DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO. PANEL: MICHAEL HOGARD, RPN Chairperson CHERYL EVANS, RN TERRY HOLLAND, RPN Member

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1 DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO PANEL: MICHAEL HOGARD, RPN Chairperson CHERYL EVANS, RN Member TERRY HOLLAND, RPN Member ASHLEIGH MOLLOY Public Member MARGARET TUOMI Public Member BETWEEN: COLLEGE OF NURSES OF ONTARIO ) JESSICA LATIMER for ) College of Nurses of Ontario - and - ) ) LORI SIMEONE ) SELF-REPRESENTATION for Reg. No ) Lori Simone ) ) ) Heard: March 15, 2017 DECISION AND REASONS This matter came on for hearing before a panel of the Discipline Committee (the Panel ) on March 15, 2017 at the College of Nurses of Ontario ( the College ) at Toronto. The Allegations Counsel for the College advised the panel that the College was requesting leave to withdraw the allegations set out in paragraphs 1, d, f, h, k, and 3 d, f, h, and k of the Notice of Hearing dated January 9, The Panel granted this request. The remaining allegations against Lori Simeone (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 employed as a Registered Nurse by ParaMed Home Health Care (the Facility ), in North Bay, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, and in particular:

2 a. on or about April 13, 2012, you failed to attend to provide care to [Client A], as scheduled and/or in circumstances that required your attendance; and/or b. on or about April 13, 2012, you improperly delegated a nursing task, disconnecting [Client A] s PICC line pump, to non-registered staff over the telephone; and/or c. on or about January 18, 2014, you failed to provide appropriate care to [Client B], with respect to pain management; and/or d. [Withdrawn] e. on or about January 18, 2014, you failed to document the telephone call with [Client B] s wife regarding [Client B] s pain and request for nursing care; and/or f. [Withdrawn] g. on or about February , you failed to complete a wound assessment flow chart regarding[client C]; and/or h. [Withdrawn] i. on or about February 27, 2014, you failed to complete a medication error report form regarding a documentation error in respect of medication administered to [Client D]; and/or j. on or about March 16, 2014, you did not provide proper wound care to [Client E]; and/or k. [Withdrawn] l. on or about April 3, 2014, you failed to provide timely or appropriate care to [Client F], when you failed to respond to the client s and the Facility s requests for immediate nursing care. 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 employed as a Registered Nurse at the Facility, you failed to keep records as required, and in particular: a. on or about January 18, 2014, you failed to document the telephone call with [Client B] s wife regarding [Client B] s pain and request for nursing care; and/or b. on or about February , you failed to complete a wound assessment flow chart regarding [Client C]; and/or c. on or about February 27, 2014, you failed to complete a medication error report form regarding a documentation error in respect of medication administered to [Client D].

3 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 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 of the profession as disgraceful, dishonourable or unprofessional, and in particular: Member s Plea a. on or about April 13, 2012, you failed to attend to provide care to [Client A], as scheduled and/or in circumstances that required your attendance; and/or b. on or about April 13, 2012, you improperly delegated a nursing task, disconnecting [Client A] s PICC line pump, to non-registered staff over the telephone; and/or c. on or about January 18, 2014, you failed to provide appropriate care to [Client B], with respect to pain management; and/or d. [Withdrawn] e. on or about January 18, 2014, you failed to document the telephone call with [Client B] s wife regarding [Client B] s pain and request for nursing care; and/or f. [Withdrawn] g. on or about February , you failed to complete a wound assessment flow chart regarding [Client C]; and/or h. [Withdrawn] i. on or about February 27, 2014, you failed to complete a medication error report form regarding a documentation error in respect of medication administered to [Client D]; and/or j. on or about March 16, 2014, you did not provide proper wound care to [Client E]; and/or k. [Withdrawn] l. on or about April 3, 2014, you failed to provide timely or appropriate care to [Client F], when you failed to respond to the client s and the Facility s requests for immediate nursing care. The Member admitted the allegations set out in paragraphs 1. a, b, c, e, g, i, j, l; 2 a, b, c, and 3 a, b, c, e, g, i, j, l, in the Notice of Hearing. The Panel received a written plea inquiry which was

4 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 and the member advised the panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads as follows. THE MEMBER 1. Lori Simeone (the Member ) obtained a degree in nursing from Nipissing University in The Member registered with the College of Nurses of Ontario (the College ) as a Registered Nurse ( RN ) on May 22, The Member was employed by ParaMed Home Health Care (the Agency ) from June 29, 2010 and April 16, 2014, when her employment was terminated as a result of the incidents described below. THE AGENCY 4. The Agency is located in North Bay, Ontario. 5. The Member worked at the Agency as a full-time RN providing home care to clients. In that role, the Member was the primary nurse for approximately 30 clients in a given week. INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONALMISCONDUCT Client A 6. Client A was 33-years old at the time of the incident. Client A was receiving palliative care from the Agency. 7. The Member was scheduled to attend Client A s home at 10:00 on April 13, She failed to attend as scheduled. 8. The Member called Client A s home around 10:00 and learned that an ambulance had been called, because Client A was vomiting and his mother did not think she could wait for the Member to arrive. Over the phone, the Member instructed the Personal Support Worker ( PSW ), who was present, to disconnect Client A s PICC line pump before the Client was sent to the hospital.

5 9. The PSW disconnected the pump incorrectly. He left the cap off, which increased the risk of infection, and the line was out approximately 20cm so it could not be reinserted and had to be removed through an invasive procedure. 10. The Member did not take any steps to confirm that the PSW was comfortable and competent removing the PICC line pump. After the PSW disconnected the pump, he advised the Member that he was uncomfortable performing this procedure. 11. The Member acknowledges that RNs can only delegate procedures to competent care providers and in situations where it is safe to do so. The Member admits that assigning this procedure over the phone to a PSW was a breach of the guidelines set out in the College s Authorizing Mechanisms practice guideline. Client B 12. Client B was a palliative care client. He was 61 years old at the time of the incident. 13. The Member was working an on-call night shift on January 18, 2014 until 08:00. At 05:27, Client B s wife called the Agency s on-call line, reached the Member, and reported that her husband was in a lot of pain. She asked the Member to attend to check on and/or adjust the pump that administered Client B s pain medication. 14. The Member questioned whether she needed to attend right away and indicated that she did not like to change doses in the middle of the night while a client is sleeping. She advised Client B s wife that her visit could wait until her next scheduled appointment at 10:00. When Client B s wife told the Member that her husband s pain level was at 7/10, the Member told her to call back if it reached 9/10 or 10/ The Member failed to document this call. 16. The Member admits that there is no reason she could not have adjusted Client B s pain pump in the middle of the night. 17. The Member further admits that she should have assessed Client B in person, rather than over the phone, and that she should have documented the call with Client B s wife. Client C 18. Client C was 85 years old at the time the incident.

6 19. The Member was assigned to Client C s home on February 25, The visit was arranged because, the previous day, a care coordinator reported that Client C had a wound on his right scapula and thought that a nurse should look at it. 20. The Agency s policy required nurses to conduct a full assessment of a client, including the completion of a wound assessment flow chart, regardless of the purpose of the visit. 21. The Member inadequately documented her assessment of Client C s wound in the chart and failed to document on the wound assessment flow chart, as required by the Agency. Client D 22. Client D was 79 years old at the time of the incident. He was legally blind. 23. On February 27, 2014, the Member documented that she administered Lantus insulin for Client D. However, the order was for Novolin insulin and the Member did, in fact, administer Novolin insulin. 24. The Member failed to complete the Medication Error Report Form, which she was expected to do according to the Agency s policy. 25. The Member s Nursing Supervisor requested that the Member return to the home to fix the error as it could be confusing to nurses who were assigned to Client D s care. The Member did so a few days after the error took place. Client E 26. Client E was 69 years old at the time of the incident. During a bladder lift procedure, her bowel was punctured. As a result, Client E required daily dressing changes between February and May The Member only provided care to Client E on one occasion on March 16, 2014, when she attended at the Client s home to cleanse the wound near her groin. 28. The Member failed to follow the care path that was documented in Client E s file. She did not irrigate the wound and cleaned the wound by pushing ribbons of gauze dipped in normal saline in and out of the wound with forceps, which was an inappropriate technique.

7 29. Client E was uncomfortable with the care the Member provided. She found the Member s dressing change technique very painful. Client E also noted that her wound leaked after the Member provided care and she needed to change the dressing again herself. 30. The Member admits that the wound care she provided caused discomfort to Client E. Client F 31. Client F was a palliative care client. She was 69 years old at the time of the incident. The Member was Client F s primary nurse. 32. On April 3, 2014, the Member was working 10:00 to 20:00. At approximately 19:22, the Agency phoned the Member to ask her to attend at Client F s home because her daughter believed Client F was dying and requested care. 33. The Member failed to answer her phone. She later advised that she had been taking a break and was in the shower at that time. The Agency ed the Member at 19:23, but the Member also failed to respond to that . Client F s daughter called the Member as well, but did not receive a response. 34. At 19:57, the Agency called the Member s personal cell phone. Although the Member answered, she refused to attend on the basis that her shift was just about to end and she was not on call once her shift ended. 35. The next morning, on April 4, 2014, the Member called Client F s daughter at 09:45. When the Client s daughter requested that the Member attend at the start of her shift at 10:00, the Member stated that she had already pre-booked another appointment for that time. Another nurse attended to set up the palliative care home kit and later to pronounce Client F s death. 36. The Member acknowledges that, as Client F s primary nurse, she was expected to attend to Client F during her shift on April 3, The Agency s Hours of Work policy allowed the Member to have a half hour meal break, but that break was to take place approximately five hours into the shift. Accordingly, the Member admits that by taking a break in the last 45 minutes of her shift, she was ignoring her client responsibilities. ADMISSIONS OF PROFESSIONAL MISCONDUCT 37. The Member admits that she committed the acts of professional misconduct, as described in paragraphs 6 to 36 above, and as alleged in the Notice of Hearing in the following paragraphs:

8 1(a), (b), (c), (e), (g), (i), (j) and (l) 38. The Member admits that she failed to keep records as required, as described in paragraphs 6 to 36 above, and as alleged in the Notice of Hearing in the following paragraphs: 2(a), (b) and (c) 39. The Member admits that she committed the acts of professional misconduct, as described in paragraphs 6 to 36 above, and as alleged in the Notice of Hearing in the following paragraphs: 3(a), (c) and (l), in that her conduct was dishonourable and unprofessional; 3 (b), (e), (g), (i) and (j), in that her conduct was unprofessional. 40. The College withdraws the following allegations in the Notice of Hearing: 1(d), (f), (h), and (k); Decision 3(d), (f), (h), and (k). The panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1 a, b, c, e, g, i, j, l, and 2 a, b, c of the Notice of Hearing. As to allegation #3 a, c, and l the panel finds the Member engaged in conduct that would reasonably be considered by members to be dishonourable and unprofessional, in that she failed to provide care to clients as required. In allegations 3, b, e, g, i, and j the panel finds that the Member engaged in conduct that would reasonably be considered by members to be unprofessional in that she inappropriately delegated a nursing task, failed to document, and failed to communicate in an appropriate fashion. 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 a and b in the Notice of Hearing is supported by paragraphs 6 11, allegation 1 c and e is supported by paragraphs 12 17, allegation 1g is supported by paragraphs 18 21, allegation 1 i is supported by paragraphs 22-25, allegation 1 j is supported by paragraphs 26-30

9 and allegation 1 l is supported by paragraphs 31-36, in the Agreed Statement of Facts. These paragraphs show that the Member failed to meet the standard of practice in various important ways with multiple clients, including through improper delegation of care, failing to provide appropriate care, and even failing to provide care at all. Allegation #2 in the Notice of Hearing is supported by paragraphs 12 to 25 in the Agreed Statement of Facts. The Member s breaches included failing to provide appropriate documentation, which is essential in order to ensure continuity of care. With respect to Allegation # 3 a, b, c, e, g, i, j and l, the panel finds that the Member s conduct, in that she failed to attend at client s homes when required, failed to document assessments and conversations, failed to follow the care path in a patient s file and failed to answer her phone when on call, was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations. The panel also finds that the Member s conduct in Allegations 3 a, c, and l was dishonourable. It demonstrated an element of dishonesty and deceit through failure to provide care for three patients who were scheduled or required immediate attention. Penalty Counsel for the College and the Member advised the panel that a Joint Submission on Order had been agreed upon. The Joint Submission requests that this panel make an order as follows. 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 five 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 the practising 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 two meetings with a Nursing Expert (the Expert ), at her own expense and within six months from the date of this Order. To comply, the Member is required to ensure that: i. The Expert has expertise in nursing regulation and has been approved by the Director of Professional Conduct (the Director ) in advance of the meetings;

10 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 publications and completes the associated Reflective Questionnaires, online learning modules and online participation forms (where applicable): 1. Professional Standards, 2. Medication, 3. Documentation, iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires and online participation forms; 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 clients, 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 his/her report to the Director, 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 her behaviour;

11 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 her certificate of registration; b) For a period of 18 months from the date the Member returns to the practice of nursing, the Member will notify her employers of the decision. To comply, the Member is required to: i. Ensure that 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; ii. 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. Only practise nursing for an employer who agrees to, and does, forward a report to the Director within 14 days of the commencement or resumption of the Member s employing in any nursing position, confirming: 1. that they received a copy of the required documents, 2. that they agree to notify the Director 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 four random spot audits of the Member s practice at the following intervals and provide a report to the Director regarding the Member s practice after each audit: a. the first audit shall take place within three months from the date the Member begins or resumes employment with the employer,

12 b. the second audit shall take place within six months from the date the Member begins or resumes employment with the employer, c. the third audit shall take place within nine months from the date the Member begins or resumes employment with the employer, d. the fourth audit shall take place within 12 months from the date the Member begins or resumes employment with the employer. iv. The audits shall, on each occasion, involve the following: 1. reviewing a random selection of the Member s charts to ensure they meet both College and employer standards, 2. discussing (by telephone or in person), with at least three of the Member s clients, the care provided by the Member to ensure that the Member is utilizing appropriate communication techniques and providing appropriate care. c) The Member shall not practise independently in the community for a period of 18 months from the date the Member returns to the practice of nursing. 4. All documents delivered by the Member to the College, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain. Penalty Submissions Submissions were made by College Counsel. The Member indicated that she agreed with those submissions. The parties agreed that the mitigating factors in this case were that the Member has cooperated with the College, admitted the allegations, accepts responsibility for her actions and has no prior discipline history with the College. The aggravating factors in this case were that the Member s conduct was very serious with multiple incidents, involving six patients over two years including some palliative care patients. She showed a lack of passion or care and demonstrated a breach of trust. Through her actions she discredited the profession and herself. She demonstrated a serious disregard for her professional obligations.

13 The proposed penalty provides for general deterrence through the oral reprimand and the suspension, sending a message to the profession that conduct of this nature will not be tolerated.. The proposed penalty provides for specific deterrence through the oral reprimand and the suspension The proposed penalty provides for remediation and rehabilitation through the meeting with the expert, employer reporting and random audits of the Member s work. Overall, the public is protected because of the suspension and the terms, conditions and limitations, which include an 18-month restriction on the Member s practice. Counsel submitted a case to the panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee. In CNO v. Nugent (Discipline Committee, 2015), the member did not appear for the hearing and committed similar acts of misconduct. In that case, all the misconduct occurred over the course of one day. There was no cooperation with the College. That member received a 6 month suspension, a reprimand, and terms, conditions and limitations. She was also ordered to pay costs to the College of $ Penalty Decision The Panel accepts the Joint Submission as to Order and accordingly make an order as follows: 1. The Member shall appear before the Panel to be reprimanded within three months of the date that this Order becomes final. 2. The Executive Director is directed to suspend the Member s certificate of registration for five 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 the practising class. 3. The Executive Director is directed to impose the following terms, conditions and limitations on the Member s certificate of registration: a) The Member will attend two meetings with a Nursing Expert (the Expert ), at her own expense and within six months from the date of this Order. To comply, the Member is required to ensure that: i. The Expert has expertise in nursing regulation and has been approved by the Director of Professional Conduct (the Director ) in advance of the meetings;

14 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 publications and completes the associated Reflective Questionnaires, online learning modules and online participation forms (where applicable): 1. Professional Standards, 2. Medication, 3. Documentation, iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires and online participation forms; 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 clients, 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 his/her report to the Director, 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 her behaviour;

15 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 her certificate of registration; b) For a period of 18 months from the date the Member returns to the practice of nursing, the Member will notify her employers of the decision. To comply, the Member is required to: v. Ensure that 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; vi. Provide her employer(s) with a copy of: 6. the Panel s Order, 7. the Notice of Hearing, 8. the Agreed Statement of Facts, 9. this Joint Submission on Order, and 10. a copy of the Panel s Decision and Reasons, once available; vii. Only practise nursing for an employer who agrees to, and does, forward a report to the Director within 14 days of the commencement or resumption of the Member s employing in any nursing position, confirming: 1. that they received a copy of the required documents, 2. that they agree to notify the Director 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 four random spot audits of the Member s practice at the following intervals and provide a report to the Director regarding the Member s practice after each audit: a. the first audit shall take place within three months from the date the Member begins or resumes employment with the employer,

16 b. the second audit shall take place within six months from the date the Member begins or resumes employment with the employer, c. the third audit shall take place within nine months from the date the Member begins or resumes employment with the employer, d. the fourth audit shall take place within 12 months from the date the Member begins or resumes employment with the employer. viii. The audits shall, on each occasion, involve the following: 3. reviewing a random selection of the Member s charts to ensure they meet both College and employer standards, 4. discussing (by telephone or in person), with at least three of the Member s clients, the care provided by the Member to ensure that the Member is utilizing appropriate communication techniques and providing appropriate care. c) The Member shall not practise independently in the community for a period of 18 months from the date the Member returns to the practice of nursing. 4. All documents delivered by the Member to the College, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain. Reasons for Penalty Decision The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly. The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility. The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection. These objectives

17 are reached by the Member not practicing independently in the community for 18 months, and by the remediation of the Member. The penalty is in line with what has been ordered in previous cases and the Member s cooperation shows the Member is willing to work with the College to improve her practice. I, MICHAEL HOGARD, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel. Chairperson Date