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Blackmore, Irene H.

Irene H. Blackmore 6626584

Published June 2002

Discipline Committee Of The College Of Nurses Of Ontario

FULL-TEXT DECISION

Note: This is the full text of the decision of the Discipline panel in this matter. Any information identifying clients, witnesses or facilities has been removed [ ]. The member’s name is omitted if the allegations have been dismissed or if the results are not placed on the public portion of the Register.

Panel:

Janise Johnson, RN   Chairperson
Arlene Grant, RN   Member
Kim Pederson, RPN   Member
Kay Wetherall   Public Representative
Tom Clifford   Public Representative

BETWEEN

COLLEGE OF NURSES OF ONTARIO   Nick Coleman for College of Nurses of Ontario
- and -    
IRENE H. BLACKMORE
#66-2658-4
  Joshua Liswood for Irene H. Blackmore, RN
     
    Heard: December 10, 2001

DECISION AND REASONS

This matter came on for hearing before a panel of the Discipline Committee on December 10, 2001 at the College of Nurses of Ontario at Toronto. The Member was present and represented by legal counsel.

The Discipline Hearings for Irene H. Blackmore, RN and Norm Joseph Zink, RN, were held simultaneously on December 10, 2001 at the College of Nurses of Ontario at Toronto, because both RNs were involved in the incident regarding the client L.S. on or about July 17, 1997.

The Allegations

The allegations against Irene Blackmore as stated in the Notice of Hearing dated September 20, 2001, are as follows:

  1. You have committed an act of professional misconduct as provided by subsection 51(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that, while employed as a Registered Nurse at [the Hospital], you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to your nursing care of the patient, [ ], on or about July 17, 1997; and/or
  2. You have committed an act of professional misconduct as provided by subsection 51(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(13) of Ontario Regulation 799/93, in that, while employed as a Registered Nurse at [the Hospital], you failed to keep records as required with respect to your nursing care of the patient, [ ], on or about July 17, 1997.

Member’s Plea

Irene Blackmore admitted the allegations set out in paragraphs #1 and #2 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 Members

Ms Blackmore

  1. Ms Blackmore graduated from the nursing program at [ ] in 1965.
  2. She has worked at [the Hospital] for the past twenty-five years in the following areas: medicine; rheumatic diseases; rehabilitation; hematology; and orthopedic surgery. Ms Blackmore currently works in the areas of rehabilitation and orthopedics.

Mr. Zink

  1. Mr. Zink graduated from the nursing program at [ ] in 1990.
  2. Mr. Zink worked as a staff nurse on the orthopedic surgery unit at [the Hospital] from 1990 to 1998. Since 1998, Mr. Zink has worked at [the Hospital’s Sports Clinic].

The Hospital and the Unit

  1. [The Hospital] is an acute care facility in [ ].
  2. The fourth-floor orthopedic unit (the Unit) contains 36 adult beds. The Unit treats clients requiring elective and emergency services including joint replacements, amputations, sports injuries and multiple trauma.

The Client and her course in hospital

  1. [The client] was a 63 year-old morbidly obese woman who had fractured her left tibia and fibula in the latter part of 1996. She was treated with a plaster cast for six months, however, she continued to experience discomfort and pain associated with weight-bearing. It was determined that the fracture had not properly healed, and the Client was scheduled a surgical grafting and plate insertion on July 17, 1997 at the Hospital.
  2. The Client was considered a high-risk surgical candidate due to severe chronic obstructive pulmonary disease (COPD) and a previous episode of supra-ventricular tachycardia. At the time of surgery, the Client had developed pulmonary hypertension and was being treated with continuous home oxygen therapy. The Client informed nursing staff that she occasionally had cyanosis in her fingertips and toes as a result of these problems.
  3. The Client underwent the surgery without incident and was transferred to the Unit for post-operative care at 1300 hours. Although initially the Client’s recovery was uneventful, during the evening the Client was found in a cyanosed state, unresponsive, although breathing. A pre-arrest was called and the Client was eventually transferred to the Intensive Care Unit, where she died seven days later.

Nursing care provided to the Client by the Members

Ms Blackmore

  1. Ms Blackmore worked the day shift on July 17th, 1997, from 0730 to 1930 hours. She received the Client on the Unit from the Post Anaesthesia Recovery Unit at 1300 hours.
  2. Post-operative orders for the Client included:
    • vital signs monitored every four hours; and
    • neurovascular checks for circulation, sensation and movement to be completed every hour for the first six hours.
  3. Between 1300 hours to 1700 hours, Ms Blackmore monitored the Client’s vital signs, assessed the dressing, assisted the Client with deep breathing and coughing, and noted the circulation, sensation and movement of the operative leg. Nothing untoward was noted.
  4. The Client was awake and restless during this period of time. Ms Blackmore turned and repositioned the Client several times and also administered several medications as follows:
    • Stemetil 10 mg IM at 1310 hours for nausea;
    • Morphine 10 mg IM at 1425 hours for pain control;
    • Tylenol #3 ii tabs P.O. at 1545 hours for pain control;
    • Ventolin, Atrovent and Becloforte inhalers at 1600 hours; and
    • Ativan 1 mg sublingual at 1600 hours for restlessness.
  5. At approximately 1700 hours, the Client appeared to settle and went to sleep.
  6. At approximately 1830 hours, a family member visiting the Client expressed concern to Ms Blackmore that the Client was sleeping a lot and had blue fingernails. In response, Ms Blackmore raised the Oxygen level from 4 litres/minute to 5 litres/minute despite the fact that increasing the oxygen level may not have assisted the Client’s condition in light of her COPD condition. She made no further assessment of the Client for the remainder of her shift.

Mr. Zink

  1. Mr. Zink worked the night shift from 1930 hours on July 17th to 0730 hours on July 18th, 1997. He was assigned to care for the Client.
  2. Mr. Zink did not make any check on the Client for the first hour of his shift. At approximately 2030 hours, Mr. Zink entered the Client’s room to provide care to the other client in the room. At that time, he made a brief visual check of the Client and introduced himself to the Client’s visitor.
  3. At approximately 2100 hours, the Client’s visitor told Mr. Zink that she was very concerned that the Client had been sleeping so soundly since 1800 hours, despite the fact that she had undergone a spinal anaesthetic rather than a general anaesthetic. She also reported that the Client had been incontinent of urine and required changing. Mr. Zink responded that he would return in 30 minutes, when he had completed other clients’ care and would have some assistance from other staff.
  4. At 2200 hours, Mr. Zink returned to assess the Client and found her breathing, but unresponsive and cyanotic. He immediately called a Pre-arrest.
  5. Mr. Zink completed late entry charting on the next shift.

Allegation 1 - Contravention of and/or failure to meet the standards of practice

Ms Blackmore

  1. Ms Blackmore admits that her conduct amounts to professional misconduct as set out in allegation 1 of the Notice of Hearing in that she contravened the standards of practice of the profession or failed to maintain the standards of the profession in relation to the care she provided to the Client in that she:
    • failed to fully assess the Client when concerns were raised at approximately 1830 regarding the Client’s sleep pattern and the Client’s cyanotic extremities;
    • failed to reassess the Client after the Oxygen rate was increased; and
    • failed to carry out hourly neurovascular checks after 1700 hours, i.e. at 1800 and 1900 hours.

Mr. Zink

  1. Mr. Zink admits that his conduct amounts to professional misconduct as set out in allegation 1 of the Notice of Hearing in that he contravened the standards of practice of the profession or failed to maintain the standards of the profession in relation to the care he provided to the Client in that he:
    • failed to fully assess the Client at the beginning of his shift despite the fact that the Client was a high risk client;
    • failed to assess the Client immediately after concerns were expressed by the Client’s visitor regarding the Client’s status; and
    • failed to deal promptly with the Client’s incontinence.

Allegation 2 - Failure to keep records as required

Ms Blackmore

  1. Ms Blackmore admits that her conduct amounts to professional misconduct as set out in allegation 2 of the Notice of Hearing in that she failed to keep records as required regarding the Client in that she:
    • failed to record the Client’s respiratory rate at 1700 hours;
    • failed to record that the Client was sleeping soundly and that her fingernails were blue; and
    • failed to record that she administered more oxygen to the Client as a result of observing cyanosis.

Mr. Zink

  1. Mr. Zink admits that his conduct amounts to professional misconduct as set out in allegation 2 of the Notice of Hearing in that he failed to keep records as required regarding the Client in that he:
    • failed to fully record his assessment and observations of the Client in a timely manner.

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 and #2 of the Notice of Hearing, in that while employed as a registered nurse at [the Hospital], she contravened a standard of practice of the profession or failed to meet the standard of practice of the profession with respect to her nursing care of patient [ ] on or about July 17, 1997; and failed to keep records as required with respect to her nursing care of the patient [ ] on or about July 17, 1997.

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:

THE COLLEGE AND THE MEMBER JOINTLY SUBMIT that the appropriate penalty in this case is for the Panel of the Discipline Committee (the Panel) to make the following order:

  1. Directing the Executive Director to suspend the Member’s certificate of registration for a period of one month. This suspension shall commence to run from the date of the Panel’s order without interruption;
  2. Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration: namely, the Member shall review the College publication, Standards of Nursing Documentation, and, subsequently, but in any event within three months from the date of the Panel’s order, the Member shall meet with a Practice Consultant at the College of Nurses to review the incident giving rise to the Panel’s order, and in particular to review the necessity to carry out complete and timely assessments of clients and to document the assessments and care given to clients; and
  3. Requiring the Member to appear before the panel of the Discipline Committee to be reprimanded at a date to be arranged, but in any event, within three months of the date the Panel’s order.

Counsel for the College indicated that this was a serious incident of professional misconduct. The Member did accept responsibility for her actions. The penalty addresses the appropriate message to the Member as the penalty includes suspension and a rehabilative component. The College counsel is of the view that the Member’s meeting with the practice consultant is appropriate. Counsel asked the panel to accept the penalty.

Defense counsel acknowledged the Member’s acceptance of the seriousness of the matter and informed the panel of the Member’s unblemished record. Counsel echoed the assessment of College counsel. The Member has enjoyed the support of her employer and continues to work at [the Hospital]. Counsel drew the attention to the fact that the Member’s education record was good both inside and outside the hospital setting.

Upon the panel questioning the Member regarding the nurse-patient ratio on July 17,1997 at [the Hospital], forth floor orthopaedic unit, the Member informed the panel that fresh post-operative patients were not clustered together and the nursing assignments where scattered through out the unit. Following this incident the hospital has changed their practice of management of post-operative patients. The Member has been supported by her employer, and remains employed at [the Hospital].

Penalty Decision

The panel unanimously accepts the Joint Submission as to Penalty and accordingly orders:

  1. the Executive Director to suspend the Member’s certificate of registration for a period of one month. This suspension shall commence to run from the date of the Panel’s order without interruption;
  2. the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration: namely, the Member shall review the College publication, Standards of Nursing Documentation, and, subsequently, but in any event within three months from the date of the Panel’s order, the Member shall meet with a Practice Consultant at the College of Nurses to review the incident giving rise to the Panel’s order, and in particular to review the necessity to carry out complete and timely assessments of clients and to document the assessments and care given to clients; and
  3. the Member to appear before the panel of the Discipline Committee to be reprimanded at a date to be arranged, but in any event, within three months of the date of the Panel’s order.

The panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College by agreeing to the facts and the proposed penalty and has accepted responsibility for her actions. The meeting with a practice consultant at the College of Nurses to review assessment and practice standards represent the rehabilitative component of the order.

I, Janise Johnson, 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

Arlene Grant, RN
Kim Pederson, RPN
Kay Wetherall, Public Representative
Tom Clifford, Public Representative

Page last reviewed September 28, 2010