Redacted Decisions

Decision & Undertaking: Reprimand

Date: May 30, 2006

On May 30, 2006, the Complaints Committee of the College of Registered Nurses of Nova Scotia (the College) ordered that pursuant to Section 32(4)(c)(v) of the Registered Nurses Regulations, and with the consent of an occupational health nurse “Nurse X”, that Nurse X receive a reprimand for failing to exercise appropriate discretion and judgment. This was a unique factual situation involving a husband and wife who had the same employer, but worked in different departments. Nurse X was the occupational health nurse for their employer and her involvement in this matter resulted from an Employee Assistance Program (EAP) request by the wife (Nurse X’s ‘client’) for marital counselling. An external contractor, not Nurse X, provided the occupational health and EAP services for the department in which the husband was employed.

According to the Complaints Committee, Nurse X was to receive a reprimand for failing to exercise appropriate discretion and judgment with respect to: (i) discussing confidential information about the husband of a client with a physician without the husband’s consent; (ii) becoming involved in the husband’s work situation by suggesting that he leave work; (iii) disclosing the husband’s name to the police; and (iv) failing to provide the husband with a copy of his medical file as requested.

On March 5, 2004, the wife and husband attended a marital counselling session with a physician arranged by Nurse X. Following that session, the wife told Nurse X that she had concerns about her husband’s mental stability and her own safety. Nurse X then contacted the physician who had conducted the counselling session, discussed the husband’s mental status, and questioned whether the husband was a safety risk, “mainly in reference to his job”.

On March 11, 2004, Nurse X contacted the husband and requested that he meet with her at her office. Nurse X also contacted the police to request the presence of a police officer as she had safety concerns about the husband. When the husband arrived there were a number of uniformed police officers around and in the building. Nurse X told the husband that she was concerned that he was a safety risk and, through her communications with the husband, left the impression with him that he had no choice but to leave the workplace that day.

Nurse X made entries on the husband’s medical file, which she retained in her office. In April 2004, the husband contacted Nurse X to request a copy of his complete medical file. Nurse X provided the file with the exception of the nurses’ notes. In November 2004, the husband found out that Nurse X had failed to provide him with a copy of the nurses’ notes from his file.

Reasons for the Reprimand

Breach of confidentiality
It is the Complaints Committee’s belief that Nurse X showed poor judgment and breached confidentiality when she contacted the physician who provided the marital counselling to discuss the mental status of her client’s husband. Nurse X did not have the husband’s consent to contact or request medical information from the physician. Nurse X asserted that she contacted the physician because she believed the husband was a potential “safety risk”. However, the committee believes that Nurse X could have addressed these concerns in other ways that would not have impacted the husband’s right to confidentiality, such as suggesting that her client contact the physician with her safety concerns. In this instance, the committee believes that Nurse X failed to respect the husband’s right to informational privacy of his medical information (i.e., control, access, disclosure and collection: Code of Ethics – Confidentiality).

In the committee’s opinion, Nurse X’s poor judgment continued when she met with her client’s husband at her office to discuss her safety risk concerns and his work situation. As the husband was not Nurse X’s client, it was the committee’s opinion that her involvement in his workplace situation was inappropriate. In addition, the committee believes that Nurse X was inappropriate and breached confidentiality when she gave the police the husband’s name as a person that she had concerns about meeting.

The committee believes that it would have been prudent for Nurse X to consult with the employer’s medical consultant and/or legal counsel, and perhaps with a Nursing Practice Consultant at the College, before taking any action related to her client’s husband.

Medical file
It is the committee’s belief that Nurse X inappropriately withheld a portion of the medical file from the husband without telling him that she had withheld it, and without offering him another avenue to attempt to access this information. According to a document published by the Occupational Health Nurses of Nova Scotia, entitled Confidentiality of Occupational Health Records and Information, as well as the College’s Documentation Guidelines for Registered Nurses, individuals own the information in their health records and have a right of access to any and all parts of their records. Information provided to the committee from persons within the employer’s Information Management department indicated that in rare cases staff could refuse to provide part of a file if provision of the information would harm the client’s physical or mental state. In any event, even in those circumstances, if a portion of a file is not released, it is the employer’s practice that the client be notified of the omission and told how to make application to get the information.

The committee found that Nurse X’s action/inactions, with respect to her involvement with the husband of her client, breached the following Standards for Nursing Practice:

  • Standard 1.5 Each registered nurse exercises reasonable judgment in practice.
  • Standard 4 Each registered nurse protects confidentiality of all information gained in the context of a professional relationship and exercises
  • discretion in respect to disclosure of confidential information.
  • Standard 1.6 Each registered nurse seeks assistance appropriately and in a timely manner

At the Complaints Committee meeting, Nurse X informed the committee that she believed her actions were appropriate and given the same circumstances she would act in the same manner. As Nurse X’s actions/inactions breached several of the Standards for Nursing Practice, the committee believes that the issuance of a reprimand is the appropriate outcome in this case.

Nurse X consented to the reprimand on July 8, 2006.

Decision & Undertaking: Reprimand

Date: March 17, 2004

On March 17, 2004, the Complaints Committee of the College of Registered Nurses of Nova Scotia (the College) ordered that pursuant to s. 32(4)(c)(v) of the Registered Nurses Regulations, and with Nurse A’s consent, Nurse A receive a reprimand with respect to his actions/inactions during the “corking” of a patient’s tracheotomy on December 19, 2003. The committee found that Nurse A’s action in holding a patient’s hand during the placement of a cork over the patient’s tracheotomy affected the patient’s ability to remove the cork and his ability to communicate any change in his consent during the corking session. The Complaints Committee further reprimanded Nurse A for his failure to appropriately assess the patient and intervene when the patient exhibited signs of distress during this corking attempt.

On October 15, 2003, the patient was given a tracheotomy because of breathing problems. A few weeks after the initial tracheotomy was performed efforts were made to get the patient to breathe on his own without the tracheotomy. The process used to facilitate the transition from breathing through the tracheotomy to breathing normally was described as “corking”. In this process, a cork is placed over the opening of the tracheotomy and the patient then has to breathe through her/his mouth and nose instead of through the tracheotomy. The patient’s parents informed the nursing staff that they wanted the patient to “be in control” during the corking sessions (i.e., thus allowing him to remove the cork from the opening of the tracheotomy should he become uncomfortable during the process).

On December 19, 2003, Nurse A was assigned to care for the patient. Information provided to the committee suggested that when Nurse A “corked” the tracheotomy, he held one of the patient’s arms and instructed a “sitter” to hold the patient’s other arm. The information also suggested that Nurse A held the cork over the tracheotomy against the patient’s wishes rather than allowing the patient to be in control of the “corking”. Information was provided that during the corking session the patient’s bladder and bowels released and the patient’s oxygen saturation level dropped from the normal of 96-97% to the abnormal level of 61%. Information was also provided that the patient was traumatized and scared of Nurse A, and that this incident caused the patient serious psychological problems that persisted for at least one year.

Approximately one month following the above incident, it was discovered that scar tissue had developed in the area surrounding the trachea causing a blockage of the patient’s throat. Surgical removal of that scar tissue was required before the patient could breathe normally on his own.

Reasons for Reprimand
The information provided to the Complaints Committee suggested that corking is a traumatic experience because patients must relearn to breath through their mouth and nose. Successful corking requires good nursing skills and patience on behalf of a nurse because patients often become anxious during the procedure. In this case, on December 19, 2003, Nurse A made four attempts to cork the patient. The first three attempts lasted between 10-30 seconds each, with the patient removing the cork at his discretion. However, during the fourth attempt Nurse A instructed the sitter to hold the patient’s left arm while Nurse A held the patient’s right hand. In his written submission, Nurse A stated that he held the patient’s hand for support. However, at the Complaints Committee meeting, he also said that during the fourth corking session, he decided to “take control” of the corking.

It was the committee’s belief that the holding of both the patient’s hands was not a form of support to the patient but instead, interfered with the patient’s ability to remove the cork. In light of the fact that the patient was able to remove the cork on three previous occasions and because he could only communicate verbally by whispering, the committee believed that Nurse A should have realized that interfering with the patient’s hand movement would affect his ability to communicate any change in consent for the corking.

The information further provided that the patient was exhibiting signs of distress during Nurse A’s fourth attempt to cork him. Nurse A’s entries in the chart read that the patient was “panicking, thrashing and trying to pull off cork”. Because Nurse A charted these observations at the time of the occurrence, the committee believed that these physical signs of distress were evident to Nurse A. However, instead of removing the cork immediately, Nurse A persisted with the fourth corking effort until the oxygen saturation monitor dropped from 96-97% to 61% and the patient was incontinent of bladder and bowel. Therefore, the committee believed that Nurse A failed to intervene in a timely and thorough manner when the patient’s non-verbal cues indicated that he was in distress. As a result, it was the committee’s belief that Nurse A’s persistence in continuing with the corking caused the patient immediate stress and long lasting anxiety.

The committee found that Nurse A’s actions, which included ignoring the patient’s wishes and not responding appropriately during the corking session, breached the following Standards for Nursing Practice and Code of Ethics value:

  • Standard 1.3 Each registered nurse exercises reasonable judgment in practice.
  • Standard 3.1 Each registered nurse applies appropriate knowledge and skills to assess, plan, intervene and evaluate services, and revises plan as needed.
  • Choice Nurses must ensure that nursing care is provided with the person’s informed consent. Nurses must also recognize that patients have the right to refuse or withdraw consent for care or teatment at any time.

The committee reviewed the definition of professional misconduct in the Registered Nurses Act. The clause reads as follows: “… such conduct or acts relevant to the practice of nursing that, having regard to all the circumstances, would reasonably be regarded as disgraceful, dishonourable or unprofessional which, without limiting the generality of the foregoing, may include:

  1. failing to maintain the College of Registered Nurses of Nova Scotia Standards for Nursing Practice,
  2. failing to uphold the code of ethics adopted by the College.

It was the committee’s belief that Nurse A’s actions/inactions constitute professional misconduct. As this appeared to be an isolated incident in Nurse A’s 17-18 year nursing career, the committee believed that the issuance of a reprimand was the appropriate outcome in this case.

On April 26, 2004, Nurse A consented to the reprimand.

Decision & Undertaking: Revocation

Date: December 5, 2003

The Professional Conduct Committee of the College of Registered Nurses of Nova Scotia (the College; CRNNS) met on October 14, 2003, to hear an application from a registered nurse for a Consent Revocation of the nurse’s licence to practise nursing. This application was made pursuant to Section 35 of the Registered Nurses Regulations and was in response to a complaint made against the nurse by the employer.

The allegations included in the application were that while undergoing orientation, the nurse:

  1. made several serious medication errors that significantly impacted the nurse’s ability to practise nursing safely. For example, the nurse prepared Dilaudid for a subcutaneous injection, but then proceeded to continue with the process for the administration of the Dilaudid by IV, despite advice to the contrary from the preceptor;
  2. demonstrated a lack of knowledge of basic nursing matters. For example, the nurse failed to demonstrate an understanding of the five rights of medication administration;
  3. consistently demonstrated a lack of ability to chart in a timely and accurate manner, despite instruction to the contrary;
  4. failed to carry out appropriate nursing intervention in response to a STAT order; and
  5. demonstrated cognitive difficulties that significantly impacted the nurse’s ability to practise nursing safely.

In September 2002, the nurse sought medical advice and was diagnosed with a medical condition which would not allow for the return to the type of nursing work in which the nurse was previously employed.

The nurse admitted the allegations set out above and agreed that the nurse was incapacitated within the meaning of the Registered Nurses Act.

On December 5, 2003, the Professional Conduct Committee accepted the Request for Consent Revocation, and thereby revoked the nurse’s licence to practise nursing.