The Health Professions Appeal and Review Board has confirmed a decision to issue professional advice to a registered practical nurse at an Ontario retirement home who failed to properly document patient care and communicate with family members.
The board upheld the College of Nurses of Ontario’s decision to provide remedial advice to the nurse, identified as P.C., following a complaint about care provided to an elderly patient at The Village of Erin Meadows retirement facility between 2019 and 2021.
The complaint was filed by V.T., whose father resided at the facility from June 2019. V.T. raised 21 specific concerns about the nurse’s conduct across five main categories of alleged professional failures.
The college’s Inquiries, Complaints and Reports Committee investigated the complaint and found support for four of the concerns, determining that advice rather than disciplinary action was appropriate.
Documentation and communication failures
The committee found the nurse failed to update the patient’s care plan after an incident in April 2020 when the patient threatened to harm himself with a knife if he was not removed from COVID-19 isolation. While the nurse had developed behavioural management strategies following the incident, she acknowledged the care plan was not properly updated to document this information.
The committee also supported a complaint that the nurse failed to respond to a family email for seven days regarding the patient’s left shoulder pain in May 2020. The nurse had spoken to the on-duty nurse the same day the email was received and arranged for a physician visit, but she acknowledged she should have responded to the family to advise them of the plan.
“The Respondent expressed regret for not doing so, but stated that it was a busy time and she was faced with competing demands due to the pandemic,” the committee noted.
The committee found the nurse failed to properly report and document a September 2020 incident when the patient left the facility unescorted and later expressed intent to harm himself. While reporting the incident to the Retirement Homes Regulatory Authority was not required, the committee determined the patient’s care plan should have been updated.
Professional designation disclosure
The fourth supported complaint involved the nurse’s failure to properly disclose her RPN credentials in communications with the family. The nurse acknowledged that in some emails she did not disclose her professional designation when she should have, apologized for the oversight, and committed to ensuring it would not happen again.
Rejected complaints
The committee rejected 17 other complaints, finding no support for allegations including improper COVID-19 isolation procedures, failure to arrange medical care, and providing inaccurate information to hospital staff.
Regarding COVID-19 related complaints from April 2020, the committee noted the emails from the patient’s family were not addressed to the nurse but to other staff members. The nurse forwarded the emails to the facility’s assistant general manager, who responded to the family’s inquiries on the same day.
The committee also considered that the incident occurred during the early days of the COVID-19 pandemic when leadership teams faced significant challenges and changing public health directives.
For complaints about health care assessments conducted between December 2020 and April 2021, the committee found the patient had not been declared incapable and was able to consent to assessments. The family had been invited to discuss assessment results and approve revised care plans.
Professional advice issued
Rather than pursuing disciplinary action, the committee issued comprehensive professional advice addressing documentation standards and therapeutic nurse-client relationships.
The advice emphasized that nurses are accountable for ensuring documentation is accurate and meets college practice standards, noting that “failing to document may put the patient at risk, as health records are used to communicate patient information and ensure continuity of care.”
The committee reminded the nurse that “nurses are required to maintain a record of care given or service provided regardless of how busy they might be during a particular shift.”
Regarding communication, the advice stated that “effective communication is an essential factor in creating and maintaining a successful relationship” and that nurses have “a commitment to respect patient’s family members and significant others.”
Appeal board review
V.T. requested the Health Professions Appeal and Review Board review the committee’s decision in November 2023. The appeal board, comprised of Mason Greenaway as designated vice-chair and board members Mark Gordon and Eleni Palantzas, conducted the review by teleconference in January 2025.
The appeal board found the committee’s investigation was adequate, noting it obtained essential information including the complaint letter, interview summaries, health records, police reports, facility correspondence, and the nurse’s detailed responses.
The board determined the committee’s decision was reasonable, finding it was “based on a chain of analysis that is coherent and rational and is justified in relation to the relevant facts and the laws applicable to the decision-making process.”
Accountability and remedial approach
The appeal board noted the committee recognized that P.C. took accountability by acknowledging her errors and expressing remorse. The board found the advice was “detailed and comprehensive” and “tailored to address the Committee’s concerns regarding the Respondent’s failure to maintain effective communication with the patient and his family and to ensure that the patient’s care plan was maintained accurately and up to date.”
The complaint and the committee’s disposition will remain on the nurse’s permanent but private record with the college and will be considered if another complaint arises in the future.
For more information, see V.T. v Croucher, 2025 CanLII 78690 (ON HPARB).
