NURS 217: Scholarly Assignment

Natasha Singh
Humber College

Discipline Committee Decisions summary

The Discipline Committee Decisions case that I chose to examine is that of John Derek
Gordon, registration number 9533001, who was heard on November 12, 2012. The member was
assigned to one-on-one care in the Intensive Care Unit before he was terminated. The member
was suffering from a long-standing health condition at the time that he would say, if he testified,
resulted in significant lapses of judgment.
The client involved was a 70 year old diabetic patient who was admitted with congestive
heart failure, underwent surgery to amputate her left leg due to sever ischemia, and was later
diagnosed with sepsis when her health rapidly declined. Physician's orders included hourly vital
signs monitoring, two-hourly blood glucose checks related to her Critical Care IV Insulin
Infusion Protocol, and resuscitation in the case of cardiac arrest. The client was also on an
electronic monitor that triggered an alarm when vitals fell below certain levels. The client's cause
of death was determined to be "hypoglycemia and hyperinsulinemia during insulin treatment for
diabetes".
According to the Professional Conduct Professional Misconduct CNO document (CNO,
2014), the member has committed a number of acts of professional misconduct including abuse,
falsifying records, failure to report his conviction and failing to meet the standard of practice of
the profession when he: (a) spent an unreasonable about of time on personal phone calls during
his shift. (b) failed to follow the Insulin Clinical Protocol by not checking the blood glucose
levels as required and not adjusting the insulin rate administered as required. (c) documented an
inaccurate blood pressure reading. (d) failed to appropriately document client care. (e) failed to
appropriately monitor and/or assess the client's cardiac rhythms and blood pressure. (f) failed to

respond appropriately to changes in the client's cardiac rhythms, blood pressure, and alarms on
the monitor. (g) failed to call a code blue in a timely manner. (h) failed to inform the physician
and resuscitation team that the client was diabetic, receiving insulin infusion and of her most
recent blood glucose readings. (i) failed to appropriately document care and medication
administered during the cardiac arrest and resuscitation efforts. (j) inaccurately documented the
time the client was pronounced dead. The member also failed to report his conviction of Driving
Under the Influence as well as his conviction of assault on his common-law spouse.
The decisions made by the Discipline Committee was that "the member's conduct is
beyond unprofessional and dishonourable and approaches the level of disgraceful (CNO,
2012a)". The member was ordered to attend meetings with a Nursing Expert to discuss
consequences of his conduct and prevention strategies, complete reflective questionnaires,
learning modules, and nurse workbooks, as well as the member not practice independently for
one year. Although the member had no prior disciplinary history, was remorseful and was
cooperating with the College, I still believe the member should have had a greater consequence
because of gross negligent conduct resulting in the loss of human life.
Ethical Values
The ethical values that the member contravened would be (a) client well being, (b)
maintaining commitment and (c) truthfulness. Client well being as defined in the CNO Ethics
document as "Promoting client well-being means facilitating the clients health and welfare, and
preventing or removing harm [also] in collecting data, nurses need to watch for adverse
responses in participants, and to report positive and negative responses promptly to the research
team." (CNO, 2009a). This value was contravened when the member failed to check the client's

blood glucose levels as often as required as well as to adjust the rate of insulin. The member
checked the blood glucose level an hour after it was scheduled, at which time the reading had
dropped from 14.1 to 7.9. He should have decreased the insulin rate by 1.0 unit per hour but
failed to do so. The member failed to monitor and accurately interpret the vital signs and
therefore failed to detect the critical drop in systolic blood pressure at 0615. In addition, he failed
to interpret the arrhythmias and respond to the cardiac alarm. Had he recognized these and other
critical findings, he could have accessed additional assistance for the client sooner.
The second ethical value the member failed to uphold is maintaining commitment.
Maintaining commitment is defined as "Nurses are obliged to refrain from abandoning, abusing
or neglecting clients, and to provide empathic and knowledgeable care" (CNO, 2009a). Abuse
includes verbal or non-verbal, physical or non-physical behaviour towards a client, and includes
neglect pertaining to the client's care (CNO, 2014). Giving the evidence that the alarm on the
cardiac monitor began sounding at 0643 and the code was not called until 0650, the member
failed to respond appropriately and the member neglected the client's care. By neglecting to
assess and interpret the client status, the member was unable to provide knowledgeable care.
Also, the client's blood glucose read 7.9, in which the member should have adjusted the insulin
but failed to do so. His last glucose reading was done at 2200. The second blood glucose check
was not done until 0545, almost 8 hours later. This demonstrates the member neglected to
provide appropriate care in a timely manner.
The third ethical value the member breached is truthfulness. "Truthfulness means
speaking or acting without intending to deceive. Omissions are as untruthful as false
information." (CNO, 2009a). The member falsified the documentation of the client's blood
pressure as being 85/45 when in fact the monitor recorded the blood pressure was 36/20. This

information was critical as it signified the client's rapidly deteriorating status. The member also
reported he had no knowledge that the client's blood pressure and cardiac rhythms had changed,
although there was an electronic monitor in the nursing station where he was stationed. The
member failed to inform the physician and the resuscitation team that the client was a diabetic
patient on an IV insulin infusion and did not provide the pertinent data of the client's last blood
glucose reading. This omission of critical information constitutes lack of truthfulness. Also, the
member falsified the documentation of the client's pronounced time of death. He documented the
time of death being 0650 when in fact the code was called at 0650. The actual time of death was
0715, 25 minutes later. According the CNO document Documentations, Revised, documentation
should reflect the nursing care of the client and should provide a clear picture of the outcomes
and evaluations of the actions taken by the nurse (CNO, 2009b). The member falsified both the
blood pressure reading and the time of death, thus was untruthful. Finally, the member did not
disclose his recent convictions of his Driving Under the Influence and assault on his spouse.
According to the CNO document of Mandatory Reporting, the nurse must self-report any
findings of guilt for an offence including but not limited to offences under the Criminal Code
(CNO, 2012b). This is another example of how the member failed to comply with the ethical
value of truthfulness.
Prevention Strategies
One strategy that could be used to prevent situations like this from occurring in the future
would be to have a buddy system where two nurses pair up and jointly care for their two
assigned patients. This will allow for closer monitoring, a second opinion on identifying critical
data and increases the chance of policy adherence. Had there been a buddy system, the second
nurse may have responded to the cardiac monitor alarm and followed the IV insulin infusion

protocol as well as the blood glucose monitoring schedule. This would promote client well being,
truthfulness in documentation, and prevention of neglect.
Another strategy would be to identify a set of clinical skills and expectations for the area
of practice and implement a policy that the nurses are required to review and/or complete
learning modules on a scheduled basis. This could be incorporated as part of their annual
performance review, and may help the nurses to identify their strengths and weaknesses and
efforts will be focused where necessary to improve skills. This will also promote client well
being as well as maintaining commitments related to preventing neglect and providing more
knowledgeable care.
Conclusion
To summarize, there was overwhelming evidence of gross misconduct including but not
limited to: (a) failed to follow clinical protocol including insulin protocol, blood glucose
monitoring protocol, and adjusting insulin. (b) inaccurate documentation including blood
pressure readings, care provided by the resuscitation team and the time of death. (c) failed to
appropriately monitor and assess the client's cardiac rhythms, changes in blood pressure, blood
glucose and respond to the alarms on the monitors. (d) failed to provide the resuscitation team
with critical data pertaining to the client's diagnosis of diabetes, her IV insulin infusion and
recent lab values. (e) failed to call a code blue in a timely manner. In other words, failure to
follow protocols including monitoring blood pressure, monitoring blood glucose and adjusting
insulin rate, monitoring cardiac rhythms and interpreting findings as well as responding
appropriately to the cardiac alarms, contributed to the client's death. The member breached at
least three ethical values: client well being, maintaining commitments and truthfulness by

falsifying and omitting information, neglecting client's care, and failing to access additional help
as needed.
To prevent similar situations from occurring, two proposed solutions to consider are,
firstly, to implement a buddy system for the nurses. This will potentially minimize errors and
provide extra attention and care to clients. Secondly, to implement a policy that requires nurses
to complete quarterly modules pertaining to their area of practice to improve their skills that will
positively impact the client outcomes.
The panel's recommendations included to meet with the Nurse Expert, complete
Reflective Questionnaires, and to complete the Nurses' Workbook. While the panel's
recommendations were appropriate, I feel the overall sanction of the Disciplinary Committee
was not severe enough when tested against the totality of the infractions the member committed.
A harsher penalty would have sent a much stronger message to the member as well as to all
members and aid in preserving the public's trust in the nursing profession.