DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO PANEL: Tammy Hedge, RPN Chairperson Ashley Friest, RPN Member Susannah McGeachy, RN Member Abdul Patel Public Member Devinder Walia Public Member BETWEEN: COLLEGE OF NURSES OF ONTARIO ) EMILY LAWRENCE for ) the College of Nurses of Ontario - and - ) ) LANCELOT E. WILLIAMS ) DAVID LEONARD LEE for Registration No. HC03414 ) Lancelot E.Williams ) ) ) JOHANNA BRADEN ) Independent Legal Counsel ) ) ) Heard: December 15, 2014 DECISION AND REASONS This matter came on for hearing before a panel of the Discipline Committee on December 15, 2014, at the College of Nurses of Ontario ( the College ) at Toronto. The Member was present and represented. The Allegations 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 on April 3, 2011, while working as a registered practical nurse at [the Facility], you contravened a standard of practice of the profession or failed to meet a standard of practice of the profession in that you failed to: a) provide appropriate care and treatment to [the Client] before, during and after [the Client] suffered an anxiety attack;
b) follow a physician s order in respect of the care and treatment to be provided to [the Client] during an anxiety attack; c) appropriately document your observations of [the Client] and/or the care and treatment you provided to [the Client] before, during and after [the Client] suffered an anxiety attack; and/or d) provide appropriate measures to [the Client] when you discovered [the Client] with vital signs absent; and/or 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(14) of Ontario Regulation 799/93, in that on April 3, 2011, while working as a registered practical nurse at [the Facility], you failed to keep records as required in connection with your care and treatment of [the Client] before, during and after [the Client] suffered an anxiety attack; and/or 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 on April 3, 2011, while working as a registered practical nurse at [the Facility], 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, in that you failed to: Member s Plea a) provide appropriate care and treatment to [the Client] before, during and after [the Client] suffered an anxiety attack; b) follow a physician s order in respect of the care and treatment to be provided to [the Client] during an anxiety attack; c) appropriately document your observations of [the Client] and/or the care and treatment you provided to [the Client] before, during and after [the Client] suffered an anxiety attack; and/or d) provide appropriate measures to [the Client] when you discovered [the Client] with vital signs absent. The Member admitted the allegations set out in paragraphs 1, 2, and 3 in the Notice of Hearing. The panel received a written plea inquiry which was signed by the Member. In addition, the panel conducted an oral plea inquiry. During the oral plea inquiry, the Member initially denied allegation 1b, but after consulting with his legal representative, admitted to all the allegations in paragraphs 1, 2, and 3 of the Notice of Hearing. The panel initially had concerns that the Member may not have made his plea with full understanding of its implications. To satisfy its concerns, the panel chair repeated the oral plea inquiry and the panel members were ultimately 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. Lancelot E. Williams (the Member ) obtained a certificate in nursing [ ] in 1983. 2. The Member registered with the College of Nurses of Ontario (the College ) as a Registered Practical Nurse ( RPN ) in January 1983. 3. The Member was employed at [the Facility] between November 2010 and April 2011. He worked at [the Facility s] predecessor, [ ], for 28 years before November 2010. 4. The Member was terminated from [the Facility] on April 21, 2011 as a result of the incident described below. He grieved his termination and was successful. The termination was rescinded. The Member now works at [another facility]. THE FACILITY 5. [The Facility] was located [in] Ontario. 6. [The Unit] located at [the Facility] was a [ ] tertiary care mental health facility [ ]. The purpose of the Unit was to treat tertiary mental health clients (i.e. those who had clinically complicated and challenging mental health issues requiring specialized care). As a result of the Unit opening, [the Facility s predecessor] would no longer offer tertiary mental health resources. It transferred some of their tertiary care beds [ ] as well as other staff and clients to [the Facility] at that time. 7. The Unit [ ] is divided into three pods [ ]. Pods 1 and 2 were for tertiary mental health [clients] while pod 3 is for senior mental health [clients]. 8. Each pod was to be staffed with two nurses and a float nurse. 9. The Member was assigned to pod 2 of the Unit. Relevant [Facility] Policies A. Observation of Clients 10. The [Facility] had a policy describing the levels of observation for inpatient psychiatric [clients]. Three levels of observation were relevant:
a. Routine Observation an awareness of a client s whereabouts at all times, and accounting for each client every 60 minutes. Hourly rounds are documented on an Hourly Round Count; b. Close Observation ( Q15 checks ) observation every 15 minutes, documented on a Close Observation Form; and c. Constant Observation a staff member must be present with the client at all times, having a clear visual of the client and being within hearing distance. 11. Treating physicians could order a certain observation level for their clients. Otherwise, nurses determined the appropriate observation level by assessing a client s behaviour and risk factors for harm. Nurses were not permitted to decrease the level of observation ordered without a physician s order. Nursing staff were required to notify the physician in charge if there was a change in the client s level of observation. B. Documentation 12. The [Facility] also had a documentation policy that required all documentation to be complete, concise and timely. All staff were required to document the care provided personally to a client, which was consistent with the College s standards on documentation. 13. It was not the Unit s practice for one nurse to document observation checks that another nurse performed. Where a nurse is performing Q15 checks, he or she was expected to document the Q15 checks, as well as documenting relevant information that occurred between those checks. In cases of constant observation, the nurse was expected to document regularly and would be relieved for short breaks to do the documentation. C. Codes 14. All staff in [the Facility] were trained in code procedures along with other policies and procedures during orientation. Staff new to [the Facility] were trained within the first three weeks of employment on all [Facility] procedures, including calling codes. As part of that training, staff were required to complete and pass an electronic learning module on all codes. A grade of 80% was a passing mark for the electronic training module. 15. A Code Blue was to be initiated when an adult client is found with no pulse and no respirations. The Code Blue procedure was as follows: a. Staff who found a client in Code Blue were to: i. call for help;
ii. confirm whether the client had a do not resuscitate order; iii. dial [##] to page and state Code Blue and the location; and iv. initiate CPR. b. Upon hearing a page, one person from each in-patient unit and security would respond to the location of the Code Blue; and c. Additional responders to the Code Blue would dial 911 to request an ambulance, obtain a Code Cart and assist with the CPR and documentation. THE CLIENT 16. [The Client] was an involuntary [client] who entered the Unit in January 2011. Doctors were trying to clarify his diagnosis. He had a long history of recurrent psychosis, disorganized and disruptive behaviour, as well as self-injurious behaviour. In addition, he had extreme episodic anxiety attacks. 17. [The Facility], as a whole, was moving away from a philosophy of seclusion and restraint to one of rehabilitation and coaching. Dr. [A], the Client s physician, made it known to staff that seclusion and restraints were to be avoided to allow the Client to develop coping mechanisms during his anxiety attacks. Different strategies were used to manage and de-escalate the Client s behaviour, such as holding ice, deep breathing, cue cards with calming thoughts and other coaching by staff. 18. As set out in the Client s care plan dated January 20 [ ], staff were expected to encourage the Client to use coping mechanisms. If they were unsuccessful, the Client would be given PRN medication at his request. The Client was prescribed a number of medications, including, but not limited to, Lorazepam and Quetiapine PRN, as well as Clozapine twice daily. 19. On March 22 [ ], Dr. [A] created a physician s order which stated that the Client was to be on constant observation (NOT SECLUSION) with coaching for the 2-3 hour episode (emphasis in original) when the Client became agitated. Staff were to remain with him during an episode. The Member was aware of this order. 20. Between March 22 [ ] and April 1 [ ], Dr. [A] periodically ordered and discontinued Q15 checks. However, the order for constant observation during an anxiety attack was a continuing order. Staff, including the Member, were aware that this was a continuing order. 21. The Member had worked with the Client on and off over many years and was familiar with the Client s behaviour.
INCIDENT RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT The Events of the Evening of April 3 [ ] 22. The Client was anxious, but was not having an anxiety attack, during the afternoon of April 3 [ ]. His assigned nurse assisted him with cue cards, but did not employ constant observation. She checked on him every five minutes so she could attend to other [clients]. These interactions were not documented in the progress notes or on a close observation form, as required. The Client eventually settled. 23. The Member and RN [A] were scheduled to work the evening/night shift from 7 p.m. to 7 a.m. in pod 2. 24. There were 13 clients in pod 2. The Member was assigned to seven clients, including the Client. RN [A] was assigned the other six clients. The float nurse was sick and another staff member was called in to work from 11 p.m. to 7 a.m. As a result of the scheduling, the Member and RN [A] were the only staff members in pod 2 from 7 p.m. to 11 p.m. 25. The Client requested PRN medication at the beginning of the Member s shift, but wanted to wait until later for administration because he was socializing with a female peer. The Client s behaviour escalated when the peer went to bed around 8:30 p.m. The Member administered Lorazepam PRN at approximately 9:30 p.m. and documented this administration. 26. The Member did not document any Q15 checks at any point during the shift. 27. Despite Dr. [A s] order, the Member did not initiate constant observation. If the Member were to testify, he would state that he disagreed with the order for constant observation because, it had not been beneficial to the Client in the past and was not feasible given the staffing on pod 2. The Member admits that he did not document his concerns regarding the order for constant observation or raise these concerns with his manager or Dr. [A]. If the Member were to testify, he would state that he did speak with RN [A] regarding such concerns and understood [RN A] had raised them with Dr. [A], who dismissed them. 28. Between 9:30 p.m. and 10:45 p.m., the Client was disruptive. He was undressed and running around the Unit. He was redirected to his room. The Member observed the Client naked on his bed, rolling around and shaking a soda bottle over his room. The Client was instructed to clean up his room and take a shower, but was instead observed masturbating in his bathroom. The Member did not document the behaviour.
29. If the Member was to testify, he would state that he completed hourly and Q15 checks of the Client. 30. RN [A] documented the routine hourly checks even though the Member completed them, contrary to the Unit s policy as well as College standards. 31. Between 10:45 p.m. and 11:00 p.m., the Member settled other clients and advised RN [A] that the Client had soiled his room. At 11:05 p.m. or 11:10 p.m., the Member returned to the Client s room and found the Client naked on his bed, with his extremities mottled and his face discoloured. The Member checked for a pulse and found the Client vital signs absent. He went to find RN [A] and brought her to the Client s room. 32. Neither the Member nor RN [A] initiated CPR or a Code Blue. 33. Instead, RN [A] called nurses in pods 1 and 3 to confirm the appropriate procedure for handling a client with vital signs absent. RN [A] and the Member were advised by several colleagues to call a Code Blue, start CPR if there was no do not resuscitate order, call 911 and call the doctor. They did not call a Code Blue or initiate CPR immediately. Instead, a colleague paged the administrator on call while RN [A] called 911. Three RNs from other pods who had been called by RN [A] attended in pod 2 and began CPR on their own initiative at 11:21 p.m. 34. The Code Blue was announced at the [Facility s other] site at 11:25 p.m., and then at the [Facility] at 11:30 p.m., as a result of the call to the administrator on call. 35. There were at least 11 minutes between finding the Client vital signs absent and beginning CPR, and 15 to 20 minutes between finding the Client vital signs absent and calling Code Blue. 36. The fire department arrived at 11:30 p.m. and the ambulance arrived at 11:33 p.m. The Client was pronounced dead at 11:53 p.m. 37. At 12:07 a.m., the Member charted the events of the evening in the progress notes, these being the only notes he made regarding the Client all shift (excluding the medication administration entry at 9:30 p.m.). Around this time, the Clinical Manager arrived and secured the chart. The Coroner s Investigation 38. The coroner found no anatomical cause of death. He concluded that the Client died of a cardiac arrhythmia in an excited delirium state. He noted that the use of Clozapine is associated with cardiac arrhythmia and that schizophrenics are at a slightly increased risk of sudden death for unknown reasons.
ADMISSIONS OF PROFESSIONAL MISCONDUCT 39. The Member admits that he breached the standards of practice of the profession when he failed to provide appropriate care and treatment to the Client, failed to follow a physician s order in respect of the care and treatment to be provided to the Client, failed to appropriately document his observations and/or the care and treatment of the Client, and failed to provide appropriate measures to the Client when the Client was discovered with vital signs absent. 40. The Member also admits that he breached s. 1(14) of Ontario Regulation 799/93 when he failed to keep records as required in connection with his care and treatment of the Client. 41. The Member admits that he committed the acts of professional misconduct as described in paragraphs 22 to 37 above and as alleged in the Notice of Hearing at paragraphs: 1(a), (b), (c), (d); 2; and 3(a), (b), (c), (d) in that the conduct was unprofessional. Decision The panel considered the Agreed Statement of Facts and finds that the facts support findings of professional misconduct. In particular, the panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1 and 2 of the Notice of Hearing in that he: failed to meet a standard of practice with respect to providing appropriate assessment, care, and treatment to a client before, during, and after an anxiety attack; failed to follow a physician s order, and failed to follow an appropriate process when he disagreed with a physician s order; and failed to document his actions appropriately. The panel also finds the Member committed acts of professional misconduct as alleged in paragraph 3 of the Notice of Hearing in that he engaged in conduct relevant to the practice of nursing which would reasonably be regarded by members of the profession as unprofessional. Reasons for Decision The panel considered the Agreed Statement of Facts and the Member s plea and finds that the evidence supports findings of professional misconduct as alleged in the Notice of Hearing. Allegation 1(a) is supported by paragraphs 17, 19, 27, and 28 in the Agreed Statement of Facts. Allegation 1(b) is supported by paragraphs 17, 19, 20, 21, and 27 in the Agreed Statement of Facts.
Allegation 1(c) and Allegation 2 are supported by paragraphs 26, 27, 28, and 30 in the Agreed Statement of Facts. Allegation 1(d) is supported by paragraphs 31, 32, and 33 in the Agreed Statement of Facts. With regard to allegations 3(a), 3(b), 3(c), and 3(d), the panel finds that the Member engaged in conduct relevant to the practice of nursing that, having regard to all circumstances, would reasonably be regarded by members of the profession as unprofessional. The Member s conduct was unprofessional in that he failed to provide appropriate care or advocate for appropriate care and treatment of a client before, during and after an anxiety attack and during a crisis situation when he discovered a client with vital signs absent. Furthermore, the Member failed to follow a physician s order and failed to take appropriate steps for disagreeing with an order or plan of care, and failed to document as required regarding his care and treatment of a client. The expectation that nurses provide adequate care to clients, particularly in crisis situations, is at the heart of public trust of the profession. The panel finds that, when taken together, this conduct demonstrated serious disregard for the Member s professional obligations. 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: 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 two 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 three meetings with a Nursing Expert (the Expert ), at his own expense and within six months of 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; 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 and online learning modules: 1. Professional Standards, 2. Documentation, 3. Therapeutic Nurse-Client Relationship, and 4. Disagreeing with the Plan of Care; 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 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 his behaviour; vii. If the Member does not comply with any [one or more] of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on his certificate of registration; b) For a period of 24 months from the date the Member s suspension ends, the Member will notify his 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 his 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. 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 Counsel for the College submitted that the penalty proposed in the Joint Submission on Order meets the goals of general and specific deterrence, public protection, and remediation. The oral reprimand and two-month suspension meet the requirement of general deterrence by sending a clear message to professional members that this conduct is serious and will not be tolerated. Specifically, adequately documenting care following a client s plan of care, and initiating code blue procedures fall at the core of nurses obligations. All members have a clear responsibility to meet these standards. College Counsel submitted that the oral reprimand and two-month suspension also provide specific deterrence for the Member himself, ensuring against engaging in similar conduct in [the] future. Counsel for the College further submitted that the suspension and education components of the penalty package provide for public protection, and that the goal of remediation is met through requirements regarding meetings with a nursing expert, professional standards review and online learning modules. Counsel for the College submitted that the proposed penalty, including the two-month suspension, falls within the range of penalties imposed by panels of the Discipline Committee in the past for similar misconduct. Counsel provided the panel with two previous discipline panel decisions: CNO v. Sircar (Discipline Committee, 2011) and CNO v. Alleyne (Discipline
Committee, 2012). The misconduct found in these cases, like the current case, involved failure to provide appropriate care and monitoring to a deteriorating [client] who subsequently died, and failure to document adequately. The penalties in the Sircar and Alleyne decisions included [five-] and [three-] month suspensions, respectively, along with reprimands, remedial education, and a period of employer notification. Counsel for the College highlighted mitigating factors in this case regarding both the Member and the events. As to the Member, he participated fully in the discipline process and in doing so has taken responsibility for his actions and avoided a lengthy and costly hearing. Furthermore, he has a long career in mental health nursing with no previous findings of professional misconduct. The College is aware that the Member has undertaken significant self-reflection and that the events described in the allegations were intensely traumatic for him. As to the circumstances, the College acknowledges as mitigating factors that the unit was significantly understaffed at the time of the events, and that the Member was managing competing responsibilities at the time as a result. Counsel for the College submitted that aggravating factors for the case included the seriousness of the conduct and the seriousness of the outcome, that being the death of a client. Finally, College Counsel submitted that the proposed penalty strikes an appropriate balance in acknowledging mitigating factors, including the Member s lengthy career and the events of the day, against the seriousness of the misconduct. The Member s representative agreed with [College] Counsel s submissions and made no further submissions. Penalty Decision The panel accepts the Joint Submission as to Order and accordingly orders: 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 two 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 three meetings with a Nursing Expert (the Expert ), at his own expense and within six months of 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; 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. [the] 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 and online learning modules: 1. Professional Standards, 2. Documentation, 3. Therapeutic Nurse-Client Relationship, and 4. Disagreeing with the Plan of Care; 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 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 his behaviour; vii. If the Member does not comply with any [one or more] of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on his certificate of registration; b. For a period of 24 months from the date the Member s suspension ends, the Member will notify his 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 his employer(s) with a copy of: 1. the Panel s Order, 2. the Notice of Hearing, 3. the Agreed Statement of Facts, 4. [the] Joint Submission on Order, and 5. 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 considered the Joint Submission as to Order and concluded that the proposed penalty is reasonable and in the public interest. The panel finds that the penalty provides for the goals of general and specific deterrence and sends a clear message to the Member and the professional membership at large that nurses have an obligation to adhere to a client s plan of care; follow established procedures for disagreeing with a plan of care; provide an adequate level of care, monitoring, treatment to clients in crisis; initiate emergency procedures promptly; and document appropriately. Failure to meet these responsibilities is unprofessional and unacceptable. The suspension, period of employer
notification, and educational review meetings with a nursing expert provide for public protection by ensuring the Member receives adequate practice support and monitoring following his return to practice. Meetings with the nursing expert, standards review, and online learning modules provide the Member with opportunities for remediation and support a safe return to practice for the Member and the public. The panel acknowledges the Member s cooperation with the College and recognizes that in agreeing to the facts and proposed penalty, he has accepted responsibility for his actions. The panel also appreciates both the mitigating and aggravating factors in this case and finds that the proposed penalty strikes [an] acceptable balance in taking into account all circumstances, and falls within the range of reasonable outcomes. I, Tammy Hedge, 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 as listed below: Chairperson Date Panel Members: Ashley Friest, RPN Susannah McGeachy, RN Abdul Patel, Public Member Devinder Walia, Public Member