DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO. PANEL: Lindsay Hyslop, NP Chairperson Sandra Steele, RPN Member Tammy Hedge, RPN Member

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1 DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO PANEL: Lindsay Hyslop, NP Chairperson Sandra Steele, RPN Member Tammy Hedge, RPN Member Linda Bracken Public Member Gino Cucchi Public Member BETWEEN: COLLEGE OF NURSES OF ONTARIO ) EMILY LAWRENCE for ) College of Nurses of Ontario - and - ) ) GILLIAN GAMBLE ) NO REPRESENTATION for Registration No. IE10835 ) Gillian Gamble ) ) ) Heard: October 10, 2012 DECISION AND REASONS This matter came on for hearing before a panel of the Discipline Committee on October 10,2012 at the College of Nurses of Ontario ( the College ) at Toronto. The hearing commenced at 09:10am, at which time the panel noted the Member was not in attendance. The panel recessed to allow the Member time to arrive. The hearing subsequently commenced at 10:05am with the Member in attendance. The Allegations The allegations against Gillian Gamble (the Member ) as stated in the Notice of Hearing dated September 13, 2012, 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(15) of Ontario Regulation 799/93, while working at [the Facility] in [ ] Ontario during the period from April 24, 2003, to August 30, 2010, and while your certificate of registration with the College of Nurses of Ontario

2 was suspended effective April 24, 2003, for non-payment of fees, you signed or issued in your professional capacity a document or documents that you knew or ought to have known contained a false or misleading statement, and in particular, a. you signed nursing files of clients of [the Facility] indicating that you were a "registered practical nurse" or nurse or a variation, abbreviation or equivalent thereof when you were not a member of the College and not so registered; and/or b. you signed Annual Registration Payment Cards for the years 2007, 2008 and/or 2009 which you knew or ought to have known were altered or fabricated. 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(17) of Ontario Regulation 799/93, during the period of April 24, 2003 to August 30, 2010, while working at [the Facility] in [ ] Ontario, and in the course of providing or offering to provide services within the scope of nursing, and while your certificate of registration with the College of Nurses of Ontario was suspended effective April 24, 2003, for non-payment of fees, you used a name other than the name set out in the Register, without notification to the College, in that you used the name Gillian Downs in the nursing files of clients of [the Facility], when the name set out in the Register with the College of Nurses is Gillian Gamble. 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(19) of Ontario Regulation 799/93, while working at [the Facility] in [ ] Ontario, during the period of April 24, 2003, and August 30, 2010, and while your certificate of registration with the College of Nurses of Ontario was suspended effective April 24, 2003, for non-payment of fees, you contravened provisions of the Nursing Act, 1991 and the Regulated Health Professions Act, 1991 and in particular, a. you contravened section 27 of the Regulated Health Professions Act, 1991, and Section 4 of the Nursing Act, 1991 by performing controlled acts, namely, administering a substance by injection, in the course of providing health care services to residents of [the Facility] when you were not authorized to do so by a health profession Act, as follows: i. on March 30, 2005, you administered Gravol by intramuscular injection to [Client A] ; and/or ii. on January 3, 2009, you administered cyanocobalamin, a B12 vitamin, by injection to [Client B]; b. you contravened section 11 of the Nursing Act, 1991 by using the title registered practical nurse or nurse or a variation, abbreviation or equivalent thereof that title when you were not a member of the College and not so registered; and/or

3 c. you contravened section 11 of the Nursing Act, 1991 by holding yourself out as a person who is qualified to practise in Ontario as a registered practical nurse when you were not a member of the College and not so qualified. 4. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, while working at [the Facility] in [ ] Ontario, during the period of April 24, 2003, and August 30, 2010, and while your certificate of registration with the College of Nurses of Ontario was suspended effective April 24, 2003, for non-payment of fees, you engaged in conduct or performed [ ] acts, 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. you engaged in the practice of nursing even though you were not a member of the College; b. you represented to your employer [ ] and to the public that you were a registered practical nurse, qualified to practise in Ontario as a nurse or practical nurse, and/or a member of the College when such was not the case; c. you used the title "registered practical nurse" or nurse or a variation, abbreviation or equivalent thereof when you were not a member of the College and not so registered; d. you used a name other than the name set out in the Register in the course of providing or offering to provide services within the scope of nursing, in that you used the name Gillian Downs in the nursing files of clients of [the Facility], when the name set out in the Register with the College of Nurses is Gillian Gamble, and did not notify the College of your desire to do so; e. you performed controlled acts in the course of providing health care services to residents of [the Facility] when you were not a member of the College of Nurses of Ontario or otherwise authorized to do so and in particular, i. on March 30, 2005, you administered Gravol by intramuscular injection to [Client A] ; and/or ii. on January 3, 2009, you administered cyanocobalamin, a B12 vitamin, by injection to [Client B]; and/or f. you altered, fabricated and/or executed false Annual Registration Payment Cards for the years 2007, 2008 and 2009 and provided those cards to your employer, [ ].

4 Member s Plea Gillian Gamble admitted the allegations set out in paragraphs numbered 1 a, b; 2; 3 a, b, c; and 4 a, b, c, d, e, f 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 admission was voluntary, informed and unequivocal. Agreed Statement of Facts Counsel for the College advised the panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts [ ] which provided as follows. THE MEMBER 1. Gillian Gamble (the Member ) received her diploma [ ] in The Member registered with the College of Nurses of Ontario (the College ) as a Registered Practical Nurse ( RPN ) on August 8, On May 29, 2000, the Member's certificate of registration ( certificate ) was suspended for non-payment of fees. The Member reinstated on June 27, Again, on May 13, 2002, the Member's certificate was suspended for non-payment of fees. The Member reinstated on June 14, On April 24, 2003, the Member's certificate was suspended for non-payment of fees for a third time. The Member's certificate remains suspended for non-payment of fees. 3. The Member was employed at [the Facility] from approximately 1998 until her termination on August 30, THE FACILITY 4. The Facility is a long-term care facility [ ] that provides assisted living amenities to its residents, including meals, house-keeping and social activities. 5. The Member worked as a casual RPN approximately once per month and was the Charge Nurse on these occasions. 6. The Facility requires a current certificate of registration for the Charge Nurse position. 7. As the Charge Nurse, the Member was responsible for providing front line care and supervising personal support workers. Her duties included medication administration, taking blood pressure, documentation, coordinating transfers to hospitals and making referrals to doctors. Occasionally, her duties also included monitoring glucose and administering insulin injections to diabetic residents. From late 2008, Charge Nurses also administered B12 injections.

5 8. The Facility had a charting by exception policy where only care that deviated from the baseline care was documented. As such, the nursing notes from the Facility do not reflect the totality of the care provided by the Member. INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT A. Use of a Non-Registered Name 9. From approximately April 2003 until August 2010, the Member used her married name "Gillian Downs" in the course of her employment at the Facility. 10. The Member also used the name "Gillian Downs" while providing services to clients and signed entries in the clients' records using this name. 11. This name was not in the College's Register and the Member did not notify the College that she was practising under this name. B. Use of the Title Nurse, Registered Practical Nurse, RPN 12. Between April 24, 2003 and August 30, 2010, while the Member's certificate was suspended for non-payment of fees, the Member held herself out as an RPN while working as a Charge Nurse at the Facility. 13. During this same time period, while suspended for non-payment of fees, the Member used the designation RPN next to her signature in clients' records. C. Controlled Acts 14. On March 30, 2005, at 21:00, [Client A] was vomiting. The Member injected [Client A] with 50 g. of Gravol by intramuscular injection. The Member documented administering this injection in [Client A] s progress notes by signing the entry "G.Downs, RPN." 15. On January 3, 2009, at 19:00, the Member injected [Client B] with cyanocobalamin, a prescribed B12 vitamin. The Member documented administering this injection in [Client B] s progress notes by signing the entry, "G.Downs, RPN." 16. On both of these dates, the Member was suspended for non-payment of fees and was not authorized to practise as an RPN. In particular, while under suspension, the Member was not authorized to perform the controlled act of administering a substance by injection. D. Falsified Annual Payment Cards

6 17. Until 2011, the College issued Annual Payment Cards ("APCs") to registered members upon payment of the annual membership fees. Suspended members were not issued APCs. 18. The Facility's policy was to request copies of APCs issued by the College, from all registered staff. 19. The Facility had APCs on file for the Member from 1998, 1999, 2001, 2002, 2007, 2008 and The Member provided copies of these APCs to the Facility, in accordance with the Facility s policy. 20. The APCs for 2007, 2008 and 2009 were not issued by the College. 21. The falsified APCs for 2007, 2008 and 2009 indicated that they were issued to "Gillian K. Downs," a name not on the College's Register. The Member signed the APCs as G. Downs. 22. The "Certificate Numbers" printed on the APCs for these years belonged to other College members. During these years, "Certificate Numbers" were assigned annually by the College and no two Members would have had the same Certificate Number in the same year. 23. The Member falsified the APCs for 2007, 2008 and 2009, signed the falsified APCs for 2007, 2008 and 2009 knowing that they were falsified, and provided them to the Facility. ADMISSIONS OF PROFESSIONAL MISCONDUCT 24. If the Member were to testify, she would say that she was under great personal stress between 2003 and 2010 and that she made bad decisions. The Member would express great remorse for her conduct. 25. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1 to 4 of the Notice of Hearing, as described in paragraphs 8 to 23 above and in particular that her conduct was disgraceful, dishonourable and unprofessional. Decision The panel considered the Agreed Statement of Facts and finds that the facts support a finding of professional misconduct and, in particular, finds that the Member committed acts of professional misconduct as alleged in paragraphs 1 a, b; 2; 3 a, b, c; and 4 a, b, c, d, e, f of the Notice of Hearing. Reasons for Decision

7 The panel considered the Agreed Statement of Facts and found that the evidence therein was clear and convincing. The facts admitted clearly demonstrated that the Member held herself out as and practised as [a] Registered Practical Nurse ( RPN ) while her certificate of registration with the College was suspended. Further, the evidence clearly establishes that the Member falsified the Annual Payment Cards she provided to her employer during the relevant time period. These acts amount to professional misconduct as alleged. The panel considered the allegations and found [the Member s] conduct would be reasonably regarded by members of the profession to be disgraceful, dishonourable and unprofessional. Specifically the Member s certificate of registration has been suspended for non-payment of fees since 2003 and she continued to practise while under suspension. Further, she held herself out to be a RPN while not registered at the College, she performed controlled acts when not authorized to do so, and she provided false Annual Payment Cards to her employer. The Member signed documents in a professional capacity indicating she was an RPN when in fact she was not registered with the College. Finally the Member used a name other than the name set out in the Register in the course of providing or offering to provide services within the scope of nursing practice. The panel finds that this persistent pattern of deception demonstrates conduct that is disgraceful, dishonourable and unprofessional. Penalty Counsel for the College advised the panel that a Joint Submission as to Order had been agreed upon. The Joint Submission as to Order provides as follows WHEREAS the Member s certificate of registration is currently suspended for nonpayment of fees, NOW THEREFORE, THE COLLEGE OF NURSES OF ONTARIO (THE COLLEGE ) AND GILLIAN GAMBLE (THE MEMBER ) JOINTLY SUBMIT THAT, in view of the facts and admissions set out in the Agreed Statement of Facts and the findings of professional misconduct, the Panel of the Discipline Committee (the Panel ) should make an Order: 1. Requiring the Member to appear before the Panel to be reprimanded within three months [of the date] that this Order becomes final. 2. Directing the Executive Director to suspend the Member s certificate of registration for four months. This suspension shall take effect from the date that the Member obtains an active certificate of registration and shall continue to run without interruption. 3. Directing the Executive Director to impose the following terms, conditions and limitations on the Member s certificate of registration:

8 a) The Member will attend one session with a Nursing Expert (the Expert ), at her own expense and within four months from the date that the Member obtains an active certificate of registration. i. The Expert has expertise in self-regulation, has been approved by the Director of Professional Conduct (the Director ) in advance of the meeting, and has confirmed he/she will provide a report following the session; ii. At least seven days before the first meeting, 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 College publication and completes the associated Reflective Questionnaire and online learning module: 1. Professional Standards (Revised 2002), iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaire and online participation form; v. The subject of the session 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 clients, colleagues, profession and self, 3. strategies for preventing the misconduct from recurring, 4. the publication, questionnaire and module 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 session, the Expert forwards his/her report to the Director, in which the Expert will confirm: 1. the date the Member attended the session,

9 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 her behaviour; vii. If the Member does not comply with any 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 her certificate of registration; b) For a period of 12 months from the date the Member resumes employment as a nurse, the Member will notify her employers of this decision. To comply, the Member is required to ensure that: (i) (ii) The Director 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; Provide her 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; (iii) 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 the Director, in which it will confirm: 1. that it received a copy of the required documents and 2. that [it] agrees to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession; 4. All documents delivered by the Member to the College, the Expert or the employer(s) will be made by verifiable method of delivery, the proof of which the Member will retain. Submissions on Order College Counsel submitted that this order was appropriate for the following reasons. The Member s actions represented very serious misconduct, [and] were dishonest and intentional.

10 The Member displayed disregard for the role of the College as a regulator. The reprimand and period of suspension serve as both a general and specific deterrent to both the Member and the membership as a whole. The remedial program increases [ ] public confidence in the profession. College Counsel acknowledged that the mitigating factors in this matter include the fact the Member cooperated with the College, has expressed remorse for her misconduct, and finally if the Member were to testify that it had been a very stressful time period in her life. The Member did not make any submissions with regard to the joint submission as to order. Decision on Order The panel accepts the Joint Submission as to Order and accordingly orders: 1. The Member to appear before the Panel to be reprimanded within three months [of the date] that this Order becomes final. 2. The Executive Director to suspend the Member s certificate of registration for four months. This suspension shall take effect from the date that the Member obtains an active certificate of registration and shall continue to run without interruption. 3. The Executive Director to impose the following terms, conditions and limitations on the Member s certificate of registration: a) The Member will attend one session with a Nursing Expert (the Expert ), at her own expense and within four months from the date that the Member obtains an active certificate of registration. i. The Expert has expertise in self-regulation, has been approved by the Director of Professional Conduct (the Director ) in advance of the meeting, and has confirmed he/she will provide a report following the session; ii. At least seven days before the first meeting, 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 College publication and completes the associated Reflective Questionnaire and online learning module:

11 1. Professional Standards (Revised 2002), iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaire and online participation form; v. The subject of the session 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 clients, colleagues, profession and self, 3. strategies for preventing the misconduct from recurring, 4. the publication, questionnaire and module 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 session, the Expert forwards his/her report to the Director, in which the Expert will confirm: 1. the date the Member attended the session, 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 her behaviour; vii. If the Member does not comply with any 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 her certificate of registration; b) For a period of 12 months from the date the Member resumes employment as a nurse, the Member will notify her employers of this decision. To comply, the Member is required to ensure that: (i) (ii) The Director 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; Provide her 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 Penalty, and

12 5. a copy of the Panel s Decision and Reasons, once available; (iii) 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 the Director, in which it will confirm: 1. that it received a copy of the required documents and 2. that [it] agrees to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession; 4. All documents delivered by the Member to the College, the Expert or the employer(s) will be made by verifiable method of delivery, the proof of which the Member will retain. Reasons for Penalty Decision The panel concluded that the proposed order is reasonable and in the public interest. The Member has cooperated with the College and, by agreeing to the facts and a proposed order, has accepted responsibility for her actions. Specifically, the panel considered the elements of specific deterrence, general deterrence, remediation and public protection. The reprimand and period of suspension act as both specific and general deterrence. The period of education will allow the Member to reflect upon her actions and develop strategies to prevent similar misconduct in the future. Finally, the terms, conditions and limitations combined with the period of ongoing monitoring meet[] the objective of public protection. I, Lindsay Hyslop, NP, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel as listed below: Chairperson Date Panel Members: Sandra Steele, RPN Tammy Hedge, RPN Linda Bracken Gino Cucchi