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Appel, Craig

Craig Appel IG07670

Discipline Committee Of The College Of Nurses Of Ontario

FULL-TEXT DECISION

Panel:

 -    Chairperson
 -    Member
 -    Member
 -    Public Representative
 -    Public Representative

BETWEEN

COLLEGE OF NURSES OF ONTARIO   Counsel for College of Nurses of Ontario
- and -    
CRAIG APPEL
#IG-0767-0
  Member Unrepresented
     
    Heard: November 13-15, 2000

DECISION AND REASONS

A panel of the Discipline Committee of the College of Nurses of Ontario (the “College”) met in Toronto on November 13, 14, 15, 2000, to hear evidence of the following allegations against Craig Appel.

The Member was not present for the hearing nor was he represented by legal Counsel.

The Hearings Administrator had been in contact with Craig Appel by telephone. The Member informed her that he would not be attending the hearing, however, the panel adjourned the hearing for 30 minutes in order to give the Member the opportunity to appear for the hearing. The hearing reconvened without the Member.

Counsel for the College entered into evidence an Affidavit of Service (Exhibit #1) dated September 27, 2000, which stated that the Member was served the Notice of Hearing. A number of documents, which informed the Member of the hearing process, accompanied the Affidavit.

The panel was satisfied the Member had personally received proper notice of the proceedings.

Counsel for the College then entered into evidence the Notice of Hearing (Exhibit #2). Counsel requested that the Notice of Hearing be amended as follows: Allegations #4(c), #9(c) and #10 (i) were omitted; allegations #10(g) and #10(h) became #10(g) and #10(I) became #10(h), and finally that #6(a) reflect the value under $5,000.00. Counsel also advised the panel that no evidence would be called with respect to allegations #4(a) and #5(a) in the Notice of Hearing.

The Allegations

The allegations against Craig Gordon Appel as stated in the Amended Notice of Hearing dated September 18, 2000, are as follows:

  1. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that in January, 1999, while working as a Registered Practical Nurse at the Versa Care Retirement Community in Brantford, Ontario, you contravened a standard of practice of the profession or failed to maintain the standards of practice of the profession with respect to the following:
    1. your failure to give medications as prescribed to client #1 at 1700 hours on January 24, 1999; and/or
    2. your failure to give medications as prescribed to client #1 at 1700 hours and 2100 hours on January 25, 1999; and/or
    3. your failure to give medications as prescribed to client #2 at 1700 hours on January 25, 1999; and/or
    4. your failure to give medications as prescribed to client #3 at 2100 hours on January 25, 1999; and/or
    5. your failure to document client on client #4’s chart on January 28, 1999, despite the fact that the resident was suffering from lung congestion; and/or
    6. your failure to document client on client #5’s chart on January 28, 1999, despite the fact that the resident was suffering from lung congestion; and/or
    7. your failure to document client on client #6’s chart on January 28, 1999, despite the fact that the resident was suffering from lung congestion; and/or
    8. your failure to document on client #7’s chart in a timely manner the results of a glucoscan conducted at or about 1630 hrs on February 11, 1999 in accordance with a doctor’s order; and/or
    9. on or about February 12, 1999, your failure to document physician’s orders for a new client #8 in a timely manner, and/or to initiate a MAR for #8 in a timely manner and/or to order medication from the pharmacy for #8 in a timely manner; and/or
    10. on or about February 12, 1999, your conduct in administering medication to client #8 which the client had brought from home, when you had not initiated a MAR for the client, and/or recorded the physician’s orders and/or ordered medication from the pharmacy; and/or
    11. your conduct in signing the MAR for a dose of Gentamycin to client #9 on February 12, 1999, when you had not in fact given the medication to the client; 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 d#9ined in subsection 1(14) of Ontario Regulation 799/93, in that in January, 1999, while working as a Registered Practical Nurse at the Versa Care Retirement Community in Brantford, Ontario, you falsified a record relating to you practice with respect of the following:
    1. your record on the client’s MAR that you gave medications as prescribed to client #1 at 1700 hours on January 24, 1999, when you did not in fact give the medications; and/or
    2. your record on the client’s MAR that you gave medications as prescribed to client #1 at 1700 hours and at 2100 hours on January 25, 1999, when you did not in fact give the medications; and/or
    3. your record on the client’s MAR that you gave medications as prescribed to client #2 at 1700 hours on January 25, 1999, when you did not in fact give the medications; and/or
    4. your record on the client’s MAR that you gave medications as prescribed to client #3 at 2100 hours on January 25, 1999, when you did not in fact give the medications; 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(13) of Ontario Regulation 799/93, in that in January, 1999, while working as a Registered Practical Nurse at the Versa Care Retirement Community in Brantford, Ontario, you failed to keep records as required with respect to the following:
    1. your failure to document on client #4’s chart on January 28, 1999, despite the fact that the resident was suffering from lung congestion; and/or
    2. your failure to document client #5’s chart on January 28, 1999, despite the fact that the resident was suffering from lung congestion; and/or
    3. your failure to document client #6’s chart on January 28, 1999, despite the fact that the resident was suffering from lung congestion; and/or
    4. your failure to document on client #7’s chart in a timely manner the results of a glucoscan conducted at or about 1630 hrs on February 11, 1999 in accordance with a doctor’s order; and/or
    5. on or about February 12, 1999, your failure to document physician’s orders for a new client #8 in a timely manner, and/or to initiate a MAR for #8 in a timely manner; and/or
    6. your conduct in signing the MAR for a dose of Gentamycin to client #9 on February 12, 1999, when you had not in fact given the medication to the client; and/or
  4. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(8) of Ontario Regulation 799/93, in that November, 1998 and February, 1999, while working as a Registered Practical Nurse at the Versa Care Retirement Community in Brantford, Ontario, you misappropriated property from a client or workplace with respect to the following:
    1. your misappropriation of Dilaudid prescribed to client #10 on one or more dates between January 28 and February 8, 2000; and/or
    2. your misappropriation of Statex prescribed to client #11 on one or more dates between November 6, 1998 and January 17, 1999; and/or
  5. 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 in January and February, 1999, while working as a Registered Practical Nurse at the Versa Care Retirement Community in Brantford, Ontario, you engaged in conduct or performed an act, relevant to the practice of nursing that, having regard to all of the circumstances would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional with respect to the following:
    1. your misappropriation of Dilaudid prescribed to client #10 on one or more dates between January 28 and February 8, 2000; and/or
    2. your misappropriation of Statex prescribed to client #11 on one or more dates between November 6, 1998 and January 17, 1999; and/or
  6. You have committed an act of professional misconduct as provided by subsection 51(1)(a) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, in that on November 17, 1999, in the Ontario Court of Justice in the Brantford, Ontario, you were found guilty of an offence relevant to your suitability to practice, and in particular, you were convicted of the following charge:
    1. between the 28th day of January 1999 and the 08th day of February 1999 at the City of Brantford in the said Region, did steal medication (between 8 and 31 single doses of the pill “Dilaudid” 2 mgs), of a value under $5,000.00, the property of Versa Care, contrary to Section 334(b) of the Criminal Code of Canada, RSC 1985, as amended.
  7. 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(15) of Ontario Regulation 799/93, in that in May, 1996 and April, 1997, you signed or issued, in your professional capacity, a document that you knew or ought to have known contained a false or misleading statement with respect of the following:
    1. you failed to disclose a criminal conviction for break and enter and theft on your Application for Assessment to Determine Eligibility for Registration dated May 16, 1996 and your Application for a Certificate of Registration dated April 14, 1997; and/or
    2. you failed to disclose a criminal conviction for acquisition of a firearm without a FAC on your Application for Assessment to Determine Eligibility for Registration dated May 16, 1996 and your Application for a Certificate of Registration dated April 14, 1997; and/or
  8. 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(23) of Ontario Regulation 799/93, in that in May, 1996 and April, 1997, you failed to take reasonable steps to ensure that requested information was provided in a complete and accurate manner where you were required to provide information to the College pursuant to the regulations under the Act with respect of the following:
    1. you failed to disclose a criminal conviction for break and enter and theft on your Application for Assessment to Determine Eligibility for Registration dated May16, 1996 and your Application for a Certificate of Registration dated April 14, 1997; and/or
    2. you failed to disclose a criminal conviction for acquisition of a firearm without a FAC on your Application for Assessment to Determine Eligibility for Registration dated May 16, 1996 and your Application for a Certificate of Registration dated April 14, 1997; and/or
  9. 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 in May, 1996 and April, 1997, you engaged in conduct or performed an act, relevant to the practice of nursing that, having regard to all of the circumstances would reasonably be regarded by members of the profession as disgraceful, dishonourable or unprofessional with respect of the following:
    1. you failed to disclose a criminal conviction for break and enter and theft on your Application for Assessment to Determine Eligibility for Registration dated May 16, 1996 and your Application for a Certificate of Registration dated April 14, 1997; and/or
    2. you failed to disclose a criminal conviction for acquisition of a firearm without a FAC on your Application for Assessment to Determine Eligibility for Registration dated May 16, 1996 and your Application for a Certificate of Registration dated April 14, 1997; and/or
  10. You have committed an act of professional misconduct as provided by subsection 51(1)(a) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, in that on February 15, 1999, in the Ontario Court of Justice in Brantford, Ontario, you were found guilty of offences relevant to your suitability to practise, and in particular, you were convicted of the following charges:
    1. on or about the 29th day of September, 1998 at the City of Cambridge in the said Region, did knowingly use a forged document, to wit: a drug prescription forged in the name of Dr. “A” of London Health Science Centre, as if it were genuine, contrary to Section 368(1)(a) of the Criminal Code of Canada, RSC 1985, as amended; and/or
    2. on or about the 30th day of September, 1998 at the City of Cambridge in the said Region, did knowingly use a forged document, to wit: a drug prescription forged in the name of Dr. “A” of London Health Science Centre, as if it were genuine, contrary to Section 368(1)(a) of the Criminal Code of Canada, RSC 1985, as amended; and/or
    3. on or about the 13th day of October, 1998 at the City of Cambridge in the said Region, did knowingly use a forged document, to wit: a drug prescription forged in the name of Dr. “A” of London Health Science Centre, as if it were genuine, contrary to Section 368(1)(a) of the Criminal Code of Canada, RSC 1985, as amended; and/or
    4. on or about the 13th day of October, 1998 at the City of Cambridge in the said Region, did knowingly use a forged document, to wit: a drug prescription forged in the name of Dr. “B”, St. Joseph Hospital, Brantford, as if it were genuine, contrary to Section 368(1)(a) of the Criminal Code of Canada, RSC 1985, as amended; and/or
    5. on or about the 18th day of September, 1998 at the City of Brantford in the said Region, knowing a certain document to be forged, to wit: a prescription, did unlawfully cause the staff of Pharmacy #1 to act upon it as if it were genuine, contrary to Section 368(1)(b) of the Criminal Code of Canada, RSC 1985, as amended; and/or
    6. on or about the 19th day of September, 1998 at the City of Brantford in the said Region, knowing a certain document to be forged, to wit: a prescription, did unlawfully cause the staff of Pharmacy #2 to act upon it as if it were genuine, contrary to Section 368(1)(b) of the Criminal Code of Canada, RSC 1985, as amended; and/or
    7. on or about the 19th day of September, 1998 at the City of Brantford in the said Region, knowing a certain document to be forged, to wit: a prescription, did unlawfully cause the staff of Pharmacy #3 to act upon it as if it were genuine, contrary to Section 368(1)(b) of the Criminal Code of Canada, RSC 1985, as amended; and/or
    8. on or about the 13th day of October, 1998 at the City of Brantford in the said Region, knowing a certain document to be forged, to wit: a prescription, did unlawfully cause the staff of Pharmacy #4 to act upon it as if it were genuine, contrary to Section 368(1)(b) of the Criminal Code of Canada, RSC 1985, as amended.

Member’s Plea

In the absence of the Member, the Chair of the panel entered a plea of not guilty to the allegations as set out in the Amended Notice of Hearing on be-half of the Member.

Overview

The Member made application to the College of Nurses of Ontario for Assessment to Determine Eligibility for Registration on May 16, 1996. The Member received Medical Assistant training through the Canadian Armed Forces Medical School, Camp Borden, in Borden, Ontario and received the Medical Assistant TQ3, TQ4, and TQ5 between May 1991 and October 1994.

The Member made application for a Certificate of Registration to the College of Nurses of Ontario for a Practical Nurse General on April 14, 1997. The date of Registration Issuance by the College of Nurses of Ontario was April 17, 1997.

The Member was employed by Versa Care Retirement Community, in Brantford Ontario between November 4, 1998 and February 16, 1999. He was assigned to the Lodge from November 4, 1998 until January 17, 1999 and transferred to the Long Term Care facility January 18, 1999 until termination on February 16, 1999.

The issues are as follows:

  • Did the Member fail to give medications as prescribed and falsify medication records?
  • Did the Member fail to document on progress notes on client charts?
  • Did the Member make documentation errors?
  • Did the Member fail to document physician orders, initiate a Medical Administration Record, order medication from the pharmacy?
  • Did the Member administer medication brought from the client’s residence without a MAR or Dr.’s orders in place?
  • Did the Member sign for a medication that was not administered?
  • Did the Member misappropriate Statex belonging to a client?
  • Was the Member found guilty of stealing Dilaudid?
  • Was the Member found guilty of using forged prescriptions and causing others to act on forged prescriptions?
  • Did the Member fail to disclose his criminal conviction on his Application of Registration?

The Evidence

The panel heard evidence from eleven witnesses.

Witness #1

Witness #1 was an acting supervisor for the Brantford Police Service, Records Department. He had access to records of convictions which he submitted. College counsel entered these documents into evidence as Exhibit #8 and Exhibit #9. Exhibit #8 was a P.R.I.D.E. LIVE RMS. form of the Brantford Police Arrest History (Identification Number BR014781) showing that the Member, Craig Appel, had been convicted of a number of criminal offences and Exhibit #9 is a form from the Central Registry of the Royal Canadian Mounted Police (RCMP) showing that the Member, Craig Appel was arrested and fingerprinted and the information sent to the RCMP.

Exhibit #3 is an information document from the Waterloo Regional Police, dated September 29, 1998, listing the following offences:

  • the Member knowingly forged a document that being a drug prescription in the name of Dr. “A” of London Health Science Center.
  • the Member knowingly forged a document that being a drug prescription in the name of Dr. “B” of St. Joseph’s Hospital, Brantford.

On February 15, 1999, the Member pleaded guilty to the offences and received a suspended sentence with 18 months probation as listed on the Ontario Court of Justice form included with Exhibit #3.

Exhibit #4 is an information document of the Brantford Police Service dated September 18, 1998 listing the following offences:

  • the Member knowingly caused the staff of Pharmacy #1 to act on a prescription that he knew to be a forgery contrary to Section 368(1)(b) of the Criminal Code of Canada, RSC 1985 as amended (98-27428)
  • the Member knowingly caused the staff of Pharmacy #2 to act on a prescription that he knew to be a forgery contrary to Section 368(1)(b) of the Criminal Code of Canada, RSC 1985 as amended (98-27576)
  • the Member knowingly caused the staff of Pharmacy #3 to act on a prescription that he to be a forgery contrary to Section 368 (a)(b) of the Criminal Coded of Canada, RSC 1985 as amended (98-27589)
  • the Member knowingly caused the staff of Pharmacy #4 to act on a prescription that he knew to be a forgery contrary to Section 368(1)(b) of the Criminal Code of Canada, RSC 1985 as amended (98-30056)

On February 15, 1998, the Member pleaded guilty to the offences and received a suspended sentence with 18 months probation, as outlined in the Ontario Court of Justice form accompanied with Exhibit #4.

Exhibit #5 is a transcript from the Ontario Court of Justice dated May 14, 1999, in which the Honourable Justice states the reasons for sentence against Craig Appel and which states that the Member must attend and actively participate in a rehabilitative program as arranged by his probation officer.

Exhibit #6 is an information document from a Special Constable of the Brantford Police Service which states the following offence.

  • Between January 28, 1999, and February 8, 1999, the Member did steal medications, specifically between 8 and 31 single doses of the pill “Dilaudid 2 mgms.” of a value under $5000.00, the property of Versa Care, contrary to Section 334(b) of the Criminal Code of Canada, RSC 1985 as amended.

On October 8, 1999, the Member pleaded guilty to the offence and received a fine of $750.00 as outlined in the Ontario Court of Justice form accompanied with Exhibit #6.

Exhibit #7 is a transcript from the Ontario Court of Justice dated November 17, 1999, in which the Honourable Justice states the reason for the sentence against Craig Appel and which outlines for the Member a repayment schedule for the fine of $750.00 for the above infraction.

Exhibit #8 is a Brantford Police Arrest History (P.R.I.D.E.) for Craig Appel, showing that the Member was convicted of theft under $5000.00 on February 24, 1999, and was required to pay a fine of $750.00.

On October 19, 1998, the Member Craig Appel was convicted on four separate incidents of issuing forged documents and received a suspended sentence and 18 months probation.

Exhibit #9 is a form from the Central Registry which identified that the Member, Craig Appel, was arrested and finger-printed and the information sent to the Royal Canadian Mounted Police (RCMP). Witness #1 testified that this document, Exhibit #9, was the best available record of the convictions.

Witness #2

Witness #2 is the Registration and Examination Co-ordinator for the College of Nurses of Ontario. He identified for the panel the Application for Assessment to Determine Eligibility for Registration (Exhibit #10), the Practical Nurse General A-1 form, the Application for a Certificate of Registration (Exhibit #11) and the Practical Nurse General R-1 form, as those signed by Craig Appel. Witness #2 identified the Declaration of Registration Requirements for all Classes (A-5 form) which was Side 2 of Exhibit #10 and #11. The panel was directed to question #7 of both forms which stated “Have you ever been convicted of a criminal offence or an offence under the Narcotic Control Act (Canada) or the Food and Drugs Act (Canada)?”. This question was answered “no” and the form was signed by Craig Appel, dated both May 16, 1996 and April 14, 1997.

Witness #3

Witness #3 graduated as Registered Nurse in 1968. She was employed at Versa Care Retirement Community in Brantford Ontario since January 25, 1999. She was the former Director of Care on the Long Term Care facility (LTC). Her area of responsibilities was to hire, terminate, and discipline staff. She was also responsible for the clinical care of the residents. She managed Registered Nurses (RN), Registered Practical Nurses (RPN), Health Care Aides (HCA) and Personal Support Workers (PSW).

At the time, the Member, Craig Appel, was already an employee of Versa Care as a part-time RPN in the Long Term Care facility. He had begun his employment at Versa Care in the Lodge area of the facility on November 4, 1998. He transferred to the LTC area on January 18, 1999 and was given an additional one day of orientation. Normally, new employees would be given a longer orientation, but the Member was familiar with the facilities medication procedure. The Member was buddied with another RPN on his one day of orientation. The LTC facility has 79 residents. The residents living in the Long Term Care facility are extremely frail, totally dependent on nursing staff, and some have cognitive impairment.

The resident care responsibilities are divided between two wings. The RPN is responsible for approximately 40 residents and the RN is responsible for approximately 40 residents, but the RN has overall responsibility of the LTC. Witness #3 indicated to the panel that the roles of the RN and RPN differ minimally. It was the responsibility of the RN to give intramuscular injections to all residents in the LTC facility, when required. The Member was scheduled to work the evening shifts (1500-2300 hrs) on January 28, 29, 31, 1999 and February 1, 2, 6, 7, 8, 11, and 12, 1999. He also worked a day shift (0700-1500 hrs) on February 7, 1999. He called in sick on February 15, 1999 and his employment was terminated on February 16, 1999.

When a resident is admitted to the facility, it is the responsibility of the registered staff to set up the chart. The responsibilities of the admitting nurse includes obtaining doctors’ orders for medication, diet, activity, and lab work. The expectations of charting for the staff was to document any unusual occurrences with the residents’ conditions. If a resident required a prn (as needed) medication, the proper procedure was to initial the medication on the MAR and make an entry on the progress notes regarding the medication, dosage and effect in the residents’ chart. The aberration was to note any usual laboratory results and actions taken in the progress notes. The nurses are also required to carry out and document an admission assessment and to order medication from the pharmacy and implement a MAR.

The initial MAR for the residents are kept on the chart. All others for the wing are kept in a separate binder. The binder is kept on the medication cart which is stored in the medication room by the nursing station. The cart is locked and both the RN and RPN on duty have a set of keys for the medication cart while on duty. The Director of Care also has a key which is kept separate from the staff. Medication for each resident is dispensed from a blister pack on the cart. There is one card for each resident. Each blister pack contains medication for a four week period. If medication is not administered it remains in the blister pack. It is later destroyed by the pharmacist. Pills are punched out of the blister packs according to the date. The proper procedure for administration of medication is to confirm the right medication from the label on the blister pack, verify the correct medication, dose and time, and initial the MAR. The administration for narcotics differs from regular medications.

An Individual Control Drug Sheet is used to keep track of narcotics given. Each resident has a separate sheet. The date, time, dose, number of narcotics when started and finished and nurses’ initials are to be documented. The narcotics are kept in the medication cart in a separate locked bin. There is a different key used for the narcotic bin which is kept with the other keys. The procedure at the facility, at the time in question, was not to count the narcotic drugs on a regular basis. This practise to record the number of narcotics left in the blister pack has since been corrected. Once the narcotic is given to the resident, the nurse is required to initial the MAR sheet and record its administration in the progress notes. In January and February of 1999, there was no allowable exception to this procedure.

The Member’s employment was terminated on February 16th, 1999 as a result of problems with his professional practice. A Letter of Complaint (Exhibit #15) was written by Witness #3 to the CNO after that date. On March 5,1999, Witness #3 sent an addendum to the Letter of Complaint (Exhibit #16) to the CNO, which outlines the disappearance of narcotics from Versa Care, Brantford. The incident was reported to the Brantford Police on February 12, 1999. On February 24, 1999, following a police investigation, the Member was arrested and charged with three counts of theft of narcotics from this facility. On November 17,1999, the Member was convicted of theft under $5000.00.

During the Member’s employment at Versa Care there were several incident reports written regarding his professional practice (Exhibits # 17, #21 and #24). Staff members expressed their concerns, both verbally and in writing, regarding the Member’s professional practice to Witness #3 on several occasions. Witness #3 discussed and reviewed these concerns with the Member and documented this meeting in his file, dated January 29, 1999. (Exhibit #28). A meeting attended by the Member, Witness #3, the Lodge Director, and a union steward on February 16, 1999 outlined the concerns which resulted in the Member’s termination. This meeting was documented (Exhibit #36).

Witness #4

Witness #4 has been an RPN since 1984. She has been employed at Versa Care in Brantford, Ontario since December of 1993. In early 1999, she worked six shifts in a two week period, which was usually the afternoon shift (1500-2300 hours). Witness #4 oriented the Member to RPN duties and general policies and procedures of Versa Care. She testified that she did not review the documentation expectations with the Member. On January 26, 1999, when Witness #4 was administering her 1700 hr. and 2100 hr. medications, she noticed that medications from January 24 and 25, 1999, were still in their blister packs. This caused her concern and she checked the Medication Administration Record (MAR) which revealed that those same medications were not signed for nor was there any documentation or explanation as to why they were not administered. The witness testified that she was unable to locate a Medication Incident Discrepancy Report (MIDR). She recorded the omissions on a piece of paper and passed it on to the oncoming RN with the understanding that the RN would fill out the MIDR.

Witness #5

Witness #5 has been an RN since 1995. She had been employed at Versa Care in Brantford Ontario since August 1995. Witness #5 testified that she occasionally worked the shift following Mr. Appel and therefore received report from him. Witness #5 had serious concerns regarding the Member’s documentation practice. The concerns consisted of two separate incidents. The first incident pertained to the Member verbally reporting changes in residents’ conditions. There was no documentation on the progress notes to indicate any changes. The second incident involved a resident with episodes of hypoglycemia. Witness #5 attested to the fact that at the time, the Member did not document any Glucosan result on the MAR (Exhibit #34) for resident #7 at 1630 hrs. on February 11, 1999. Further to that, the Resident Care Progress Notes (Exhibit #37) for resident client #7 had no documentation regarding the Glucosan result, medication, or ingestion of food or drink. The Progress Notes and Physician’s Orders for #7 (Exhibit #33) indicates that Glucoscan readings were to be taken three times a day with the expectation that the results would be documented and insulin given accordingly. Witness #5 testified that the MAR (Exhibit #34) now (at the time of her testimony) had a Glucosan result of 8.1 recorded for February 11, 1999. Witness #5 testified that on February 11, 1999, there was no notation on the MAR regarding #7’s Glucosan result. Witness #5 wrote a note (Exhibit #32) on February 12, 1999, to Witness #3 in which she listed her concerns regarding the Member’s practice.

Witness #6

Witness #6, RN, was employed at Versa Care in Brantford in 1992 as casual part time. She was hired full time in 1993. Witness #6 was the Acting Director of Care of LTC on three occasions since 1997 and is currently the Acting Director of Care since Witness #3 retired. The witness first met Craig Appel in late January, 1999. She was in the role of Acting Director of Care when she hired the Member as a casual RPN for the LTC facility. She gave the Member a tour of the LTC facility; however, no in-depth orientation was given to the Member as he had already worked in the Lodge.

The witness outlined for the panel the expectations for new admissions to the facility. The Staff Time Sheet (Exhibit # 14) shows that Witness #6 was working with the Member on the 3-11 p.m. shift of February 12, 1999. There was a new admission, #8, to the Member’s wing of the LTC. At report, the RN on day shift outlined in writing for the Member the orders required for the new admission. The witness offered to help the Member with the admission. There was no response by the Member. At the end of the nursing report, it was understood that he would obtain admission orders for the new resident. The witness stated that she expected the Member to receive the orders and obtain medication from the pharmacy by 1700 hours. At 2245 hours, the witness went to the Member’s desk to co-sign the orders for the new admission. She discovered that there was no chart and no orders to co-sign. She asked the Member if he had received any orders and the Member responded with a “blank expression.” He told her that he had received the orders and showed her the sheet of paper that the day shift RN had given him. There were red ink markings in his handwriting beside the list of orders to be obtained on this sheet of paper. The witness concluded that the Member had spoken to the doctor but didn’t write any doctor’s orders on the chart. Witness #6 was concerned because it was late in the shift and he had not initiated a MAR but had administered medications that the new resident had brought from home. Witness #6 instructed the Member to write the doctor’s orders (Exhibit #38) and implement a MAR. There had been no record keeping at this point in the shift by the Member on the new admission.

During the same shift on February 12, 1999, at 1900 hours Witness #6 found the Member in the medication room drawing up an intramuscular (IM) syringe of Gentamycin for client #9. The policy and procedure at Versa Care stated that RNs administer IM injections. Some RPNs at the facility had the added skills that enabled them to administer IM medications. The witness had no knowledge of the Member having this added skill, as he had not shown his certificate to do IM injections. Witness #6 took the syringe and vial of Gentamycin from the Member and proceeded to administer the medication to the resident #9. The witness then proceeded to initial the MAR (Exhibit #40) for #9 where she discovered that the Member had already signed off the medication. This was contrary to the facility’s charting practice. Witness #6 wrote a memo (Exhibit #35) to Witness #3 about her concerns regarding the Member’s practice.

Witness #6’s testimony was clear and concise. Her testimony was supported by the lack of documentation by the Member on resident client #8’s Admission Progress Notes and Physicians Orders (Exhibit #38). Her testimony regarding the Gentamycin’s administration is supported by the MAR for #9 (Exhibit #40) which clearly has the Member’s initials entered on February 12, 1999 at 1700 hours.

Witness #7

Witness #7, the daughter of resident #11, testified that her mother lived at Versa Care Lodge from October, 1998 until her death in November, 2000. She moved to the Lodge after being hospitalized in Lindsay for a compression fracture in the back. She had been treated with Morphine (Statex) while in hospital but had been successfully weaned off the Morphine (Statex) and was taking extra strength Tylenol with a standing order for prn Morphine (Statex) for back spasm. The witness visited her mother on a regular basis at the Ross Memorial Hospital in Lindsay Ontario. She testified that while her mother was taking the Morphine (Statex) she exhibited many side effects from the medication. These side effects included drowsiness, disorientation, nausea, loss of appetite, confusion, difficulty to rouse, and decreased mobility. These side effects all disappeared when she was weaned off the Morphine. Resident client #11 was a client in the Ross Memorial Hospital for two and one half months. Her condition was good when she left the hospital and she tolerated the car trip to Brantford. She was comfortable and not in any severe pain. The client was under the care of Witness #11 (Doctor) at Versa Care. When Witness #7 visited her mother daily at Versa Care, she found her mother to be alert with a good appetite, good activity level, oriented, and generally well. When Witness #7 questioned her mother about her pain, client #11 responded that occasionally she required pain medication. Witness #7 was not aware that client #11 had ever received any Statex while in the Lodge. She stated that she had spoken with the staff and was told that she was given Tylenol only. Witness #7 was “shocked and surprised” when she was shown the MAR which indicated the frequency of Statex given to her mother. She testified that her mother was not exhibiting any of the side effects of the Statex.

Witness #7 was clear and concise in her testimony, in fact, she told the panel exactly how she found her mother’s status on her daily visits. Witness #7 testified she was shocked when she was visited by a detective of the Brantford Police Department on February 19, 1999, who indicated that there was an investigation into the frequency of Statex administration to her mother.

Witness #8

Witness #8 has been a pharmacist since 1972. He is the owner of Pharmacy #5 and Pharmacy #1 in Brantford Ontario. He worked predominantly at Pharmacy #5 for the past 13 years. Pharmacy #1 fills prescriptions for Versa Care. The witness works personally with Versa Care serving both the Lodge and LTC. The witness performed a biannual audit of pharmaceuticals at the facility (Quality Assurance Pharmacy Audit, dated December 21, 1998, Exhibit #41). The audit includes ensuring that appropriate medication administration is carried out by nursing staff, documentation is implemented, medication correspond with resident condition, appropriate lab tests are carried out in conjunction with medication administration, and to ensure that the Narcotic Administration Sheets match the MAR records for the narcotic count.

Witness #8 told the panel he conducted random audits four to five times per year of the narcotic administration sheets versus MAR records to ensure that counts match. During a random audit of the narcotics, he became concerned over the number of times that the Member had administered Statex to client #11 as signed for in the Individual Controlled Drugs (Exhibit #43) for the client. He became concerned about the amount of Statex client #11 was using. He noted when checking the Individual Controlled Drug Sheet (Exhibit #43) that it did not correspond with the number of Statex in the blister pack. He also noted a pattern of frequent administration of Statex to client #11 by the Member as opposed to other nurses.

Further investigation caused him to be concerned due to the sparse documentation by the Member in client #11’s MAR (Exhibit #44) and Resident Care Progress Notes (Exhibit #45) to support why the client required the Statex.. He took his concerns regarding the missing Statex and the lack of documentation to the Director of Care for the Lodge.

Witness #9

Witness #9, an RPN since 1969, has been employed as the Director of Care in the Lodge at Versa Care since November 1994. Her responsibilities include overseeing daily operations and management of staff.

The Lodge has 91 residents, some of whom are independent, while others required minimal assistance with activities of daily living. The majority of the residents are medicated by the nursing staff. Medication administration was one of the duties of the registered staff in the lodge. Witness #9 outlined for the panel the policy and procedure for medication administration at Versa Care. The witness hired Craig Appel in November 1998, as a casual on-call RPN in the Lodge. He received four shifts of orientation, which included one day shift, two evenings and one night shift. Witness #9 testified that Witness #10, RPN, had drawn her attention to the number of times that the Member had administered Statex to client #11 in comparison to other staff. She informed the witness that Witness #8 had done an audit in December 1998, where he discovered the narcotic count was missing one Statex. Witness #9 conducted an investigation and concluded that Craig Appel had given an unusual amount of Statex to client #11. She also noted that his documentation was minimal. She saw client #11 Monday to Friday and testified that she was “a witty, lovely and bright little lady.” The witness stated that client #11 did not exhibit any manifestations of an individual taking that amount of Statex. Her investigation also revealed that Craig Appel had made notations on the Individual Control Drug Sheet on days he had not been scheduled to work. The witness spoke with Witness #3 about her findings and a call was placed to the Brantford Police Department. Witness #9 submitted a letter of complaint to CN0 (Exhibit #47) sometime after February 15, 1999 regarding the Member’s practice.

Witness #10

Witness #10 has been an RPN since 1970. Witness #10 began her employment with Versa Care in 1982 as a Health Care Aid (HCA). The witness testified within a year her status changed to RPN. Witness #10 worked in the LTC facility for 5 years and transferred to the Lodge 12 or 13 years ago. From November 1998, until early 1999, Witness #10 worked with the Member on occasion. At the time she had “no concerns” about the Member’s nursing practice. However, in December, 1998, while doing a quarterly review with Witness #8, the pharmacist, Witness #10 had concerns with the amount of narcotics administered to client #11 by the Member. During the review, it was discovered that the Narcotic Individual Controlled Drugs Sheet (Exhibit #43) for client #11 was out by two Statex. It was noted that the Member’s signature appeared frequently on the Individual Control Drug Sheet with little or no corresponding documentation on the MAR (Exhibit #44) and sparse documentation on the Resident Care Progress Report (Exhibit #45) to explain the reason for the frequent administration of the Statex to client #11 on the Member’s shifts. She took her concerns to her superior, Witness #9.

The witness testified that she saw client #11 every day that she was at work. Client #11 complained of periodic back pain, which was relieved with back rubs, ambulation and the occasional Tylenol. Witness #10 stated that client #11’s mental condition was quite good, usually independent in her activity with some periods of confusion.

On November 21, 1998, the witness worked the day shift (0700 hr. to 1500 hr) immediately following the Member’s night shift (2300 hr – 0700 hr). During the Member’s night shift, he documented the following (Exhibit #45, Tab D, the Resident Care Progress Notes, 544A), “Resident did not sleep all shift. Complained of back pain + + and a HCA stated she never heard [client #11] complain so much about her back. Pain medication given regularly on request. Resident asked if day shift would let her stay in bed today. Day shift notified”. However, Witness #10 testified after receiving report on that day, client #11 was dressed and walking in the halls with no further complaints of pain from her.

Witness # 11

Witness #11 (Doctor) was an M.D. since 1982. He was in family practice in the Brantford area since 1984. Witness #11 attended to some clients at Versa Care about once a month. Client #11 was a client of Witness #11 for “a long time”. Her condition in late 1998, was termed mild dementia and back pain. Upon Client #11’s transfer to Versa Care from the hospital in Lindsay, Witness #11 (Doctor) reviewed her prescriptions. His practice in prescribing pain medication was to give discretion to the nurse to start with the least potent pain medication and if required administer stronger analgesic. Witness #11 (Doctor) concluded that his assessment of Client #11 indicated that she rarely complained of back pain. His expectations would have been to be consulted if pain control was not achieved.

Witness #11 first became concerned about the amount of Statex given to client #11 when he was contacted by the Police. The witness was shown the Doctor’s Order Sheet (Exhibit #42) for client #11, the Resident Progress Notes (Exhibit #45) for client #11, the MAR (Exhibit #44) for client #11 and the Individual Controlled Drug Sheet (Exhibit #43) for client #11 at which time he noted that drug administration of Statex most often occurred during the Member’s shift. The witness concluded that client #11 was dosed with narcotics inappropriately and the documentation and communication with the nursing staff, did not support its use.

Decision

Having considered the evidence and the fact that the College bears the onus of proving the allegations in accordance with the Standard of Proof a set out in Re: Bernstein and College of Physicians and surgeons of Ontario (1977), 15 O.R. (2nd) 447; namely that the proof must be clear and convincing and based on cogent evidence, which was accepted by the panel.

The panel deliberated and unanimously concurred that the Member had committed acts of professional misconduct as alleged in paragraphs #1, #2, #3, #4 (b), #5(b), #6, #7, #8, #9 and #10 in the Amended Notice of Hearing.

Counsel for the College advised the panel that no evidence would be put before the panel in relation to Allegations #4(a) and #5(a), therefore, the panel would not be required to make a finding on Allegations #4(a) and #5(a).

Reasons for Decision

Allegation #1(a)(b)(c)(d)(e)(f)(g)(h)(i)(j)(k)

The panel found there was clear, convincing and cogent evidence that supports the finding of professional misconduct in relation to Allegation #1(a) (b)(c)(d)(e)(f)(g)(h)(i)(j)(k). The Member failed to maintain the standards of practice of the profession when he:

  1. failed to administer medication to client #1 at 1700 hours on January 24, 1991 and 2100 hours on January 25, 1999
  2. failed to administer medication to client #2 at 1700 hours on January 25, 1999
  3. failed to administer medication to client #3 at 2100 hours on January 25, 1999
  4. failure to document lung congestion on chart for client #4 on January 28, 1999
  5. failure to document lung congestion on chart for client #5 on January 28, 1999
  6. failure to document lung congestion on chart for client #6 on January 28, 1999
  7. failure to document results of Glucosan on chart for client #7 in a timely manner on February 11, 1999
  8. failure to document physician orders, initiate MAR and order medication from pharmacy to client #8 in a timely manner on or about February 12, 1999
  9. administered medication to client #8 that the client brought from home, had not initiated a MAR, or recorded physician order or ordered medication from pharmacy
  10. signed for Gentamycin on the MAR of client #9 when he had not administered the medication

The Member’s failure to document clients’ changing health status is supported by Resident Care Progress Notes (Exhibit #29) of client #4, the Resident Progress Notes (Exhibit #31) of client #6, the Resident Progress Notes (Exhibit #30) of client #5, for the date of January 28, 1999, demonstrates failure to maintain standards of practice.

The Member’s failure to administer medications as ordered to client #1 on January 24 and 25, 1999 is supported by the Medication Incident/Discrepancy Report (MIDR) (Exhibit #17) which he signed January 29, 1999 after co-worker, Witness #4, RPN, found the error and made out the report. Failure to administer medication to client #3 is supported by MIDR (Exhibit #24) which was signed by the Member on January 29, 1999, after co-worker, Witness #4, RPN, discovered the error and made out the report. This demonstrates failure to maintain the standards of practice.

Failure to document the result of Glucosan on client #7 on February 11, 1999, is supported by the testimony of Witness #5, RN, and her written account (Exhibit #32) dated February 12, 1999. This demonstrates failure to maintain the standards of practice.

Failure to process physician order, initiate a MAR and order client medication from pharmacy in a timely manner is supported by the testimony of Witness #6 who was the RN that worked with the Member on February 12, 1999. This demonstrates failure to maintain the standards of the profession.

The Member’s signing for medication (gentamycin) when in fact he did not administer it to client #9 is supported by Witness #6’s testimony and the MAR (Exhibit #40) for client #9 which shows the Member’s initials as having given the medication at 1700 hours. This demonstrates failure to maintain the standards of practice of the profession.

Allegation #2(a)(b)(c)(d)

The panel found clear, cogent and convincing evidence that supports a finding of professional misconduct for Allegation #2(a, b, c, d). The MAR (Exhibit #20) supports the testimony of Witness #4, RPN, that the Member did in fact sign for medications that he failed to administer to client #1 on January 24, 1999 at 1700 hours and on January 25, 1999 at 2100 hours. The MAR (Exhibit #23) supports the testimony of Witness #4, RPN, that the Member did in fact sign for the medication that he failed to administer as ordered to client #3 on January 25, 1999 at 2100 hours. This demonstrates falsification of a record relating to practice.

Allegation #3

The panel found clear, cogent and convincing evidence that supports a finding of professional misconduct for Allegation #3 dealing with:

  1. failure to keep records as required for clients #s 4-6, who all suffered from lung congestion on January 28, 1999, is supported by the clients’ Resident Care Progress Notes (Exhibits #29, #30 and #31) which all indicate a lack of documentation by the Member regarding these clients changing health statuses. This demonstrates failure to keep records as required.

Allegation #4(b) and #5(b)

The panel found clear, cogent and convincing evidence on the misappropriation of Statex prescribed to client #11 on one or more dates between November 6, 1998 and January 17, 1999. These allegations are supported by circumstantial evidence given by Witness #7, the client’s daughter, when she described her mother’s behaviour when on morphine (Statex) and when she was no longer on the Statex.

The testimonies of Witness #4, RPN, Witness #10, RPN, and Witness #9, Director of Care at the Lodge, regarding the status of client #11, further supports that the client did not receive the Statex as documented on the client’s Individual Controlled Drugs (Exhibit #43, page 431A and 431B) and the MAR (Exhibit #44, pages 426A 428A and 430A). All three nurses testified that client #11 was bright, alert and independent whenever they saw her and especially when the Member had reported that client #11 had a very poor night and requested that she be able to remain in bed. When Witness #10 saw client #11 after morning report she was surprised to see her up and walking in the hallway. This demonstrates theft and conduct relevant to the practice of nursing that would be reasonably regarded by members of the profession as disgraceful, dishonourable or unprofessional.

Allegation #6(a)

The panel found clear, cogent and convincing evidence to support the theft of Dilaudid as is proven by the Information Document of the Brantford Police Service and conviction record (Exhibit #6) dated October 7, 1999 and the Ontario Court of Justice Reasons for Sentence by the Honourable Mr. Justice (Exhibit #7) which asks the Member to pay a fine of $750.00. This conduct is relevant to the Member’s suitability to practice.

Allegation 7(a)(b)

The panel found clear, cogent and convincing evidence to support a finding of professional misconduct for failure to disclose criminal conviction for break and enter and acquisition of a firearm as alleged in Allegation 7(a)(b). Through the Application for Assessment and the Declaration of Registration Requirements (Exhibit #10) dated May 16, 1996, to determine eligibility for registration, the Member answered “no” to the question of having ever been convicted of a criminal offence or an offence under the Narcotic Act.

The allegations are further supported by the Declaration of Registration Requirements and the Application for a Certificate of Registration for a practical nurse (Exhibit #11) dated April 14, 1997, signed by the Member in which he also answered "no" the question of former convictions.

Allegation #8 (a) (b)

The panel found clear, cogent convincing evidence to support a finding of professional misconduct for failure to disclose a criminal conviction for break and enter, theft, and acquisition of a firearm. The Member failed to ensure that information requested was provided in a complete and accurate manner. The same evidence, Exhibit #10 and Exhibit #11, support this allegation. This conduct deals with failure to disclose accurate information that he knew or ought to have known contained a false and misleading statement.

Allegation #9(a)(b)

The panel found clear, cogent and convincing evidence to support this allegation as contained in Exhibit #10 and Exhibit #11. This conduct would be regarded as disgraceful, dishonourable or unprofessional by members of the profession.

Allegation #10(a)(b)(c)(d)(e)(f)(g)(h)

The panel found clear, cogent and convincing evidence to support that the Member, between September 29, 1998 to October 13, 1998, forged a number of documents and presented them as drug prescriptions to a number of individuals including Dr. “A” of London Health Science Centre, Dr. “B” of St. Joseph Hospital, Brantford, staff of Pharmacy #1 in Brantford, the staff of Pharmacy #2 of Brantford, the staff of Pharmacy #3 of Brantford and finally the staff of Pharmacy #4 of Brantford. This allegation is supported by Exhibit #3 and Exhibit #4 which deals with offences relevant to the suitability to practice.

The panel was presented with and accepted further evidence of the Brantford Police Arrest History (P. R. I. D. E.), (Exhibit #8) for the Member, dated November 10, 2000 and the RCMP Identification Services Record (Exhibit #9) dated November 10, 2000, which showed that the Member had been arrested and fingerprinted.

Mitigating Factors

Since the Member did not appear for the hearing, the panel has nothing from the Member that could be considered as mitigating circumstances. The Member has not given the panel any excuse for his actions nor shown any remorse. In fact, the Member did not take part in a pre-hearing conference, nor did he respond in any way to the allegations against him. Given the Member’s demonstrated lack of respect for the process, the panel could not assess if he could in fact be rehabilitated.

Penalty

Counsel for the College submitted that the only appropriate penalty in this case is revocation of the Member’s Certificate of Registration. She further submitted that when considering penalty for any offence, there are three criteria the penalty should address. Counsel outlined the three factors to be:

  • the rehabilitative aspect for the Member
  • specific deterrents for the Member
  • general deterrents for the membership

Penalty Decision

The panel deliberated and unanimously agreed to revoke the Member’s Certificate of Registration immediately.

Reasons for Penalty Decision

The panel agreed with College Counsel that the penalty, in this matter, effectively meets the objectives of specific deterrents for the Member. The panel has no indication that this Member would commit to rehabilitation. He gave no explanation for his actions, no expression of regret or remorse. The Member began his nursing career based on false information to the College. The nursing profession is based on trust, honesty and integrity. These virtues must be selfishly protected in order to retain the public respect for nursing.

Failure to maintain standards of practice, falsifying and failing to keep accurate records, misappropriation of property from the workplace and clients and failure to disclose criminal convictions are serious acts of misconduct which, if ignored, undermine the public confidence in the profession as a whole.

Revocation sends a clear message to the public that this kind of very serious conduct will not be tolerated by members of the profession.

I, [name], 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

RPN, Chairperson, Discipline Panel

RPN, Member, Discipline Panel

RN, Member, Discipline Panel

Public Representative, Member, Discipline Panel

Public Representative, Member, Discipline Panel

Page mise à jour le septembre 28, 2010