. If the Member were to testify, she would further say that she also acknowledges that it was not acceptable for her to complain in the presence of Patient 1 about “wasting the past two years” in reference to Patient 1’s progress while staying at the Facility.

30. If the Member were to testify, she would further say that, as the primary nurse to Patient 1 for over two years, she witnessed Patient 1 progress and greatly benefit from the consistent therapeutic routine of going on daily walks before a meal. She would say that, on September 13, 2022, she was concerned about the length of time that Patient 1 had been isolated during the Facility’s COVID-19 outbreak and the resultant interruption to her beneficial daily routines, and the Member was worried that continuing to isolate Patient 1 would cause her to regress. Nevertheless, the Member acknowledges that her conduct was inappropriate in the circumstances.

31. If the Member were to testify, she would say that the incident was an isolated lapse on her part and not reflective of her typical nursing practice or interaction with patients. She would say that she has reflected on the circumstances that led to her lapse, including: feeling heightened emotions at the start of her shift on September 13, 2022; being fatigued after having worked many long hours and overtime shifts during the Facility’s COVID-19 outbreak; and experiencing a particularly difficult time in her personal life because she was grieving the anticipated loss of a close family member suffering from terminal illness.

32. If the Member were to testify, she would also say that her reflections are neither intended, nor to be understood as an excuse for her unacceptable conduct, for which she takes full accountability as a nurse and Member of CNO, and which she deeply and sincerely regrets and apologizes for.

CNO STANDARDS OF PRACTICE

Code of Conduct

33. 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.

34. CNO’s Code of Conduct further provides, in relation to the principle requiring nurses to respect the dignity of patients, that nurses: treat patients with care and compassion; take steps to maintain patients’ dignity in the physical space where they are receiving care; and listen and collaborate with patients and any person the patients want involved in their care.

35. CNO’s Code of Conduct further provides, in relation to the principle requiring nurses to work together to promote patient well-being, that nurses show respect for patients’ rights and involve patients in making care decisions.

36. 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.

37. Attached as Exhibit “A” is a copy of CNO’s Code of Conduct in force at the time of the incident.

Professional Standards

38. 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.

39. 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.

40. CNO’s Professional Standards further provides, in relation to the ethics standard, that ethical nursing means promoting the values of client well-being, and respecting client choice.

41. CNO’s Professional Standards further provides, in relation to the relationships standard, that nurses are expected to establish and maintain respectful, collaborative, therapeutic and professional relationships. Nurses establish and maintain the therapeutic nurse-patient relationship by, among other actions:

• demonstrating respect and empathy for, and interest in patients;

• maintaining boundaries between professional therapeutic relationships and non-professional personal relationships;

• ensuring patient’s needs remain the focus of nurse-patient relationships;

• recognizing the potential for patient abuse; and

• preventing abuse when possible.

42. Attached as Exhibit “B” is a copy of CNO’s Professional Standards in force at the time of the incident.

Therapeutic Nurse-Client Relationship Standard

43. 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.

44. CNO’s TNCR Standard defines abuse as the misuse of the power imbalance intrinsic to the nurse-patient relationship. It can also mean the nurse betraying the patient’s trust, or violating the respect or professional intimacy inherent in the relationship, when the nurse knew, or ought to have known, the action could cause, or could be reasonably expected to cause, physical, emotional or spiritual harm to the patient. The intent of the nurse does not justify a misuse of power within the nurse-patient relationship.

45. CNO’s TNCR Standard requires nurses to protect the patient from harm by ensuring that abuse is prevented or stopped and reported. With respect to protecting the patient from abuse, a nurse demonstrates having met the TNCR Standard by actions such as:

• not exhibiting physical, verbal and non-verbal behaviours toward a patient that demonstrate disrespect for the patient and/or are perceived by the patient and/or others as abusive.

46. The TNCR Standard further provides that nurses meet the standard for patient-centred care by working with patients to ensure that all professional behaviour and actions meet the therapeutic needs of the patient. Nurses meet the standard by, among other actions:

• being aware of his/her verbal and non-verbal communication style and how patients might perceive it;

• 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);

• recognizing that all behaviour has meaning and seeking to understand the cause of a patient’s unusual comment, attitude or behaviour; and

• reflecting on interactions with a patient and the health care team, and investing time and effort to continually improve communication skills.

47. Attached as Exhibit “C” is a copy of CNO’s TNCR Standard in force at the time of the incident.

48. 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

49. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 1(a)(i), 1(a)(ii), 1(a)(iii), 1(a)(iv), 1(a)(v), and 1(a)(vi) 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 - 46 above.

50. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 2(a)(i), 2(a)(ii), 2(a)(iii), 2(a)(iv), and 2(a)(v) of the Notice of Hearing in that she abused Patient 1 verbally, physically, and emotionally, as described in paragraph 4 - 32 above.

51. The Member admits that she committed the acts of professional misconduct as alleged in paragraph 3(a)(i), 3(a)(ii), 3(a)(iii), 3(a)(iv), 3(a)(v), and 3(a)(vi) 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 of the profession as disgraceful, dishonourable and unprofessional, as described in paragraphs 4 - 32 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) - (vi), 2(a)(i) - (v), and 3(a)(i) - (vi) of the Notice of Hearing. The Panel finds that the Member contravened a standard of practice of the profession, engaged in verbal, physical, and emotional abuse of a patient, and that her conduct would reasonably be regarded by members of the profession as 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.

Allegation #1 in the Notice of Hearing, which relates to the Member contravening a standard of practice of the profession, is supported by paragraphs 4 - 46 and 49 of the Agreed Statement of Facts. The Member, while providing care to a highly vulnerable patient with significant cognitive and physical disabilities, used language and physical contact that were inappropriate and inconsistent with the standards of practice. These actions constituted breaches of the Code of Conduct (as set out in paragraphs 33 – 37 of the Agreed Statement of Facts), the Professional Standards (as set out in paragraphs 38 – 42 of the Agreed Statement of Facts), and the TNCR Standard (as set out in paragraphs 43 – 48 of the Agreed Statement of Facts).

The Panel found that the Member failed to meet the expectations set out in the Code of Conduct, which requires nurses to treat patients with respect and dignity, communicate effectively, and take responsibility for preventing harm. The Member’s actions undermined these principles and eroded trust in the therapeutic relationship.

The Panel further found that the Member contravened the Professional Standards, which require nurses to be accountable for their decisions and actions, demonstrate leadership, and maintain competence. By engaging in abusive behavior and neglecting the patient’s emotional and physical needs, the Member failed to uphold her professional responsibilities.

Finally, the Member breached the TNCR Standard, which emphasizes the inherent power imbalance in the nurse-client relationship and the nurse’s duty to protect the client from harm and abuse. The Panel found that the Member did not maintain appropriate boundaries, failed to advocate for the best interests of the patient, and disregarded her duty to preserve a safe, therapeutic environment.

Allegation #2, which relates to the Member’s verbal, physical and emotional abuse of Patient 1, is supported by paragraphs 4 - 32 and 50 of the Agreed Statement of Facts. The Member verbally abused the patient by using demeaning language, physically abused the patient by forcefully handling her body, and emotionally abused the patient by making belittling statements. This conduct, directed towards a patient who was nonverbal, blind and had severe intellectual disabilities, reflects a serious failure to provide compassionate, respectful, and appropriate care.

Allegation #3 is supported by paragraphs 4 - 46 and 51 of the Agreed Statement of Facts. The Panel finds that the Member's conduct was relevant to the practice of nursing as it occurred in the context of providing nursing care. The conduct was unprofessional, as it demonstrated a serious and persistent disregard for the Member’s professional obligations. The Panel also finds that the Member's conduct was dishonourable. It showed a lack of integrity, compassion, and ethical judgment, amounting to moral failing. The Member knew or ought to have known that her conduct was unacceptable and fell well below the standards expected of a nurse. The Panel further finds that the Member's conduct was disgraceful. The mistreatment of a profoundly vulnerable patient, and the fundamental betrayal of the trust inherent in the nurse-client relationship, shames the Member and brings disrepute to the profession, casting serious doubt on her moral fitness to practise.

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, and

2. Therapeutic Nurse-Client Relationship;

iv. Before the first meeting, the Member reviews and completes 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:

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;

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:

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;

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 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 was appropriate given the seriousness of the misconduct. Aggravating factors included the vulnerability of the patient and the seriousness of the conduct, the emotional and physical nature of the abuse, the discredit the Member's actions brought to the profession and the extent to which the Member disregarded her professional obligations. Mitigating factors included that the Member had no prior disciplinary history, her cooperation with the College, her early admissions to the misconduct, her expressed remorse for her actions and her acceptance of responsibility for her conduct. College Counsel submitted that the penalty achieves specific and general deterrence, supports remediation and rehabilitation, and ensures public protection.

College Counsel submitted the following cases to the Panel to demonstrate that the proposed penalty falls within the range of similar cases from this Discipline Committee.

In CNO v. Hope (Discipline Committee, 2021): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member engaged in dismissive conduct toward a patient’s complaint and used animated, inappropriate language and handled the patient roughly. The panel found that this conduct contravened standards of practice, constituted abuse and was disgraceful, dishonourable and unprofessional. The panel imposed an oral reprimand, a three-month suspension, and terms, conditions and limitations which included an 18-month period of employer notification. The case highlighted the importance of appropriate communication and physical handling of patients, particularly those who are vulnerable. The penalty reflected the need for both deterrence and rehabilitation for this kind of conduct, as well as oversight upon return to practice.

In CNO v. Agustin (Discipline Committee, 2021): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member raised her voice in an aggressive manner, used demeaning language referencing the patient's soiled condition, and struck the patient with a slipper. The patient was an elderly client with dementia. The panel found that the member’s conduct contravened standards of practice, constituted physical and verbal abuse, and was dishonourable and unprofessional. The panel imposed an oral reprimand, a four-month suspension, two meetings with a regulatory expert, and an 18-month period of employer notification. This case demonstrated that even isolated but serious lapses in conduct involving highly vulnerable patients warrant significant regulatory response, including reflection and employer monitoring.

In CNO v. Gibson (Discipline Committee, 2014): This case proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. The member failed to respond to a patient alarm in a timely manner, handled the patient roughly, and used a raised voice when addressing an elderly patient with dementia. The panel found that the conduct contravened standards of practice, was abusive and was dishonourable and unprofessional. The panel found the conduct demonstrated a lack of professional judgment and accountability. The penalty imposed was an oral reprimand, a three-month suspension, three expert meetings with a nursing expert, and a 12-month employer notification requirement. This case reinforced the practice standards for vulnerable patients and the importance of accountability in clinical settings.

College Counsel submitted that the present case similarly involves an isolated incident with a single, highly vulnerable patient and conduct that was clearly abusive. The proposed penalty mirrors those imposed in the decisions submitted to the Panel, considering the Member’s cooperation, insight, and absence of prior discipline history, while also ensuring accountability and protection of the public. The penalty is fair, proportionate, and consistent with the range of outcomes in similar matters.

Member’s Submissions on Penalty

The Member's Counsel agreed with the College's submissions. She emphasized that the Member has accepted full responsibility for her actions, expressed sincere remorse, and has already experienced significant consequences including loss of employment and an interim suspension of her certificate of registration lasting over two years. The Member was deeply affected by the incident and has reflected seriously on her conduct and its impact. Counsel submitted that the Member is committed to rehabilitation and a return to ethical, safe nursing practice.

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 College’s ability to regulate the nursing profession and is consistent with penalties imposed in similar cases.

The proposed penalty achieves general deterrence through the Member’s suspension, which signals to the profession that abuse of vulnerable patients will not be tolerated. It achieves specific deterrence through the Member’s suspension and the oral reprimand. The oral reprimand will assist the Member in understanding how her actions are perceived by the profession and public. Remediation and rehabilitation are addressed through the educational requirements and expert-led reflection, which support the Member’s insight into her conduct and professional growth. Public protection is ensured by the 12-month employer notification requirement and oversight.

The Panel acknowledges the Member’s cooperation with the College and her acceptance of responsibility as a mitigating factor. The penalty is in line with the range of what has been ordered in previous similar cases.

I, Sherry Szucsko-Bedard, 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.