DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO PANEL: Jim Attwood, RN Chairperson Cheryl McMaster, RPN Member Kris Guty, RN Member David Bishop Public Member Faira Bari Public Member BETWEEN: COLLEGE OF NURSES OF ONTARIO ) KAREN JONES for ) College of Nurses - and - ) ) JOHN FORSON ) ELIZABETH MCINTYRE Registration No. 9884701 ) for John Forson ) ) ) Heard: October 12, 2005 AMENDED DECISION AND REASONS This matter came on for hearing before a panel of the Discipline Committee on October 12, 2005 at the College of Nurses of Ontario at Toronto. The allegation against John Forson RN (the Member ) as stated in the Notice of Hearing dated September 13, 2005 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 on November 13, 2002, while employed as a Registered Nurse at [the Facility] in [ ] Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession with respect to your assessment and/or nursing interventions and treatment and/or documentation concerning a client [ ]. Member s Plea
John Forson admitted the allegation set out in paragraph number 1 in the Notice of Hearing. The panel conducted a plea inquiry and was satisfied that the Member s admission was voluntary, informed and unequivocal. Agreed Statement of Facts Counsel for the College advised the panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts which provided as follows: THE MEMBER 1. John Forson (the Member ) graduated as a Registered Nurse [ ] in 1998. He became a member of the College of Nurses of Ontario (the College ) in November 1998. 2. The Member was hired to work as a casual employee at [the Facility] on October 18, 1999, where he worked [ ] in geriatrics and medical units. At the time of the incident described below, the Member was also working as a casual employee at two other [ ] hospitals. 3. On November 13, 2002, the Member worked a 12-hour shift [ ] from 07:30 to 19:30 hours. He provided care for [the Client] for the period from 17:30 hours until the end of his shift. 4. The Member has no prior discipline history with the [Facility] or the College. THE [CLIENT] 5. [The Client], was a 72-year-old man who had been admitted via the Emergency Department of [the Facility] at approximately 11:30 hours on November 12, 2002. He had a large malignant tumour on his right salivary gland and came to the Emergency Department complaining of head and neck pain. When assessed in Emergency, it was discovered that he was in rapid atrial fibrillation, a form of irregular electrical activity in the atria of the heart. 6. As a result of the atrial fibrillation diagnosis, telemetry was ordered for [the Client] at 21:30 hours on November 12, 2002. [The Client] was kept in Emergency department until the afternoon of November 13, 2002, when a pack, channel and a bed became available to allow for his transfer to 17 South for management of his pain and atrial fibrillation. He was in satisfactory condition with a heart rate in the 80s. 7. [The Client] went into cardiac arrest in the early morning of November 14, 2002. Attempts made to resuscitate him were unsuccessful. TELEMETRY 8. The purpose of telemetry is to maintain continuous ECG monitoring of the [client] s heart utilizing a radio transmitter system. 17 South is one of the designated telemetry floors for [clients] with symptomatic but non-lethal arrhythmia who are hospitalized for arrhythmia diagnosis and/or control. It is staffed exclusively by registered nurses. [Clients] with confirmed or suspected acute myocardial infarction are cared for in the Cardiac Care Unit.
9. At the time of the incident, Hospital policy required that the department transferring a [client] to the 17 th level for telemetry monitoring was responsible for ensuring that a telemetry pack and channel were available on the 17 th level before transferring the [client]. Hospital policy also required that [clients] requiring telemetry monitoring be continuously monitored using a portable monitor during transfer from the Emergency Department, and that the telemetry transmitter, cables, and electrodes should be ready for use when a monitored [client] is received from another area. 10. It was the responsibility of the receiving nurse to physically obtain and apply the telemetry pack for the [client] and to ensure that the channel to the Critical Care Unit was working. THE INCIDENT 11. As a result of the atrial fibrillation, telemetry was ordered for [the Client] at 21:30 hours on November 12, 2002. [The Client] was kept in the Emergency Department for approximately 18 hours where his atrial fibrillation was monitored and treated and his pain was controlled with a narcotic analgesic. During the afternoon of November 13, 2002 a telemetry pack, channel and bed became available, and an order for his transfer to the 17 th level was made. 12. [The Client] s nurse in the Emergency Department, [the ER nurse], was an agency nurse who has worked in other hospitals where, in her experience, [clients] who require cardiac monitoring and are being transferred from ER to an in-patient unit, would require a portable monitor and would be accompanied by a registered nurse. 13. [The ER nurse] placed a call to the 17 th level prior to [the Client] s transfer to speak to the Member, who would be receiving [the Client] and taking over his care. She informed the Member that [the Client] was a 72-year-old male telemetry [client] who was being transferred to the 17 th level for care. She informed the Member that [the Client] s heart rate had improved, from the mid-to-high 100s to within the 80s, after treatment with Cardiazem. He has had intermittent pain which had been relieved with pain medication. [The Client] was ambulatory to the bathroom and was in stable condition. 14. [The ER nurse] did not advise the Member that a telemetry pack and channel were arranged and available for [the Client] on the 17 th level. She did not advise the Member that he would have to apply telemetry. 15. [The Client] was transferred to the 17 th level at approximately 17:30 hours by an orderly, without a telemetry pack or a portable monitor, and without being accompanied by a registered nurse. He had a saline lock in place but no IV was running. 16. The Member had not been assigned to a [client] requiring telemetry monitoring while working at this Hospital. As a result, he was not familiar with the protocol for telemetry at [the Facility]. He was, however, familiar with the protocol at the other hospitals where he worked. At those hospitals, telemetry packs were applied to [clients] in the emergency department and the [clients] were transferred to the floor by a registered nurse with telemetry packs in place.
17. At approximately 17:30 hours, the Member moved [the Client] from where he had been left at the nursing station, to his room. He saw the Doctor s Orders for telemetry and IV therapy (IV NS @ 100 cc/hr). The Member did an initial assessment of [the Client], including vital signs, oxygen level, and listened to his chest. The Member assumed that the [Client] had had a telemetry pack applied in Emergency. When he realized that the [Client] had arrived from the Emergency Department without a telemetry pack in place, despite the existing order, he concluded that he needed clarification of the doctor s order. 18. Unfortunately, before he could complete his initial assessment of [the Client], the Member s pager went off and he was needed elsewhere to assist another [client]. The Member acknowledges that his ringing pager and his other four [clients], each requiring total [client] care, distracted him from [the Client]. As a result, he did not seek clarification of the order. 19. The Member s shift ended at 19:30 hours. At approximately 19:15 hours, when the Member was doing his final check of his [clients], the Member noticed that [the Client] had pulled out his saline lock. The Member wrote this fact on the Shift Change Report for [the Client]. The Member did not write or communicate information regarding the existing orders for telemetry and IV therapy on the shift change report. It was, however, recorded on the Kardex. 20. The Member entered the following note in the [Client] s progress record: Nsg Note: Nov 13/02 17:30-19:30 rec d patient from ER via stretcher. oriented x room up and about, BR privilege. VSS 83 18 37.1 97% R/A 132/84. no c/o chest pain or any distress. 1800 meds given Pt pulled out his s/l by self. Tumour at neck remains distended. Call at reach. 21. The oncoming nurse [ ] began her shift at 19:30 hours and received the written Shift Change Report from the Member. As a result of the information communicated on it, [the oncoming nurse] attempted, at one point, to reinsert the saline lok, without success. [The oncoming nurse] was aware that, after having read the [client] s kardex, a physician s order for telemetry monitoring existed, but she neither applied the telemetry pack nor followed up with the on-call physician. She checked on the [Client] periodically over the next few hours. 22. Around 01:10 hours, [the oncoming nurse] found the [Client] with vital signs absent and called a Code Blue. Despite numerous attempts, the code team was unable to resuscitate the [Client]. ADDITIONAL INFORMATION 23. The 17 th level is a busy acute medical unit, with 24 beds at the time of the incident. The registered nurses are responsible for total [client] care of their [clients], many of whom are non-ambulatory, incontinent and require assistance with feeding. Nurses generally started their day shifts with four [clients] in the morning. One nurse would leave at 15:30 hours and the other nurses would pick up the departing nurse s [clients], for a total of five [clients] per nurse. Because the unit is so busy, nurses rely heavily on the written Shift
Change Reports, where important details are to be communicated. Nurses are expected to read the Kardex, the Doctor s Orders, and Progress Notes. 24. In response to this incident, [the Facility] conducted a thorough review of its procedures concerning the admission process and initiation of telemetry monitoring for [clients] coming from the Emergency Department. Through its investigation, the Hospital identified deficiencies in its protocols and practices with respect to telemetry monitoring. These deficiencies included the following areas of concern. The [client] was transferred from the Emergency Department to the 17 th Floor Medical Unit without a portable telemetry monitor in place. The transfer was completed by a porter and not a registered nurse. The process now ensures continuous monitoring through the use of a portable monitor during transfer and until telemetry has been established. All telemetry [clients] on a cardiac monitor who are being transferred to another unit must be accompanied by a registered nurse. The receiving unit will have the telemetry channel and pack available on the unit upon the [client] s arrival, and together the accompanying and receiving registered nurses exchange the portable monitor with the unit s telemetry pack, ensuring continuous monitoring. Flow charts have been integrated into the new policy. 25. As a result of this incident and the hospital s internal investigation, the Member was given a written warning and was required to engage in a number of remedial activities which included developing a learning plan to address deficits in his knowledge, skill and judgment in caring for [clients] diagnosed with atrial fibrillation and requiring telemetry monitoring. This plan included a review of the Hospital s telemetry policies and procedures, a review of current literature available in journals and the internet, and a review of the publications by the College. The plan also included attendance at the [Facility s] Situation Based Assessment Course. The Member successfully completed the remedial tasks requested of him. ADMISSIONS 26. The Member acknowledges that he 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 the Ontario Regulation 799/93, in that on November 13, 2002, while employed as a Registered Nurse at [the Facility] in [ ] Ontario, he contravened a standard of practice of the profession or failed to meet the standards of practice of the profession with respect to his assessment, nursing interventions, and treatment concerning a client []. 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 paragraph 1 of the Notice of Hearing. Specifically the member contravened a standard of practice of the profession with respect to his assessment, nursing interventions, and treatment concerning a client. Penalty
Counsel for the College advised the panel that a Joint Submission as to Penalty had been agreed upon. The Joint Submission as to Penalty provides as follows: Joint Submission on Penalty John Forson (the Member ) and the College of Nurses of Ontario (the College ) respectfully submit that, in view of the circumstances set out in the Agreed Statement of Facts and the Member s admissions of professional misconduct, the panel of the Discipline Committee should make an Order as follows: 1. Requiring the Member to appear before the panel to be reprimanded. 2. Directing the Executive Director to impose the following terms, conditions and limitations on the Member s certificate of registration: (a) That the Member provide evidence of successful completion of a course in assessment that has been approved by the Director of Investigations and Hearings, within 12 months of the date of the panel s decision; (b) Until the Member has completed 12 months of practice following the date of this Order, the Member shall only practi[s]e nursing where he has provided his employer s chief nursing officer, or equivalent, with a copy of the Agreed Statement of Facts and Joint Submission on Penalty or, if available, the Discipline Committee s Decision and Reasons, and the employer has agreed to write to the Director within 14 days of the Member engaging in professional practice following the date that this Order becomes final, confirming: (i) receipt of the Agreed Statement of Facts and Joint Submission on Penalty, or Decision and Reasons; and (ii) that it agrees to notify the Director of Investigations and Hearings at the College immediately upon receipt of any reasonable information that the Member has engaged in any professional misconduct. Counsel for the College submitted that penalties should provide both specific and general deterrence as well as remediation as appropriate. Counsel for the College also submitted that the Joint Submission on Penalty did meet these requirements. Counsel for the Member submitted there were several mitigating factors. The panel heard the Member had cooperated with the investigation, had willingly acknowledged his responsibility in this unfortunate incident and undertaken remediation. The Counsel for the Member also highlighted that in the three years since the incident, the Member has had favourable reports and letters pertaining to his performance in the workplace, with no further incidences of discipline. Penalty Decision The panel accepts the Joint Submission as to Penalty and accordingly orders:
1. [Requiring] the Member to appear before the panel to be reprimanded. 2. Directing the Executive Director to impose the following terms, conditions and limitations on the Member s certificate of registration: (a) That the Member provide evidence of successful completion of a course in assessment 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. (b) Until the Member has completed 12 months of practice following the date of this Order, the Member shall only practi[s]e nursing where he has provided his employer s chief nursing officer, or equivalent, with a copy of the Agreed Statement of Facts and Joint Submission on Penalty or, if available, the Discipline Committee s Decision and Reasons, and the employer has agreed to write to the Director within 14 days of the Member engaging in professional practice following the date that this Order becomes final, confirming: (i) receipt of the Agreed Statement of Facts and Joint Submission on Penalty, or Decision and Reasons; and (ii) that it agrees to notify the Director of Investigations and Hearings at the College immediately upon receipt of any reasonable information that the Member has engaged in any professional misconduct. The panel concluded that the proposed penalty is reasonable and in the public interest. The Member has cooperated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility for his actions. The panel noted the following mitigating factors: This was an isolated incident Systemic issues were identified by the hospital following their internal investigation of the incident The member was cooperative throughout the investigation The member has examined his professional practice through education and self-evaluation [ ]. 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:
David Bishop, Public Member Faira Bari, Public Member Cheryl McMaster, RPN Kris Guty, RN