DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO. PANEL: Jim Attwood, RN Chairperson Lori McInerney, RN Member Monica Seawright, RPN Member

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1 DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO PANEL: Jim Attwood, RN Chairperson Lori McInerney, RN Member Monica Seawright, RPN Member Betty Hill Public Member David Bishop Public Member BETWEEN: ) KAREN JONES for COLLEGE OF NURSES OF ONTARIO ) College of Nurses of Ontario ) - and - ) JEFFERY ROOT for ) Paul Nero PAUL NERO ) Registration No ) ) Heard: March 14, 2005 DECISION AND REASONS This matter came on for hearing before a panel of the Discipline Committee on March 14, 2005 at the College of Nurses of Ontario ( the College ) at Toronto. The Allegations The allegations against Paul Nero ( The Member ) as stated in the Notice of Hearing dated January 4, 2005, are as follows: 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 during the period , while employed as a Registered Nurse by [the hospital], you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, and in particular on one or more occasions while on duty you gave another nurse an intramuscular injection of Toradol when there was no prescription for the Toradol and/or there was no documentation of the medication administration and/or the Toradol and injection equipment belonged to your employer. 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(37) of Ontario Regulation

2 799/93, in that during the period , while employed as a Registered Nurse by [the hospital], you engaged in conduct or performed an act, relevant to the practice of nursing that, having regard to all of the circumstances would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional, and in particular: a. on one or more occasions while on duty you gave another nurse an intramuscular injection of Toradol when there was no prescription for the Toradol and/or there was no documentation of the medication administration and/or the Toradol and injection equipment belonged to your employer; b. you withheld information and/or lied to your employer when it conducted an internal investigation into its employees Toradol use. 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(8) of Ontario Regulation 799/93, in that during the period , while employed as a Registered Nurse by [the hospital], you misappropriated property from your workplace, namely Toradol and/or injection equipment. Member s Plea The Member admitted the allegations set out in paragraphs numbered 1, 2a, b, and 3 in the Notice of Hearing. The panel received a signed 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 ( ASF ) which provided as follows: THE MEMBER 1. Paul Nero (the Member ) obtained his R.N. diploma from [ ] in 1998 and registered with the College of Nurses of Ontario (the College ) that same year. 2. The Member was hired on a part-time basis at [the hospital] in January He was terminated on June 24 th, 2002 as a result of the incidents described below. 3. The Member does not have a prior discipline history with the College. THE INTERNAL INVESTIGATION AT THE FACILITY 4. In the spring of 2002, the administration at [the hospital] conducted an internal investigation into allegations that some nurses on the Operating Room/Recovery Room unit were receiving and giving intramuscular injections of Toradol during

3 5. The information came to light when one of the facility s Pharmacy Technicians was approached by the Charge Nurse in the Recovery Room area of the hospital. The Charge Nurse informed the Pharmacy Technician that some staff members had been using Toradol. This information was then reported to the Hospital Pharmacist, at which time an internal investigation ensued. 6. Narcotics and controlled drugs were kept in a locked steel box in the Recovery Room at the Welland Site. They were not stored in the Operating Room area itself. Narcotics to be used in the Operating Room are signed out by the anaesthesiologist. Narcotics to be used in the Recovery Room are signed out by the Registered Nurse on a per patient basis. 7. Toradol is a non-steroidal anti-inflammatory analgesic. It is not a narcotic. Historically at the hospital, Toradol was listed on the narcotic count sheet, counted, and kept in a locked area. The practice changed and Toradol was taken off the count and became a stock medication, which was not locked up. It was kept in an unlocked cupboard in the Recovery Room area at the time of the incidents 1. A prescription is needed for this medication. 8. As a result of the internal investigation, the Member was interviewed by hospital administration on two separate occasions. THE FIRST INTERVIEW The Member and [Nurse A]: 9. The first interview occurred on May 31 st, 2002, at which time the Member admitted that he administered two injections of Toradol to a fellow nurse, [Nurse A], for pain. He administered the first injection in the summer of 2001, and the second one in either February or March, The Member told hospital administration that there were verbal orders for both injections. He told hospital administration that he heard [Dr. A] provide a verbal order for the first injection, and that [Dr. B] had provided [Nurse A] with a verbal order for the second injection. 11. The Member admitted that no medical record was created, nor were these administrations of Toradol documented in any hospital records. 12. The Member acknowledged that he received a telephone call from [Nurse A] on May 31 st, 2002, while working in the Recovery Room. He stated, however, that he and [Nurse A] did not discuss Toradol and its use during this call. The Member and [Nurse B]: 1 Since the incidents, the facility has placed Toradol back on the narcotic count sheet. Presently it is counted and kept in a locked cupboard.

4 13. The Member further admitted that he had administered an injection to another colleague, [Nurse B], with a verbal order from one of the physicians at the hospital, [Dr. B]. The Member maintained that he verbally confirmed the order for 30 mg of Toradol to be administered intramuscularly with [Dr. B] himself. Additional Facts from the First Interview: 14. Throughout this interview, the Member repeatedly denied receiving or giving any other drugs to staff on any other occasions and repeatedly denied having knowledge of staff giving or receiving hospital drugs. 15. At the conclusion of the interview, the Member was suspended with pay pending the continuing investigation into these matters. He was cautioned, and he agreed not to discuss this situation with other staff or physicians during the continuing investigation. 16. All physicians who worked on the unit were interviewed during the hospital s investigation, and each one denied having ever given any orders, verbal or written, for injections of Toradol to hospital staff. [Dr. A] stated that he had never ordered Toradol IM for a staff member. [Dr. B] stated that, under no circumstances, did he give either verbal or written orders to any of the nurses in the Operating or Recovery Rooms for Toradol. 17. The Charge Nurse of the Recovery Room, [ ], was also interviewed during the internal investigation. She told hospital administration that on May 31, 2002 the Member spoke with [Nurse A] by phone when he was working in the Recovery Room and she heard the Member say they needed to get their stories straight. Furthermore, the Member had told her earlier that morning, after speaking with someone else on the phone, that he guessed [they] [were] all in deep shit now. [The Charge Nurse] said she told the Member, after his conversation with [Nurse A] that he needed to be truthful with hospital administration. THE SECOND INTERVIEW The Member and [Nurse C]: 18. The Member was interviewed a second time on June 7 th, At the outset of this interview, the Member admitted that he had injected another colleague, [Nurse C], with Toradol in the fall of 2001, a fact he did not disclose during his initial interview. 19. The Member admitted that he took hospital Toradol, drew up the drug into a syringe and injected [Nurse C] in the Recovery Room. He gave [Nurse C] this injection in the absence of a physician s order, which he acknowledged was required. He admitted that neither he nor [Nurse C] created a medical record, nor did they document the administration of the Toradol in any hospital record. 20. The Member told hospital administration that he did not admit to having given [Nurse C] the injection of Toradol at his initial interview because he was afraid that he would lose

5 his registration as a Registered Nurse with the College as a result of not having a physician s order to administer the drug. 21. The Member also admitted that he spoke to [Nurse C] prior to his initial interview and together they agreed that, due to the absence of a physician s order for the Toradol, both she and the Member would deny any knowledge of the injection he had given to her. This conversation occurred a few hours prior to the Member s initial interview with hospital administration. The Member maintained that he gave [Nurse C] one injection only, in November [Nurse C] was interviewed during the internal investigation, and she told hospital administration that the Member administered a second injection of Toradol to her, without a physician s order, in the nurse s lounge. The Member and [Nurse B]: 23. The Member admitted he had not been truthful in his first interview when he said he had physicians orders for the Toradol administered to [Nurse A]. However, he continued to maintain he had a physician s order for the single Toradol injection he administered to [Nurse B]. 24. The Member also admitted breaching his agreement with hospital administration not to discuss the situation with other staff. In fact, he had called [Nurse B] during the evening of May 31, 2002, following his first interview, in an attempt to confirm that she had told the same story to hospital administration during her interview. The Member and [Nurse A]: 25. The Member admitted to hospital administration that he lied in his initial interview when he claimed there were physicians orders for the two Toradol injections he gave to [Nurse A]. He stated that [Nurse A] told him [Dr. A] had given her a verbal order for the first injection, although he did not hear it himself and he did not confirm it. 26. Furthermore, the Member admitted that prior to his and [Nurse A s] initial interviews with hospital administration, they discussed the situation and [Nurse A] reminded him that there were verbal orders for the two injections he had given to her. This discussion occurred on May 31 st, 2002 over the phone while the Member was working in the Recovery Room. The Member said that earlier that morning the Charge Nurse told him that she had spoken to Pharmacy about the use of Toradol by staff, and when he spoke with [Nurse A] he informed her that her interview would be about Toradol. 27. The Member admitted that he lied during his initial interview when he told hospital administration that he had not spoken to [Nurse A] about Toradol. Additional Facts from the Second Interview: 28. The Member denied taking or using Toradol himself.

6 29. The Member told hospital administration that he had no conversations with staff about being warned against giving injections of Toradol. He later acknowledged that he spoke with his Charge Nurse, [ ], after either the first or second injection he gave to [Nurse A], and [the Charge Nurse] warned him to be careful. 30. The hospital terminated the Member s employment on June 24 th, 2002 for the following reasons: that the Member s conduct included having given injections of the prescription drug Toradol to three staff members on five occasions, over a lengthy period of time, on hospital premises, without a physician s order, and at least one of these injections occurred in the Recovery Room when patients were present. Furthermore, the Member stole hospital property (Toradol, syringes and needles), lied to the hospital, and obstructed the hospital s investigation. ADDITIONAL INFORMATION 31. Following his termination, the Member worked as a Registered Nurse at [other facilities]. 32. [The member experienced stress as a result of these incidents]. ADMISSIONS 33. The Member agrees that he failed to meet the standards of practice of the profession in that during the period , while at the hospital and on duty, he gave to other nurses intramuscular injections of Toradol, when there was no prescription for the Toradol, no documentation of the medication administration, and the Toradol and injection equipment belonged to his employer. 34. The Member agrees that he committed acts of professional misconduct during the period of when he engaged in conduct relevant to the practice of nursing that, having regard to all of the circumstances, would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional as he: a. while at the hospital and on duty, gave other nurses intramuscular injections of Toradol when there was no prescription for the Toradol, no documentation of the medication administration, and the Toradol and injection equipment belonged to his employer; and b. withheld information and/or lied to his employer when it conducted an internal investigation into its employees Toradol use. 35. The Member also agrees that he committed an act of professional misconduct when, during the period , while employed as a Registered Nurse by [the hospital], he misappropriated property from his workplace, namely Toradol and injection equipment. 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 an act of professional misconduct as alleged in paragraphs 1, 2a, b, and 3 of the Notice of Hearing.

7 The Member contravened and failed to meet the standards of practice of the profession. The Member engaged in conduct and performed an act, relevant to the practice of nursing that would reasonably be regarded by members of the profession as disgraceful, dishonourable and unprofessional. Specifically: The Member on one or more occasions while on duty gave another nurse an intramuscular injection of Toradol when there was no prescription for the Toradol and there was no documentation of the medication administration and/or the Toradol and injection equipment belonged to your employer. The Member withheld information and lied to the employer when it conducted an internal investigation into its employees Toradol use. Furthermore, the Member misappropriated property from the workplace, namely Toradol and injection equipment. Reasons for Decision The panel deliberated and accepted the Agreed Statement of Facts which substantiated the finding of professional misconduct as alleged. Penalty Counsel for the College advised the panel that a Joint Submission as to Penalty ( JSP ) had been agreed upon. The JSP provides as follows: 1. Requiring the Member to appear before the panel to be reprimanded; and 2. Directing the Executive Director to suspend the Member s certificate of registration for 90 days; and 3. Directing the Executive Director to impose the following terms, conditions, and limitations on the Member s certificate of registration: i. That the Member provide evidence of successful completion of a course in ethics that has been approved by the Director of Investigations and Hearings, within 12 months of the date of the panel s decision in this matter; ii. That the Member meet with a Practice Consultant to review the College s Professional Standards and Ethical Framework, and to discuss the issues that arose in this case as they relate to the Member and his practice, at a date mutually agreeable with both the Member and the Practice Consultant, and no

8 later than within 3 months of the Member having completed the course referred to in paragraph 3(i). Penalty Decision The panel accepts the JSP and accordingly orders: 1. that the Member to appear before the panel to be reprimanded; and 2. that the Executive Director to suspend the Member s certificate of registration for 90 days; and 3. that the Executive Director impose the following terms, conditions, and limitations on the Member s certificate of registration: i. That the Member provide evidence of successful completion of a course in ethics that has been approved by the Director of Investigations and Hearings, within 12 months of the date of the panel s decision in this matter; ii. That the Member meet with a Practice Consultant to review the College s Professional Standards and Ethical Framework, and to discuss the issues that arose in this case as they relate to the Member and his practice, at a date mutually agreeable with both the Member and the Practice Consultant, and no later than within 3 months of the Member having completed the course referred to in paragraph 3(i). Reasons for Penalty Decision 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 for his actions and has avoided unnecessary expense to the College. The panel recognizes that this is a serious matter. The Member initially and deliberately attempted to mislead and deceive the employer regarding misappropriation and administration of Torodol. There was no record, nor did the Member document the administration of the Toradol in any hospital record. The Member admitted his involvement and dishonesty in a second interview one week later. Mitigating factors included that the Member: had no previous discipline history with the College was relatively new to the profession

9 experienced serious consequences including loss of his employment as well as personal hardships both financially and emotionally The panel finds the JSP includes a significant penalty as well as a remedial component. The JSP provides specific deterrence to the Member, a general deterrence to the membership and protects the public safety. Counsel for the College and the Member presented a letter from the Member s present employer, [ ]. The letter requested the College defer the implementation of the penalty for a 60 day period. The panel considered the rationale presented in it and agreed to this request. I, Jim Attwood, RN, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel as listed below: Chairperson Date Panel Members: Lori McInerney, RN Monica Seawright, RPN Betty Hill, Public Member David Bishop, Public Member