DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO PANEL: BETWEEN: Lindsay Hyslop, NP Jim Attwood, RN Karen Laforet, RN Linda Bracken Margaret Tuomi Chairperson Member Member Public Member Public Member COLLEGE OF NURSES OF ONTARIO ) BONNI ELLIS for ) the College of Nurses of Ontario ) - and - ) ) ) TANYA GEORGE ) NO REPRESENTATION for Registration No. 09383455 ) Tanya George ) ) ) JOHANNA BRADEN ) Independent Legal Counsel ) ) ) Heard: May 8, 9 and 15, 2014 DECISION AND REASONS This matter came on for hearing before a panel of the Discipline Committee on May 8, 9 & 15, 2014, at the College of Nurses of Ontario ( the College ) at Toronto. The hearing commenced at 9:35 a.m. As Tanya George (the Member ) was not present, the hearing recessed for 15 minutes to allow time for the Member to attend. Upon reconvening, the panel noted that the Member was still not in attendance. Counsel for the College provided the panel with evidence that the Member had been sent the Notice of Hearing on February 24, 2014 [ ]. The panel was satisfied that the Member had received adequate notice of the time, date, place and nature of the hearing, and therefore proceeded with the hearing in the Member s absence. The Allegations
The allegations against the Member as stated in the Notice of Hearing dated February 20, 2014, are as follows. 1. You have committed an act or acts 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, and defined in paragraph 1.1 of Ontario Regulation 799/93 as amended, in that you contravened or failed to meet the professional standards of the profession while working as a nurse at [the Facility] on or about May 2 3, 2011, and, in particular, you: a) Communicated with the family members of [the Client] in a manner that would reasonably be regarded as rude and/or condescending; b) Communicated with the family members of [the Client] in a manner that would reasonably be regarded as expressing impatience and frustration; c) Argued with a family member of [the Client], who was palliative, as to whether she was dying; d) Interrupted family members of [the Client] when they tried to express concerns to you regarding [the Client]; e) Initiated an IV for [the Client] and/or administered a 1000 cc bolus dose of saline to [the Client], without a physician s order; f) Administered a 1000 cc bolus dose of saline to [the Client] in circumstances where the administration was not clinically appropriate; g) Administered Dilaudid to [the Client] without having first obtained a physician s order or, alternatively, you accepted a verbal order for Dilaudid for [the Client] in circumstances that did not warrant a verbal order; h) Failed to appropriately document a verbal order for Dilaudid for [the Client] when you failed to record the prescriber s name and designation; i) Failed to assess the appropriateness of the verbal order for Dilaudid that you recorded in [the Client] s chart; j) Failed to properly monitor and/or assess [the Client] s reaction to the Dilaudid that you administered between approximately 22:30 and 07:00, including but not limited to [the Client] s: (i) level of consciousness; (ii) vital signs; and/or (iii) level of pain; and/or
k) Administered 2 mg of Dilaudid to [the Client] at approximately 23:30, 00:30, 01:30, 02:30, 04:00, 06:00 and/or 07:00 without first assessing whether each administration was clinically appropriate. 2. You have committed an act or acts 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 paragraph 1.7 of Ontario Regulation 799/93, in that you abused a client physically or emotionally while working as a nurse at [the Facility] on or about May 2 3, 2011, when you: a) Communicated with the family members of [the Client] in a manner that would reasonably be regarded as rude and/or condescending; b) Communicated with the family members of [the Client] in a manner that would reasonably be regarded as expressing impatience and frustration; c) Argued with a family member of [the Client], who was palliative, as to whether she was dying; and/or d) Interrupted family members of [the Client] when they tried to express concerns to you regarding [the Client]. 3. You have committed an act or acts 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 paragraph 1.37 of Ontario Regulation 799/93, in that you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional and, in particular, while working as a nurse at [the Facility] on or about May 2 3, 2011, you: a) Communicated with the family members of [the Client] in a manner that would reasonably be regarded as rude and/or condescending; b) Communicated with the family members of [the Client] in a manner that would reasonably be regarded as expressing impatience and frustration; c) Argued with a family member of [the Client], who was palliative, as to whether she was dying; d) Interrupted family members of [the Client] when they tried to express concerns to you regarding [the Client]; e) Initiated an IV for [the Client] and/or administered a 1000 cc bolus dose of saline to [the Client], without a physician s order;
f) Administered a 1000 cc bolus dose of saline to [the Client] in circumstances where the administration was not clinically appropriate; Publication Ban g) Administered Dilaudid to [the Client] without having first obtained a physician s order or, alternatively, you accepted a verbal order for Dilaudid for [the Client] in circumstances that did not warrant a verbal order; h) Failed to appropriately document a verbal order for Dilaudid for [the Client] when you failed to record the prescriber s name and designation; i) Failed to assess the appropriateness of the verbal order for Dilaudid that you recorded in [the Client] s chart; j) Failed to properly monitor and/or assess [the Client] s reaction to the Dilaudid that you administered between approximately 22:30 and 07:00, including but not limited to [the Client] s: (i) level of consciousness; (ii) vital signs; and/or (iii) level of pain; and/or k) Administered 2 mg of Dilaudid to [the Client] at approximately 23:30, 00:30, 01:30, 02:30, 04:00, 06:00 and/or 07:00 without first assessing whether each administration was clinically appropriate. At the request of College Counsel, the panel made an order pursuant to s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991 that no person shall publish, broadcast or otherwise disclose the name of [the Client] or any information that would disclose the identity of [the Client] as referred to during the hearing or in any other document or exhibit filed at the hearing. Member s Plea Given that the Member was not present nor represented, she was deemed to have denied the allegations in the Notice of Hearing. The hearing proceeded on the basis that the College bore the onus of proving the allegations in the Notice of Hearing against the Member. Overview The Member was registered with the College on May 29, 2009, her registration was suspended for non-payment of fees as of February 15, 2012, and her registration was administratively revoked on February 1, 2013, for non-payment of fees. These allegations relate to when the Member s certificate of registration was active and she was working at [the Facility]. The allegations are concerned with her conduct with respect to [the
Client] and [the Client] s family during the night shift of May 2-3, 2011. The panel determined there were five main issues: 1. Did the Member contravene or fail to meet the standards of the profession in her communications with her client s family members? 2. Were the Member s communications physically and/or emotionally abusive of the client? 3. Did the Member contravene or fail to meet the standards of the profession in the administering of a saline bolus to the client? 4. Did the Member contravene or fail to meet the standards of the profession in the administering of Dilaudid to the client? 5. Would some or all of this conduct reasonably be perceived by members as disgraceful, dishonourable and/ or unprofessional? The Evidence The panel received testimony from six witnesses, one of whom was an expert on the standards of practice of the profession, and received 16 exhibits. Witness # 1: The witness was the director of operations of [the Facility] where the Member was working at the time of the allegations. She identified the medical records of the client [ ] and the written policies for the hospital [ ]. She also described the operations of the hospital, training and other relevant procedures. This evidence indicated that the Member was not following the procedures of the emergency department with respect [to] her care of the client. Witness # 2: The son of the client testified that at the time of the allegations, his mother was a 90-year-old woman who had been diagnosed with colorectal cancer in February of 2011. He and his sisters had not left her alone in her home since the diagnosis, as they were a very close-knit family. On the evening of May 2, 2011, his mother experienced severe abdominal pain so they took her by ambulance to the hospital. The wait was exceptionally long but finally she was admitted into the emergency department and given over to the care of the Member. The Member told the witness and his sisters to behave, not to look at other [clients], not to be overly demanding, and to leave the area when she was providing care. She talked a lot but did not listen to them. She would sigh and by her body language, he knew she felt he was in her way. She showed a lack of empathy, impatience [and] indifference and was more interested in them than caring for their mother. The panel agreed the son s testimony and his observations were consistent with the other evidence in the case and he seemed genuine. The panel believed his evidence. Witness # 3: This witness was one of the client s daughters and a retired nurse. She testified her mother was living on her own until her cancer diagnosis, after which, she, her sister and her brother would take turns staying with her. The client had several mild heart attacks, had been losing weight and was palliative. She still made her own personal care decisions and did not take her prescribed codeine pills unless necessary for pain. The witness testified to the same facts as
her brother concerning the care given by the Member, and her evidence was generally consistent with his. In addition, this witness testified that [ ] the Member was hopeless to talk to and made them feel like they were 5-year-old children. In terms of her mother s care, the witness testified that she fell asleep and when she woke up, she could see her mother s pulse was racing and she could not wake her mother up. The witness was very scared and upset, and she called her brother to come back to hospital. The panel agreed the daughter s testimony and observations were consistent with her brother s and with the medical evidence. The panel accepted her as a credible witness. Witness # 4: The College s fourth witness was the day nurse, who took over the client s care from the Member. She testified the dosage of Dilaudid given to the client by the Member was a significant amount for a 90- year old woman who weighed less than 100 pounds. She herself would have questioned such an order. Witness # 5: This witness was a palliative care physician at the hospital and was involved in the care of the client. He testified he saw the client14 hours after her arrival at the hospital and she was profoundly sedated. She finally woke up that evening when she was transferred to the floor. It was 24 hours later before she required any more pain medications. Witness # 6: This witness was tendered by the College and accepted by the panel as an expert witness qualified to give opinion evidence in the area of nursing standards in acute care settings. She was given a set of hypothetical facts that matched the evidence given in this case. She testified that based upon those hypothetical facts, the Member contravened the published standards of practice of the profession, particularly the Professional Standards [ ], the Therapeutic Nurse-Client Relationship Standard [ ] and the Medication Standard [ ]. The Member, by being rude to the family members, showing no empathy and not involving the family, contravened the Therapeutic Nurse-Client Relationship Standard [ ] and the Professional Standards [ ]. The Member s conduct was also emotionally abusive of the client s family, as supported by the Professional Standards [ ]. In terms of the medication breaches, the expert opined that the Member should have had a written physician s order for the Dilaudid as set out in [ ] the Medication Standard. The expert referred to the client s chart [ ], which showed orders that were missing the time, date and name of the physician who ordered the medication. In her opinion, the Member should have evaluated the appropriateness of the verbal order based on the client s age, weight and previous medications and the Member should have monitored the client. It appears from the record that no vitals [were] taken and no evaluation of the client s response to the medications [was] recorded. The Member did not assess the appropriateness of the medications nor did she monitor the situation as required by the Medication Standard [ ]. As to the saline bolus, the expert testified that according to the standard, the administration of a saline bolus requires a physician s order and that in the case of this [client], the administration of an intravenous bolus would be contraindicated. Final Submissions
College counsel submitted the panel would need to determine on a balance of probabilities whether it was more likely than not that the Member had breached the standards of practice of the profession, had been abusive to the client and had acted in [a] way that members of the profession would find to be disgraceful, dishonourable or unprofessional. Counsel reviewed the evidence, consisting of the family members testimonies, the professional witnesses testimonies on the appropriateness of administering the saline bolus and the Dilaudid dosages, the expert evidence, and the evidence contained in the exhibits, including the medical records, hospital policies, incident report and the relevant published College standards. Decision The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities and 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), (b), (d), (e), (g), (h), (i), (j), and (k); 2 (a), (b) and (d); and 3 (a), (b), (d), (e), (g), (h), (i), (j) and (k) in the Notice of Hearing. With respect to allegation number 2, the panel found that the Member emotionally abused the client. As to allegation 3, the panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession as unprofessional with respect to allegations 3 (a), (b), (d), (e), (g), (h) and (i).the panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession as disgraceful, dishonourable and unprofessional with respect to allegations 3 (j) and (k). The panel made no findings with respect to allegations 1(c), 1(f), 2(c), 3(c) and 3(f). Those allegations are dismissed. Reasons for Decision The panel considered each of the five issues in arriving at its decision. 1. Did the Member contravene or fail to meet the standards of practice of the profession in her communications with the client s family members? The panel accepted the opinion of the College s expert witness as to the standards of practice of the profession with respect to communication with family members of clients. For the factual basis of that opinion, the panel considered the testimony of the two family members and found their evidence to be consistent and direct concerning the Member s attitude, body language, sighing and treatment of the family members. There was no evidence to contradict the family members. The evidence they gave is sufficiently clear, cogent and convincing to support the allegations at paragraphs 1(a), (b) and (d). With regard to allegation 1(c), the family members testified that the Member did disagree with them as to whether their mother was dying. However, in their testimony they also stated that
they understood that the Member was referring to an imminent death which they agreed was not likely. In this respect the panel makes no finding of professional misconduct. 2. Did the Member abuse a client physically or emotionally? The panel heard from an expert witness who testified that the actions of the Member were emotionally abusive to the family in that she showed a lack of empathy and caring and exercised excessive power. The expert referred to the Therapeutic Nurse Client Relationship Standard (Revised 2006) and the Professional Standards (Revised 2002). There was no evidence presented to counter this opinion, the opinion was supported by the facts, and the panel finds the opinion reasonable in the circumstances. The panel found the Member showed no empathy or caring in her relationship with the client or the client s family, as stated in the Therapeutic Nurse Client Relationship, Revised 2006 [ ]. It is the nurse s responsibility to establish and maintain the therapeutic relationship. Accordingly, the panel finds that the Member abused a client emotionally as alleged in paragraphs 2 (a), (b) and (d) of the Notice of Hearing. As indicated above, the evidence did not prove on a balance of probabilities that the Member argued with a family member of the client as to whether the client was dying, and the panel makes no finding on this allegation. 3. Did the Member contravene or fail to meet the standards of the profession in the administering of a saline bolus to the client? The evidence established that the Member administered a 1000 cc bolus dose of saline to the client without a physician s order, and that this was a breach of the Medication Standard, as alleged at paragraph 1(e) of the Notice of Hearing. Regarding allegation 1(f), the panel relied on the evidence from the client s medical charts [ ] and the evidence from the palliative care doctor to come to a decision as to whether the Member contravened a standard of the profession in that the she administered such a 1000 cc bolus dose of saline to the client in circumstances where administration was not clinically appropriate. The expert testified that this fluid bolus was contraindicated and should not have been given to this client, however, the testimony from a physician directly involved in this client s care included evidence that the client was clinically dehydrated and that in this case the administration of saline may be appropriate. The panel preferred the evidence of the physician witness over the expert, as the physician was directly involved in the client s care and able to speak to the condition of the [client]. Accordingly, the panel makes no finding of professional misconduct with respect to allegation 1(f). 4. Did the Member contravene or fail to meet the standards of the profession in the administering of Dilaudid to the client? The panel considered the testimony of the expert witness, the medical charts, the palliative care doctor and the published College standard on Medication (Revised 2008) [ ]. The panel found from the evidence presented that the Member administered Dilaudid without having first obtained a proper physician s order, failed to properly monitor and assess the client s reaction to the Dilaudid, failed to assess the appropriateness of the verbal order for Dilaudid, failed to
document the verbal order properly, and administered 2 mg of Dilaudid on seven occasions without first assessing whether each administration was clinically appropriate. 5. Was some or all of the Member s conduct disgraceful, dishonourable and/or unprofessional? For the reasons given above, the allegations at 3(c) and 3(f) were not proven on the balance of probabilities. The panel finds that allegations 3 (a), (b), (d), (e), (g), (h), and (i) would reasonably be regarded by members of the profession to be unprofessional. With respect to allegations 3 (j) and (k), the panel found that members of the profession would reasonably regard this to be disgraceful, dishonourable and unprofessional. The panel found [ ] allegations [ ] 3(j) and (k) concerning the administration and monitoring of Dilaudid to be [of] an extremely serious nature as the client was put at considerable risk due to the carelessness of the Member. Penalty The College requested 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 six months. This suspension shall take effect from the date the Member obtains an active certificate of registration 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 of the date the Member obtain an active certificate of registration. 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; 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, and
3. 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 and online learning modules: 1. Professional Standards 2. Therapeutic Nurse-Client Relationship 3. Documentation 4. Medication; iv. Before the first meeting, the Member reviews and completes the College s self-directed learning package, One is One Too Many, at her own expense, including the self-directed Nurses Workbook; v. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, online participation forms and Nurses Workbook; vi. The subject of the sessions with the Expert will include: 1. the acts or omissions for which the Member was found to have committed professional misconduct, 2. the potential consequences of the misconduct to the Member s 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; vii. 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; viii. If the Member does not comply with any [one or more] of the requirements above, the Expert may cancel any session scheduled,
even if that results in the Member breaching a term, condition or limitation on her certificate of registration; b) For a period of 18 months from the date the Member obtain an active certificate of registration and returns to clinical nursing practice, 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, and 3. a copy of the Panel s Decision and Reasons, once available; iii. Ensure that within 14 days of the commencement or resumption of the Member s employment in any nursing position, the employer(s) forward(s) a report to the Director, in which it will confirm: 1. that they received a copy of the required documents, and 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 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 College counsel submitted the panel should take into account the seriousness of [the] charges, the aggravating and mitigating factors, the circumstances of the Member, the views of other members of the profession, and the public. The penalty should address the need for general and specific deterrence, public protection and preservation of public confidence in the College s ability to self-regulate. College counsel submitted that the Member s treatment through her comments and her body language to the client s three adult children was rude, impatient, frustrating, and condescending. Counsel referred back to the evidence from the expert witness and the physician witness concerning the seriousness of the allegations. Penalty Decision 1. The Member is required to 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 six months. This suspension shall take effect from the date the Member obtains an active certificate of registration 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 of the date the Member obtain[s] an active certificate of registration. 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; 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, and 3. 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 and online learning modules: 1. Professional Standards 2. Therapeutic Nurse-Client Relationship 3. Documentation 4. Medication; iv. Before the first meeting, the Member reviews and completes the College s self-directed learning package, One is One Too Many, at her own expense, including the self-directed Nurses Workbook; v. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, online participation forms and Nurses Workbook; vi. The subject of the sessions with the Expert will include: 1. the acts or omissions for which the Member was found to have committed professional misconduct,
2. the potential consequences of the misconduct to the Member s 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; vii. 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; viii. If the Member does not comply with any [one or more] of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration; b. For a period of 18 months from the date the Member obtain[s] an active certificate of registration and returns to clinical nursing practice, 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, and 3. a copy of the Panel s Decision and Reasons, once available; iii. Ensure that within 14 days of the commencement or resumption of the Member s employment in any nursing position, the employer(s) forward(s) a report to the Director, in which it will confirm: 1. that they received a copy of the required documents, and 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
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 deliberated and determined that the College s submission on order was reasonable and appropriate, taking into consideration the protection of the public, the general and specific deterren[ce] to the Member and the members of the profession and the rehabilitation and remediation of the Member. The panel found that the penalty was within the range of similar previous decisions of panels of this Discipline Committee. The reprimand and the suspension of six months are a message to the Member and the membership that these actions will not be tolerated by the profession. The meetings with the Nursing Expert and the review of the standards will give the Member an opportunity to improve her practice, care of clients and treatment of family members, and allow her to reflect upon the importance of proper drug administration and the necessity for good, clear documentation. These provisions, combined with the employer notification requirements, will protect the public and ensure public confidence in the nursing profession. 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: Jim Attwood, RN Karen Laforet, RN Linda Bracken, Public Member Margaret Tuomi, Public Member