College of Nurses of Ontario v. Yun Shen, 2026 CanLII 50887

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Grace Fox, NP Chairperson Sam Jennings, RPN Member Sherry Szucsko-Bedard, RN Member Shari Wilson Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO Denise Cooney for College of Nurses of Ontario

• and -

YUN SHEN Registration No. 21432200 Jonah Arnold for Yun Shen Elyse Sunshine, Independent Legal Counsel

Heard: January 7, 2026 via videoconference

DECISION AND REASONS

Publication Ban

By Order of the Discipline Panel dated January 7, 2026, 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 Yun Shen.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on January 7, 2026.

The Allegations

College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs 1(b)(i), 2(a) and 3(b)(i) of the Notice of Hearing dated December 9, 2025. The Panel granted this request. The remaining allegations against Yun Shen (the “Member”) 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 practicing as a Registered Nurse at Luxe Beaute Clinic in Vaughan Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, in that:

a) you performed the controlled act of administration of substances by injection without authorizing mechanisms with respect to the patients set out at Appendix A;

b) you maintained inadequate documentation with respect to the care you provided to patients as set out at Appendix A, including but not limited to following:

i. [Withdrawn]; and/or

ii. you did not ensure the documentation was a complete record of nursing care provided to each patient; and/or

c) you used products not licensed by Health Canada on patients at the Clinic and/or failed to ensure that you used products licensed by Health Canada on patients at the Clinic, and in particular:

i. you used HYACorp with respect to Patient B on or around July 17, 2022;

ii. you used BioSun PDO Threads with respect to Patient E on or around July 17, 2022.

2. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(13) of Ontario Regulation 799/93, in that, while practicing as a Registered Nurse at Luxe Beaute Clinic in Vaughan Ontario, you failed to keep records as required with respect to patients as set out in Appendix A, including but not limited to the following:

a) [Withdrawn]; and/or

b) you did not ensure the documentation was a complete record of nursing care provided to each patient.

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 practicing as a Registered Nurse at Luxe Beaute Clinic in Vaughan Ontario, you engaged in conduct relevant to the practice of nursing that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional, as follows:

a) you performed the controlled act of administration of substances by injection without authorizing mechanisms with respect to the patients set out at Appendix A;

b) you maintained inadequate documentation with respect to the care you provided to patients as set out at Appendix A, including but not limited to following:

i. [Withdrawn]; and/or

ii. you did not ensure the documentation was a complete record of nursing care provided to each patient; and/or

c) you used products not licensed by Health Canada on patients at the Clinic and/or failed to ensure that you used products licensed by Health Canada on patients at the Clinic, and in particular:

i. you used HYACorp with respect to Patient B on or around July 17, 2022;

ii. you used BioSun PDO Threads with respect to Patient E on or around July 17, 2022.

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(1) of Ontario Regulation 799/93, in that while practicing as a Registered Nurse at Elixir Beauty Clinic in Ottawa, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, in that:

a) you maintained inadequate documentation with respect to the care you provided to [Patient F] on October 16, 2024, and in particular you failed to document the authorizing mechanism you relied on in performing the controlled act of administration of substances by injection on [Patient F];

b) you provided inadequate care to [Patient F] on October 16, 2024, including but not limited to:

i. you did not explain the risks and benefits of the procedures performed; and/or

ii. you failed to obtain informed consent from [Patient F]; and/or

c) you used a product not licensed by Health Canada on [Patient F] on October 16, 2024, and in particular you used BioSun PDO Threads on [Patient F].

5. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(13) of Ontario Regulation 799/93, in that, while practicing as a Registered Nurse at Elixir Beauty Clinic in Ottawa, Ontario, you failed to keep records as required with respect to [Patient F] on October 16, 2024, and in particular you failed to document the authorizing mechanism you relied on in performing the controlled act of administration of substances by injection on [Patient F].

6. 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 practicing as a Registered Nurse at Elixir Beauty Clinic in Ottawa, Ontario, you engaged in conduct relevant to the practice of nursing that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional, as follows:

(a) you maintained inadequate documentation with respect to the care you provided to [Patient F] on October 16, 2024, and in particular you failed to document the authorizing mechanism you relied on in performing the controlled act of administration of substances by injection on [Patient F];

(b) you provided inadequate care to [Patient F] on October 16, 2024, including but not limited to:

i. you did not explain the risks and benefits of the procedures performed; and/or

ii. you failed to obtain informed consent from [Patient F]; and/or

(c) you used a product not licensed by Health Canada on [Patient F] on October 16, 2024, and in particular you used BioSun PDO Threads on [Patient F].

APPENDIX “A”

1. The administration of dermal fillers to Patient A on or around July 17, 2022.

2. The administration of dermal fillers to Patient B on or around July 17, 2022.

3. The administration of dermal fillers to Patient C on or around July 17, 2022.

4. The administration of dermal fillers to Patient D on or around July 17, 2022.

5. The administration of a PDO threading procedure to Patient E on or around July 17, 2022.

Member’s Plea

The Member admitted the allegations set out in paragraphs #1(a), (b)(ii), (c)(i)(ii), #2(b), #3(a), (b)(ii), (c)(i)(ii), #4(a),(b)(i)(ii), (c), #5 and #6(a), (b)(i)(ii), (c) 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 as amended reads, unedited and without exhibits mentioned therein, as follows:

THE MEMBER

1. Yun Shen (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) in the Temporary Class from October 26, 2015 to April 5, 2016. The Member registered with CNO as a RPN in the General Class from April 5, 2016, to October 8, 2021, when she resigned her RPN certificate of registration.

2. The Member registered with CNO as a Registered Nurse (“RN”) in the General Class on July 29, 2021.

REFERRALS TO CNO’S DISCIPLINE COMMITTEE

3. The allegations before the Discipline Committee arise from two referrals from the Inquiries, Complaints and Reports Committee (“ICRC”).

4. On December 11, 2024, allegations regarding the Member’s practice at a cosmetic clinic called Luxe Beauté Clinic (“Luxe”) were referred to the Discipline Committee. In addition to the Member, one Nurse Practitioner (“NP”) and four RPNs have been referred to the Discipline Committee for similar and related issues regarding their practice at Luxe.

5. As described below, the Member’s conduct at Luxe occurred in or around July 2022. The conduct was reported to CNO on February 29, 2024, following which the ICRC approved an investigation into the Member’s practice. The Member submitted a response, through counsel, to the investigation dated May 13, 2024.

6. On June 18, 2025, a second set of similar allegations regarding Member’s practice at a cosmetic clinic called Elixir Beauty Clinic (“Elixir”) were referred to the Discipline Committee. The conduct giving rise to these allegations occurred in or around October 2024.

7. At the time of the conduct at Elixir in or around October 2024, the Member was aware of the ICRC investigation into her practice at Luxe and the concerns regarding her practice.

8. Also, at the time of the Member’s conduct at Elixir in or around October 2024, the Member was acting as a workplace supervisor for two other members of CNO (both RPNs) with respect to their cosmetic injection practices. This workplace supervision was a term of interim undertakings that the RPNs had provided to the ICRC

LEGISLATIVE REQUIREMENTS FOR THE PERFORMANCE OF CONTROLLED ACTS

9. The Luxe allegations engage the Member’s performance of controlled acts.

10. The Regulated Health Professions Act, 1991 (the “RHPA”), prohibits the performance of controlled acts in the course of providing health care services unless the person is a member authorized by a health procession Act to perform the controlled act, or the performance of the controlled act has been delegated to the person by a member authorized by a health profession Act to perform the controlled act. Controlled acts in the RHPA include administering a substance by injection and performing a procedure on tissue below the dermis.

11. Under the Nursing Act, 1991, and O. Reg. 275/94, a RN is only authorized to perform the controlled act of administering a substance by injection and performing a procedure on tissue below the dermis if permitted by the regulations or the procedure is ordered by a person who is authorized to do the procedure, such as a NP or physician. O. Reg. 275/94 provides that controlled acts can be delegated if certain requirements are met.

12. The legal requirements for accepting the delegation of a controlled act are set out in O. Reg. 275/94, and the regulation requires that a member who performs a controlled act record the particulars of the delegation in the patient record unless a written record is otherwise available in the patient record or at the place where the controlled act is to be performed. The written record of the particulars of a delegation must include the date of the delegation, the delegator’s name, if the controlled act was delegated to the member, the delegatee’s name, if the controlled act was delegated by the member and the conditions, if any, applicable to the delegation.

HEALTH CANADA LICENSING REQUIREMENTS

13. The Food and Drugs Act and its regulations, including the Medical Devices Regulations, establish the framework to protect the safety of health products available in Canada.

14. Health Canada is responsible for the approval of medical devices and products for use in Canada through a process that monitors and evaluates their safety, effectiveness, and quality. Health Canada assesses medical devices for their safety, quality and effectiveness before issuing a device licence.

15. Healthcare professionals are responsible for the health products that they administer to patients and are required to ensure that the health products they use are approved and licensed by Health Canada.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Luxe Incidents

16. Luxe is a cosmetic clinic that provides a variety of cosmetic services such as dermal fillers, PDO threading, and Botox injections. Luxe operated at a location in Vaughan, Ontario at 7777 Weston Road, Unit 102 (the “Vaughan Location”) and at a location in Ottawa, Ontario at 25 Murray Street (the “Ottawa Location”).

17. On July 17, 2022, the Member worked at the Vaughan Location and provided care to five patients including Patient A, Patient B, Patient C, Patient D and Patient E. The Member injected dermal fillers into Patient A, Patient B, Patient C and Patient D. The Member performed a polydioxanone (PDO) threading procedure on Patient E.

18. The PDO threading procedure involved injecting a local anesthetic and then inserting dissolvable sutures into Patient E’s skin.

19. Each of these five procedures involved the Member performing the controlled act of administering a substance by injection. The PDO threading procedure also involved performing a procedure on tissue below the dermis.

20. The Member, as an RN, was required to have an authorizing mechanism to perform the controlled acts of injecting a substance by injection. The Member failed to obtain an authorizing mechanism to perform the controlled acts involved in the procedures on Patient A, Patient B, Patient C, Patient D and Patient E.

21. The only documents contained in the patient records for Patient A, Patient B, Patient C, Patient D and Patient E are completed consent forms for the specific procedure. The patient records contained the following deficiencies:

• The Member did not indicate that she was the individual performing the procedures;
• The Member did not include her signature and professional designation, except when signing as a witness to the patient’s signatures on three of the consent forms;
• The Member did not document whether she performed any nursing assessments of the patients;
• The Member did not document details of the treatment provided such as the location of injections and/or the products used; and
• The Member did not document how any of the patients responded to the treatments.

22. In addition to the issues described above, the Member used products that are not authorized by Health Canada on two of the patients: Patient B and Patient E.

23. Regarding Patient B, the Member injected the patient with HYACorp, a hyaluronic acid filler for the face and body, which the Member knew was not licensed by Health Canada.

24. With respect to Patient E, the Member used Bio-Sun PDO threads as part of a PDO threading procedure, which the Member knew was not licensed by Health Canada.

Elixir Incidents

25. Elixir is a cosmetic injection clinic located at 1279 Wellington Street West, Ottawa, Ontario, that provides a variety of cosmetic services such as dermal fillers, PDO threading, and Botox injections.

26. On October 16, 2024, the Member worked at Elixir and provided care to Patient F.

27. The Member documented that Patient F presented for non-surgical facial rejuvenation and that “after discussing treatment options, risks, and expected results” Patient F “decided to proceed with treatment during the same visit”.

28. Patient F signed a document titled “Informed Consent for PDO Thread Lift Procedure”. Patient F was asked to consent to the injection of BioSun PDO Threads. The consent form signed by Patient F states: “This product [i.e. BioSun PDO Threads] is currently under Health Canada pending approval.”

29. The Member did not discuss the risk and benefits of the procedure with Patient F, and the Member simply told Patient F, “this is what you need”. Patient F signed the consent without fully reading it. If the Member were to testify, she would state that her general practice was to provide the consent form to patients in advance of treatment and to provide patients with the opportunity to review. The Member admits and acknowledges that she did not take steps to ensure that Patient F had fully read and understood the consent form.

30. The documentation the Member completed regarding her treatment of Patient F included her assessment and a summary of the products injected into Patient F, including: Nuceiva (a neuromodulator, similar to Botox), Stylage S (injectable hyaluronic acid), and Biosun Mono Threads. The Member documented that she injected all three substances into Patient F.

31. The Member knew, or ought to have known, that BioSun PDO Threads were not licensed by Health Canada.

32. Though the Member relied on a medical directive in performing the controlled acts involved in the procedure, she failed to document anything regarding the authorizing mechanism she relied on in performing the controlled acts involved in the procedure of administering a substance by injection and performing a procedure on tissue below the dermis.

33. A few days after the treatment, Patient F experienced significant pain and returned to Elixir for assessment. The Member did not assess Patient F and instead told her that the pain was normal.

34. Elixir’s records indicate that on October 19, 2024, Patient F attended Elixir and another nurse removed the thread without complications.

35. According to Elixir’s records, Patient F returned to Elixir on October 30, 2024 for a follow-up, and the Member inserted a further PDO thread to replace the thread the other nurse had removed two weeks before.

CNO STANDARDS

Code of Conduct

36. CNO’s Code of Conduct is a standard of practice describing the accountabilities all Ontario nurses have to the public.

37. CNO’s Code of Conduct in force at the time of the incidents at Luxe provides that:

• Nurses maintain complete, accurate and timely documentation in their practice;
• Nurses recognize and work within the limits of their knowledge, skill and judgment and their legal scope of practice;
• Nurses are accountable to, and practice under, relevant laws and CNO’s standards of practice;
• Nurses are accountable for their own actions and decisions; and
• Nurses clearly communicate to patients the details of care or a service they intend to provide.

38. CNO’s Code of Conduct in force at the time of the incidents at Elixir provides that:

• Nurses obtain informed consent from [patients], or from their substitute decision-makers when [patients] are unable to do so;
• Nurses recognize and work within the limits of their legal scope of practice and their knowledge, skill and judgment;
• Nurses are accountable for maintaining, and keeping clear, complete, accurate and timely documentation as set out in CNO’s Documentation practice standard. Nurses do not document false or misleading information;
• Nurses are truthful in their professional practice;
• Nurses understand and practice in compliance with relevant laws and standards of practice and do not breach them;
• Nurses are accountable for their own decisions, actions, omissions and related outcomes; and
• Nurses take accountability for their errors and learn from them.

39. In addition, CNO’s Code of Conduct in force at the time of the incidents at Elixir provides that informed consent is:

As described under the Health Care Consent Act, a person’s consent is informed if the person receives information about a treatment that a reasonable person in the same circumstances would require to make a decision and if the person receives responses to their requests for additional information about the treatment.

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

Professional Standards

41. 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.

42. 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 meet 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:

• Providing, facilitating, advocating and promoting the best possible care for [patients]; and
• Ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation.

43. CNO’s Professional Standards further provides, in relation to the ethics standard, that ethical nursing includes acting with integrity, honesty and professionalism in all dealings with the patient and other health care team members.

44. CNO’s Professional Standards provides, in relation to the knowledge standard, that each nurse possesses, through basic education and continuing learning, knowledge relevant to their professional practice. Nurses demonstrate this standard by understanding the legislation and standards relevant to nursing and the practice area.

45. In addition, CNO’s Professional Standards further provides, in relation to the leadership standard, that nurses demonstrate leadership by providing, facilitating and promoting the best possible care/service to the public. Nurses demonstrate this standard by:

• 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].

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

Decisions About Procedures and Authority

47. 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 includes four standard statements pertaining to appropriate healthcare provider, authority, competence and managing outcomes.

48. In relation to authorizing mechanisms, CNO’s Decisions About Procedures and Authority Standard provides:

An authorizing mechanism is a means by which the authority to perform a procedure is obtained or the decision is made to perform a procedure. The appropriate authorizing mechanism depends on the nurse’s category or class, role and practice setting. Examples of authorizing mechanisms include orders, initiation, directives and delegation.

49. 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 the procedure promotes safe patient care, and if it is appropriate for a nurse to perform the procedure. Nurses meet this standard by:

• Determining whether the procedure fits within a professional nursing role; and
• Ensuring that practice setting policies support the nurse in performing the procedure.

50. 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 performing procedures. 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 additional authority is required in the form of delegation, and proceeding with delegation according to regulation;
• 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;
• Ensuring that patient records reflect the procedures that were performed;
• Initiating the performance of controlled act procedures within the boundaries of legislation, competence and agency policy; and
• Ensuring that [patient] records reflect the initiated procedures.

51. 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 a procedure prior to performing it. Nurses meet this standard by:

• Communicating with other health care team members as necessary for safe, effective and ethical patient care; and
• Reflecting on and continuously improving knowledge, skill and judgment in relation to practice.

52. In addition, CNO’s Decisions About Procedures and Authority Standard provides, in relation to the managing outcomes standard, that prior to performing procedures, nurses ensure that they are able to identify the potential outcomes of procedures, have the authority and competence to manage the outcomes, or have the resources available to manage those outcomes. Nurses meet this standard by identifying the potential risks and outcomes related to performing a procedure.

53. Attached as Exhibit “D” is a copy of CNO’s Decisions About Procedures and Authority Standard that was in force at the time of the incidents at Luxe. CNO’s Decisions About Procedures and Authority Standard has since been retired.

Scope of Practice

54. CNO’s Scope of Practice Standard outlines the legislated scope of nursing practice and other key requirements for nurses when deciding whether to perform an activity for safe patient care using three concepts, including authority, context and competence.

55. CNO’s Scope of Practice Standard provides, in relation to authority, that nurses must know their legislated scope of practice, including controlled acts and authorizing mechanisms. Nurses must ensure they have the legal authority prior to performing any activity, which includes ensuring their practice complies with all relevant legislation, they have the appropriate authorizing mechanisms in place and they have assessed the context of their practice and their own competence to ensure they can provide safe patient care. The Scope of Practice Standard further specifies that there are two ways RNs and RPNs can obtain authority to perform controlled acts, including orders (direct orders and directives) or delegation. Nurses are expected to demonstrate accountabilities with respect to authority that includes, but is not limited to:

• Know and work in compliance with legislation, including but not limited to:
  • ensuring appropriate authority is in place in the form of direct orders or directives;
  • following orders that are clear, complete and appropriate;
  • ensuring delegation, in addition to an order, is permitted and in place before performing a controlled act that is not authorized under the Nursing Act, 1991; and
  • ensuring that the initiation of activities complies with the regulatory and practice-specific legislation and employer policies;
• Document orders and activities performed or initiated as outlined in the Documentation Standard; and
• Obtain informed consent as outlined in the Consent Practice Guideline.

56. CNO’s Scope of Practice Standard provides, in relation to context, nurses must determine if their practice environment or setting supports the performance of an activity and has the available resources to support safe patient care. Nurses who have the legal authority to perform an activity must also consider if it is appropriate to do so within the context of their practice setting, which may include the broader environment in which nurses work, the health care setting and the available resources to support the nurse and patient. Nurses are expected to demonstrate accountabilities with respect to context that includes, but is not limited to:

• Consult and advocate to the employer for clear employer policies and procedures;
• Collaborate and communicate with other health care team members for safe and effective [patient] care and as needed, escalate to an appropriate health care provider; and
• Refrain from any activity that is not appropriate or safe for [patients] in the practice setting or under workplace policies.

57. CNO’s Scope of Practice Standard provides, in relation to competence, nurses must ensure they have the individual knowledge, skill and judgment to perform an activity safely within a nurse’s role and practice setting. Nursing competence also includes leadership, decision-making and critical-thinking skills. Nurses are accountable to continually reflect on their practice and determine their learning needs to ensure they can provide safe patient care. Nurses are expected to demonstrate accountabilities with respect to competence that includes, but is not limited to:

• Demonstrate the knowledge, skill, and judgment to perform an activity safely and effectively, including but not limited to:
  • understanding the [patient’s] overall condition and needs;
  • assessing the risks and benefits; and
  • managing potential outcomes and modifying actions as appropriate;
• perform an activity that is based on the best interests of the [patient] and includes the [patient’s] wishes; and
• self-reflect, identify learning needs and continuously seek out and integrate learning to improve their knowledge, skill and judgement in relation to practice.

58. Attached as Exhibit “E” is a copy of CNO’s Scope of Practice Standard that was in force at the time of the incidents at Elixir.

Documentation

59. CNO’s Documentation Standard explains the regulatory and legislative requirements for nursing documentation. It includes three standard statements and indicators pertaining to communication, accountability and security which describe nurses’ accountabilities when documenting.

60. 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 this standard by:

• Ensuring that 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;
• Documenting both objective and subjective data;
• Providing a full signature or initials, and professional designation (RPN, RPN[Temp], RN, RN[Temp] or NP) with all documentation.
• Providing full signature, initials and designation on a master list when initialling documentation; and
• Documenting informed consent when the nurse initiates a treatment or intervention authorized in legislation.

61. 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 this standard by:

• 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;
• Documenting in chronological order;
• Clearly identifying the individual performing the assessment and/or intervention when documenting; and
• Advocating at the nurse’s facility for clear documentation policies and procedures that are consistent with CNO’s standards.

62. CNO’s Documentation Standard also provides, in relation to security, that nurses safeguard patient health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures that are consistent with the standard(s) and legislation. Nurses meet this standard by ensuring that relevant patient care information is captured in a permanent record.

63. Attached as Exhibit “F” is a copy of CNO’s Documentation Standard which was in force at the time of the incidents at Luxe and Elixir.

Contravention of CNO Standards

64. The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards and Decisions about Procedures and Authority Standard while practicing at Luxe on or about July 17, 2022, when she performed the controlled act of administration of substances by injection without authorizing mechanisms with respect to Patient A, Patient B, Patient C, Patient D and Patient E.

65. The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards, Decisions about Procedures and Authority Standard and Documentation Standard while practicing at Luxe on or about July 17, 2022, when she maintained inadequate documentation with respect to the care provided to Patient A, Patient B, Patient C, Patient D and Patient E including, but not limited to, when she failed to ensure the documentation was a complete record of nursing care provided to each patient.

66. The Member admits and acknowledges that she contravened CNO’s Code of Conduct and Professional Standards while practicing at Luxe on or about July 17, 2022, when she used products not licensed by Health Canada on patients at Luxe and/or failed to ensure that she used products licensed by Health Canada on patients at Luxe, when she used HYACorp with respect to Patient B and used BioSun PDO Threads with respect to Patient E.

67. The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Scope of Practice Standard and Documentation Standard while practicing at Elixir on or about October 16, 2024, when she maintained inadequate documentation with respect to the care she provided to Patient F, and in particular, she failed to document the authorizing mechanism relied on in performing the controlled act of administration of substances by injection on Patient F.

68. The Member admits and acknowledges that she contravened CNO’s Code of Conduct and Scope of Practice Standard while practicing at Elixir on or about October 16, 2024, when she provided inadequate care to Patient F, including but not limited to when she did not explain the risks and benefits of the procedures performed and failed to obtain informed consent from Patient F.

69. The Member admits and acknowledges that she contravened CNO’s Code of Conduct while practicing at Elixir on or about October 16, 2024, when she used a product not licensed by Health Canada on Patient F, in that she used BioSun PDO Threads on Patient F.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

70. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a), 1(b)(ii), 1(c)(i), 1(c)(ii), 4(a), 4(b)(i), 4(b)(ii) and 4(c) 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 16 to 69 above.

71. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2(b) and 5 of the Notice of Hearing in that she failed to keep records as required, as described in paragraphs 16 to 35, 37 to 38, 42, 50, 55, 59 to 62, 65 and 67 above.

72. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3(a), 3(b)(ii), 3(c)(i), 3(c)(ii), 6(a), 6(b)(i), 6(b)(ii) and 6(c) of the Notice of Hearing, and in particular her conduct was disgraceful, dishonourable and unprofessional, as described in paragraphs 16 to 69 above.

OTHER

73. With the leave of the Panel of the Discipline Committee, CNO withdraws the remaining allegations in the Notice of Hearing, which are as follows:

• Paragraph 1(b)(i) of the Notice of Hearing;
• Paragraph 2(a) of the Notice of Hearing; and
• Paragraph 3(b)(i) of the Notice of Hearing.

Decision

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

Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs #1(a), 1(b)(ii), 1(c)(i)-(ii), #2(b), #3(a), 3(b)(ii), 3(c)(i)-(ii), #4(a)-(b)(i)-(ii), (c), #5 and #6(a), 6(b)(i)-(ii), 6(c)(i) of the Notice of Hearing. With respect to allegations #3(a), 3(b)(ii), 3(c)(i)-(ii), #6(a), 6(b)(i)-(ii) and 6(c), the Panel finds that the Member’s conduct would reasonably be regarded 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.

Allegations #1(a), 1(b)(ii) and 1(c)(i)(ii) in the Notice of Hearing, regarding contravening the standards of practice at Luxe, are supported by paragraphs 16 to 24 and 36 to 70 in the Agreed Statement of Facts. The Member admitted that she performed controlled acts on five patients without an authorizing mechanism in place. The RHPA requires that a controlled act, which includes injections and procedures below the dermis, is only permitted to be provided by someone authorized by legislation or where an authorized person has delegated it. The Decisions About Procedures and Authority Standard sets out the mechanisms by which authority to perform procedures is obtained. The Member did not have the required authority to perform the controlled acts involved in injecting dermal filler and threading. The Scope of Practice Standard requires nurses to know their legislated scope of practice, including controlled acts and authorizing mechanisms. Nurses are required to ensure they have the legal authority to perform activities before doing so. Accordingly, by performing controlled acts that she was not authorized to do, the Member was practising outside her scope of practice and contravened standards. The Member also breached the Code of Conduct and the Professional Standards by failing to respect the limits of her scope of practice and by using products not licensed by Health Canada, such as HYACorp and BioSun PDO. Nurses must be accountable to, and practice under, relevant laws, which the Member failed to do.

The Member further failed to meet the Documentation Standard in relation to the five patients on whom she performed controlled acts. Her documentation was deficient in several respects, including failing to document that she was the individual who performed the procedures, omitting her signature and professional designation on three consent forms, and failing to document whether any nursing assessments were conducted for any of the five patients. The Documentation Standard clearly requires that a full signature and professional designation be included, and that documentation accurately and completely reflect the nursing care provided. The Code of Conduct requires that nurses maintain complete and accurate documentation. The Member’s conduct breached these standards.

Allegation #2(b) in the Notice of Hearing, regarding failing to keep records as required, is supported by paragraphs 16 to 24, 59 to 62, 65, and 71 in the Agreed Statement of Facts. The Member admitted that she did not ensure her documentation constituted a complete record of the nursing care provided to each patient. For instance, she failed to document key details of the treatments provided, including the injection sites and/or products used, as well as the patients’ responses to the treatments. As a result, the Member did not meet the basic documentation expectations required when providing patient care.

Allegations #3(a), (b)(ii), (c)(i)(ii) in the Notice of Hearing, regarding disgraceful, dishonourable or unprofessional conduct, are supported by paragraphs 19 to 24 and 72 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct was clearly relevant to the practice of nursing, as it occurred in the context of providing patient care and her professional role as a nurse. The Panel finds the Member’s conduct in performing controlled acts, when she was not authorized to do so, in using products not approved by Health Canada and in not documenting completely, to be unprofessional as it demonstrated a serious and persistent disregard for her professional obligations in breaching the standards of practice.

The Panel also finds that the Member’s conduct was dishonourable, as she demonstrated an element of moral failing by disregarding her scope of practice and the requirements for appropriate patient care documentation. The Member knew or ought to have known that performing procedures outside her scope of practice without an authorizing mechanism, and maintaining deficient patient care records, was unacceptable and fell well below the standards expected of a professional.

Finally, the Panel finds that the Member’s conduct was disgraceful, as it shames the Member and, by extension, the profession. The use of products not licensed by Health Canada on patients casts serious doubt on the Member’s moral fitness and her ability to meet the heightened obligations that the public is entitled to expect of regulated professionals.

Allegations #4(a), (b)(i)(ii), (c) in the Notice of Hearing, regarding contravening the standards of practice at Elixir, are supported by paragraphs 25 to 70 in the Agreed Statement of Facts. While providing care to patients at Elixir, the Member failed to meet the Code of Conduct by not obtaining informed consent from a patient prior to performing a procedure. In addition, the Member used a product that was not licensed by Health Canada. The College’s Professional Standards require nurses to act with integrity and to conduct themselves ethically in all interactions with patients, obligations which the Member failed to uphold.

Allegation #5, regarding failing to keep records as required, in the Notice of Hearing is supported by paragraphs 25 to 35, 67 and 71 in the Agreed Statement of Facts. The Member admitted that she maintained inadequate records on October 16, 2024 when she failed to document the authorizing mechanism she relied on in performing the controlled act of administration of substances by injection.

Allegations #6(a), (b)(i)(ii) and (c) in the Notice of Hearing, regarding disgraceful, dishonourable or unprofessional conduct, is supported by paragraphs 25 to 69 and 72 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct was clearly relevant to the practice of nursing, as it occurred in the context of patient care and her professional role as a nurse. The Panel finds the Member’s conduct in breaching several College Standards to be unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.

The Panel also finds that the Member’s conduct was dishonourable, as she demonstrated a disregard for both her scope of practice and the requirements for appropriate patient care documentation. The Member ought to have known that performing procedures outside her scope of practice without an authorizing mechanism, failing to obtain informed consent and maintaining deficient patient care records, was unacceptable and fell well below the standards expected of a professional.

Finally, the Panel finds that the Member’s conduct was disgraceful, as it brings shame upon the Member and, by extension, the profession. The Member had already been notified by the College of Nurses of the investigation into her care at the Luxe when she was providing care at the Elixir, yet she continued to breach the multiple standards and use a product not licensed by Health Canada on a patient. This conduct casts serious doubt on the Member’s moral fitness and her ability to meet the heightened obligations that the public is entitled to expect of regulated professionals.

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 Registrar to suspend the Member’s certificate of registration for 7 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 Registrar to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) Within 6 months from the date that this Order becomes final, or a longer timeframe if approved by CNO, the Member shall successfully complete at the Member’s own expense the PROBE: Ethics & Boundaries Program offered through The Center for Personalized Education for Professionals (the “PROBE Program”). To successfully complete the PROBE Program, the Member must:

i. Receive a grade of “unconditional pass”; and

ii. Provide proof of the Member’s grade to CNO;

b) 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. Scope of Practice,
3. Documentation,
4. Therapeutic Nurse-Client Relationship,
5. Directives, and
6. Consent;

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;

c) For a period of 12 months from the date the Member returns to the practice of nursing if the Member is self-employed (which term includes employment by a corporation owned by the Member), the Member will notify the regulated health professional(s) who authorize the Member to perform controlled acts (the “Authorizing Professional(s)”) of the decision. To comply, the Member is required to:

i. Inform any Authorizing Professional of the decision prior to commencing or prior to resuming the self-employed practice of nursing;

ii. Ensure that CNO is notified of the name, address, and telephone number of all Authorizing Professional(s) within 14 days of commencing or resuming the self-employed practice of nursing;

iii. Provide the Member’s Authorizing Professional(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. Only practice nursing with an Authorizing Professional who agrees to, and does, forward a report to CNO within 14 days of the commencement or resumption of the Member’s self-employed practice of nursing, 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 4 random spot audits of the Member’s practice and documentation at the following intervals and provide a report to CNO regarding the Member’s practice after each audit:

a. the first audit shall take place within 3 months from the date the Member begins or resumes the self-employed practice of nursing, b. the second audit shall take place within 6 months from the date the Member begins or resumes the self-employed practice of nursing, c. the third audit shall take place within 9 months from the date the Member begins or resumes the self-employed practice of nursing, d. the fourth audit shall take place within 12 months from the date the Member begins or resumes the self-employed practice of nursing;

v. The audits shall, on each occasion, involve the following:

1. reviewing a random selection of 5 of the Member’s patient records to ensure they meet CNO standards, including but not limited to:

a. Ensuring the Member’s documentation is a complete record of nursing care provided, b. Ensuring the Member obtained authorization from the Authorizing Professional(s) prior to performing controlled act(s), c. Ensuring the Member obtained informed patient consent prior to performing controlled act(s), d. Ensuring that the Member included her full signature and/or initials, and professional designation; e. Ensuring the Member clearly identified the individual performing the assessment and/or intervention with respect to the patient, f. Ensuring that relevant patient care information was captured in a permanent record, and g. Ensuring that all products used on patients were licensed for use by Health Canada at the time of use;

2. discussing the care the Member provided with at least 3 of the Member’s patients, selected at random, who received procedures for which both informed consent and authorization from the Authorizing Professional(s) were required prior to the performance of the controlled act(s) to ensure the Member provided adequate care including, but not limited to, ensuring the Member explained the risk and benefits of the procedures performed and obtained informed consent;

d) For a period of 12 months from the date the Member returns to the practice of nursing if the Member is employed by an employer, 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. Subject to subparagraph 3(c) above, only practice 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 4 random spot audits of the Member’s practice and documentation at the following intervals and provide a report to CNO regarding the Member’s practice after each audit:

a. the first audit shall take place within 3 months from the date the Member begins or resumes employment with the employer, b. the second audit shall take place within 6 months from the date the Member begins or resumes employment with the employer, c. the third audit shall take place within 9 months from the date the Member begins or resumes employment with the employer, and d. the fourth audit shall take place within 12 months from the date the Member begins or resumes employment with the employer;

v. The audits shall, on each occasion, involve the following:

1. reviewing a random selection of 5 of the Member’s patient records to ensure they meet both CNO and employer standards, including but not limited to:

a. Ensuring the Member’s documentation is a complete record of nursing care provided, b. Ensuring the Member obtained authorization from the Authorizing Professional(s) prior to performing controlled act(s), c. Ensuring the Member obtained informed patient consent prior to performing controlled act(s), d. Ensuring that the Member included her full signature and/or initials, and professional designation; e. Ensuring the Member clearly identified the individual performing the assessment and/or intervention with respect to the patient, f. Ensuring that relevant patient care information was captured in a permanent record, and g. Ensuring that all products used on patients were licensed for use by Health Canada at the time of use;

2. discussing the care the Member provided with at least 3 of the Member’s patients, selected at random, who received procedures for which both informed consent and authorization from the Authorizing Professional(s) were required prior to the performance of the controlled act(s) to ensure the Member provided adequate care including, but not limited to, ensuring the Member explained the risk and benefits of the procedures performed and obtained informed consent;

e) If self-employed (which term includes employment by a corporation owned by the Member) in an independent practice environment, the Member shall post the following notice regarding practice restrictions in a visible location at all locations at which she practices nursing, as well as on any websites, social media, and/or platforms through which appointment booking is available, for a period of 12 months from the date the Member commences or resumes the self-employed practice of nursing:

ENTITLED TO PRACTISE NURSING WITH RESTRICTIONS

Yun Shen, RN, is permitted to practise nursing subject to terms, conditions and limitations. Further information regarding restrictions may be found on the College of Nurses of Ontario’s public register: https://registry.cno.org/Search/Details/%7bBBD6ED48-9354-4767-8065-67503639CD44%7d

i. If the Member chooses to practise nursing in any language other than English, the Member shall also be required to post a certified translation(s) of the notice referred to in paragraph 3(e) in a visible location at all locations at which she practices nursing, as well as on any websites, social media, and/or platforms through which appointment booking is available, for a period of 12 months from the date the Member commences or resumes the self-employed practice of nursing;

ii. The Member shall provide CNO with copies of the certified translation(s) referred to in paragraph 4(i); and

iii. The Member shall provide CNO with active links to the websites, social media, and/or platforms on which the notice referred to in paragraph 3(e) shall be posted, for a period of 12 months from the date the Member commences or resumes the self-employed practice of nursing; and

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 submitted that the proposed penalty was an agreed resolution which appropriately balanced the aggravating and mitigating factors, reflected the goals of penalty and fell within the range of outcomes for similar conduct.

College Counsel set out that the aggravating factors in this case were:

• The Member showed a fundamental disregard for her scope of practice when she performed controlled acts with no authority;
• The Member failed to meet a legal requirement when she did not document the authority under which she could perform a controlled act;
• The Member put patients at risk when she used products on patients that had not been approved by Health Canada;
• The Member continued with a similar practice when the College had alerted her to their concerns;
• The Member knew or ought to have known she was not authorized to perform the controlled acts without authority;
• The Member practiced with significant autonomy and minimal oversight and therefore was expected to exercise heightened vigilance in her practice. In addition to this autonomy, she held a position of leadership and trust as a workplace supervisor approved by the Inquiries, Complaints and Reports Committee (“ICRC”) for two RPNs. By agreeing to supervise their cosmetic injection practices when she was engaging in misconduct, she committed a serious breach of the trust placed in her by the profession, raising significant concerns about her professionalism and ethical judgment;
• Nurses are held to a higher standard in the cosmetic area and the public trusts a RN is following the law; and
• The Member’s conduct casts doubt on the Member’s professionalism and ethics.

The mitigating factors of this case were:

• The Member had no prior history;
• The Member has taken responsibility for her conduct and cooperated with the College by entering into an Agreed Statement of Facts and a Joint Submission on Order with the College; and
• The Member has worked with the College and entered into a rigorous resolution that involves education for remediation.

Counsel submitted the following cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from Discipline Committees: CNO v. Richard, 2023 107212, CNO v. Besada, 2023 149377 and CPSO v. Adams, 2017 ONCPSD 22.

College Counsel submitted this case should have a higher suspension compared to the cases put forward because of the aggravating factors in this case. The Member had autonomy in her work setting and she breached the patient’s trust in the nursing care she provided.

Member’s Submissions on Penalty

The Member’s Counsel indicated that they 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 the seven-month suspension of the Member’s certificate of registration, which signals to other members of the profession how seriously the College takes this kind of misconduct.

The proposed penalty provides for specific deterrence through the suspension which will communicate to the Member how serious this conduct is, and which will deter this Member from engaging in similar misconduct in the future.

The proposed penalty emphasizes remediation and rehabilitation through the terms, conditions, and limitations on the Member’s certificate of registration which include the completion of the PROBE Program, a minimum of two meetings with a Regulatory Expert, and a review of the College’s publications to deepen the Member’s understanding of the conduct at issue. Together, these requirements are intended to support the Member’s safe return to practice and to ensure that such conduct is not repeated. In addition, the oral reprimand will clearly communicate the Panel’s assessment of the seriousness of the Member’s conduct.

Overall, the public is protected by the 12-month notification and audit requirements that apply to employers and/or regulated health professionals who authorize the Member to perform controlled acts, whether the Member is employed by another party or self-employed.

In addition, if the Member is self-employed, including practicing through a corporation she owns in an independent practice setting, she must post a notice outlining her practice restrictions. This notice must be displayed in a clearly visible location at every site where she provides nursing services and must also appear on any websites, social media pages, or appointment booking platforms associated with her practice. The notice must remain in place for 12 months from the date she begins or resumes self-employed nursing 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, Grace Fox, NP, sign this amended decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.