Ontario’s nursing discipline system runs on a track parallel to physician discipline. The College of Nurses of Ontario prosecutes professional misconduct before its own Discipline Committee under the Nursing Act, 1991 and the Health Professions Procedural Code, using the same structure of allegations, findings, and penalty that the physician cases follow. What differs is the subject matter. Nursing discipline decisions tend to turn on the daily mechanics of bedside care: assessments, medication administration, documentation, and handover.
College of Nurses of Ontario v Paulson, 2026 CanLII 73519 (ON CNO), heard by a panel of the Discipline Committee on February 27, 2026, is a clear example. A registered practical nurse admitted a series of failures across two Guelph hospitals in the space of four months: an admission assessment that was not done and was then backdated, a lorazepam tablet that went missing with no incident report, two sets of ordered medications that were never given, a bladder scan that was charted but not performed, and a transfer of accountability that never happened. The panel found professional misconduct on every allegation and accepted a joint submission for a three-month suspension with a substantial package of conditions attached.
The patients are identified only as Patient A through Patient E. A publication ban under subsection 45(3) of the Health Professions Procedural Code prohibits disclosure of anything that could identify them.
What happened at St. Joseph’s
The member registered as an RPN in 2006. He worked in a general rehabilitation unit at St. Joseph’s Healthcare Guelph from early December 2022 to the end of January 2023.
On December 29, 2022, he was assigned to a newly admitted patient and did not complete the admission assessment that hospital policy required on the day of admission. When the Director of Clinical Services raised it the next day, he said the patient had not been in the system, which was not true. He then completed the assessment form and a progress note, recording times on December 29 for work he had not done that day, and did not indicate anywhere that the entries were late.
On January 16, 2023, the automated dispensing cabinet showed the lorazepam bin restocked to twenty tablets. The member withdrew one 0.5 mg tablet at 19:45 and the count fell to nineteen. He charted administration of a 0.5 mg dose at 20:00. The next morning a colleague reported eighteen tablets in the cabinet, one fewer than the record accounted for, and a torn pouch in the machine with no tablet in it. No one else had accessed the bin between the restock and the discovery. The unit manager asked him to file an incident report. He neither answered the email nor filed one. His account, recorded in the agreed statement of facts as what he would say if he testified, was that he found a loose pill in a torn pouch, threw it out, forgot to document the wastage because he was overwhelmed by the medication pass, and then forgot the incident report. Nothing in the notice of hearing alleged diversion, and the panel made no such finding.
Two further incidents followed. On January 21, 2023, the member charted heparin and nitrofurantoin as given to Patient B at 20:00. The cabinet record showed he did not remove either drug until 21:51 and 21:52. The following morning the day shift nurse found them in the patient’s drawer and returned them to the cabinet at 07:21 and 07:22. On the agreed facts, the two medications were never administered at all.
Four days later, seven medications ordered for Patient C at 22:00, including three agents that lower blood pressure, were not given. At 01:00 the patient rang the call bell asking where his medications were. Another nurse pulled and administered them late while the member was on break. He was told about it on his return and again filed no incident report.
What happened at Guelph General
In March 2023 the member started as a part-time RPN on a general medicine unit at Guelph General Hospital. New hires there typically receive twelve orientation shifts. He worked roughly six to eight before his preceptor raised practice concerns and he was placed on administrative leave.
The central incident concerns Patient D, who was retaining urine. On the evening of April 11, 2023, the day nurse documented that the patient had not voided in more than six hours, recorded a bladder scan of 607 mL, and drained 600 mL by in and out catheterization. The next progress note is the member’s, at 06:25 the following morning. He recorded that the patient had got up to void and that a bladder scan showed 124 mL.
His preceptor, who understood the patient had not voided overnight, asked whether he had scanned. He confirmed the scan and the volume. When she pressed, he said the patient had been helped to the bathroom during the night. She checked with the staff, and no one had. He then said the patient had been soaking wet in the morning. She spoke to the patient, who said he had not been scanned, had not walked to the bathroom, and had not been wet. She scanned him herself and found 590 mL. An in and out catheterization at 06:49 drained 700 mL.
That same morning the preceptor asked him to give a transfer of accountability to the oncoming nurse for a different patient. He said he had done so and went home. He had not.
How the record proved the case
Nothing in this decision turned on a competing clinical opinion. It turned on machine logs, timestamps, and a colleague who repeated the assessment herself.
The automated dispensing cabinet carries most of the weight: restock counts, withdrawal times to the minute, returns, and the identity of the nurse who opened the drawer. Where the chart says 20:00 and the cabinet says 21:51, it is the chart that has to be explained. Where a bin count falls by two and only one withdrawal is recorded against a single user, the field of candidates closes quickly. The bladder scan allegation was proved by the sequence of contemporaneous notes (607 mL, then 124 mL, then 590 mL within hours), the preceptor’s repeat scan, and the patient’s own account.
This is a familiar dynamic in medication error claims, where the issue is often not clinical judgement at all but whether the documented sequence of events survives comparison with the electronic record. Nursing notes, the medication administration record, dispensing cabinet reports, and electronic health record access logs are generated separately and time-stamped separately, and they are rarely all wrong in the same direction. Patients and families can obtain the chart itself on request, although dispensing and audit data usually surfaces only once a claim is underway.
The findings
The College framed the same conduct two ways: failure to meet the standards of practice of the profession under subsection 1(1) of Ontario Regulation 799/93, and conduct that members would reasonably regard as disgraceful, dishonourable or unprofessional under subsection 1(37), both engaging paragraph 51(1)(c) of the Health Professions Procedural Code. The member admitted everything, and the panel found misconduct on every allegation.
Two features of the findings are worth noting.
First, the bladder scan allegation was pleaded and found in the alternative: either the member did not perform the scan and falsely reported that he had, or he performed it and failed to identify that the patient required catheterization. The College never had to prove which. Pleading in the alternative is routine in discipline work, and it holds up because on either branch the standard of practice is breached, so resolving the factual fork adds nothing to the finding itself. It can matter at penalty, though here the panel found the dishonesty element established on other grounds in any event.
Second, the panel found the conduct dishonourable and unprofessional. It did not find it disgraceful, although the regulation makes all three characterizations available. On unprofessionalism, the panel described conduct showing “a serious and persistent disregard for his professional obligations”. On dishonour, it pointed to the dishonesty running through the handling of the missing tablet, the bladder scan report, and the charting of medications that were never given.
The contrast with the serious end of the nursing discipline range is instructive. In CNO v Coyle, a nurse altered a morphine order, charted doses that were never given, misappropriated the drug, and a patient died. She gave a permanent undertaking never to practise nursing again. Paulson is a different order of case: no diversion, no criminal proceeding, and no finding that any patient was harmed. What the two decisions share is the mechanism. In both, the chart recorded care that had not been provided, and the next person to read it was working from a false picture.
The penalty
The parties presented a joint submission on order. Under R v Anthony-Cook, 2016 SCC 43, a panel may depart from a joint submission only where the proposed penalty would bring the administration of justice into disrepute or is otherwise contrary to the public interest. That threshold was not met, and the panel made the order requested:
- an oral reprimand within three months
- a three-month suspension of the certificate of registration
- at least two meetings with a College-approved regulatory expert, at the member’s own expense, preceded by completion of the College’s Code of Conduct, Documentation, and Medication practice reflection materials
- employer notification for twelve months after his return to nursing, with the employer reporting back to the College
- a prohibition on independent practice in the community for twelve months
- a mentorship with a Registered Nurse at the same employer, meeting at least monthly, over six to nine months of continuous practice
The panel treated as aggravating the seriousness of the conduct, the number of separate documentation and medication issues, the fact that they involved different patients on different days, the potential for patient harm, and the element of dishonesty. It treated as mitigating the absence of any prior discipline history and the member’s acceptance of responsibility through the agreed statement of facts and joint submission, which spared a contested hearing. The College placed the order within the established range using CNO v Cowell, 2024 CanLII 145649 (ON CNO), CNO v Fernandez, 2021 CanLII 152475 (ON CNO), and CNO v Rogers, 2020 CanLII 51614 (ON CNO).
The shape of the order is worth more attention than its headline. The suspension is short and the oversight is long. Twelve months of employer notification, a twelve month bar on independent community practice, and a monthly mentorship do considerably more practical work than three months away from the bedside. That allocation reflects what the file was actually about: not one lapse but a pattern that needed supervision to correct. It also answers a specific feature of the facts. The member moved from one hospital to another within seven weeks, and the second employer had no way of knowing what the first had documented. Employer notification closes that gap.
Orientation, training, and the systems question
The member told the panel he had worked at another facility for seventeen years without any issue, and that at St. Joseph’s the training was inadequate, the orientation was too short, and communication was lacking. College counsel cautioned that this could be received as context but was not evidence, the only evidence before the panel being the agreed statement of facts. The panel did not treat it as mitigating.
In a discipline proceeding that is the right result. The regulator’s mandate is the individual member’s accountability, and a thin orientation does not excuse charting care that was not provided. The same facts sit differently in civil litigation. A nurse who received six to eight of twelve expected orientation shifts, who says he was unfamiliar with both the documentation system and the narcotic wastage process, and who describes himself as overwhelmed during a medication pass, is describing an institutional problem alongside a personal one. In a claim arising from an adverse event on such a shift, a plaintiff would seek orientation records, staffing levels, workload data, and supervision structure, and would advance the hospital’s own duties in training and supervision alongside vicarious liability for the nurse.
The defence answer is equally available and it is strong. A discipline finding is not proof of civil negligence. An agreed statement of facts is negotiated for a regulatory purpose, and the member’s explanations appear in it as what he would say if he testified, not as evidence tested on cross-examination. The panel made no finding that anyone was harmed and no finding on causation, because it did not need to reach either. A civil claim would have to prove both, on expert evidence, from the ground up.
Which version of the standard applied
One detail in the agreed statement of facts deserves attention from anyone pleading a breach of a College standard. The panel applied the Code of Conduct, the Documentation standard, the Medication standard, and the Professional Standards, Revised 2002, and the agreed statement records that the last of these has since been retired. The exhibits were the versions in force at the time of the incidents, not the versions in force at the hearing.
Standards documents get revised and withdrawn. Where three years separate the conduct from the decision, and considerably longer separates the care from trial in a civil case, the version that governs is the one in force on the date of the care. Downloading the current publication from a College website and pleading it against conduct from several years earlier is an easy error to make and an easy one to exploit. Confirm early which version applied and obtain a dated copy. It is also worth remembering what a College standard does and does not do in a civil action: it is evidence of the profession’s own expectations, useful and often persuasive, but the standard of care in a negligence claim is set by expert evidence, not by the publication.
What this means for patients and families
A discipline decision is a public accountability process, not a compensation process. The order in Paulson protects the public by suspending, supervising, and monitoring the member. It gives nothing to the patients whose medications were missed or whose urinary retention went unrelieved through the night, and it does not decide whether any of them were injured.
Where something has gone wrong with care, the two routes run separately and can run at the same time. A complaint to the relevant College is free, needs no lawyer, and produces a regulatory outcome; the complaint process in Ontario differs from one profession and body to the next. Compensation is a different exercise: a medical malpractice claim requires proof of a breach of the standard of care and proof that the breach caused the injury, both on expert evidence.
The practical lesson from Paulson is about the record. Care charted but not given, and charting done after the fact without being marked as a late entry, corrupts the one document everybody downstream relies on: the next nurse, the attending physician, the family, and eventually the court. That is why a panel treats documentation failures as seriously as the missed doses themselves.
College of Nurses of Ontario v Paulson, 2026 CanLII 73519 (ON CNO).
