A discipline panel of the College of Nurses of Ontario has found a Registered Practical Nurse guilty of disgraceful, dishonourable, and unprofessional conduct after evidence showed she provided approximately 36 minutes of total care to four patients over a 12-hour shift, falsified numerous medical records, and failed to escalate care for a deteriorating patient who died shortly after her shift ended1. The nurse, Dahabo Hirsi, has had her certificate of registration suspended for five months and must complete a series of remedial actions before she can return to practice.
The hearing took place by videoconference on February 5 and 6, 2025. Ms. Hirsi, the Member, did not attend the hearing and was not represented by counsel. The panel recessed for fifteen minutes at the start of the hearing to allow her time to appear. When she did not join, counsel for the College provided an affidavit from a prosecutions clerk confirming that the Notice of Hearing had been sent to the Member’s last known email and home address on the College Register via SharePoint and courier on December 17, 2024. Evidence included a Purolator delivery confirmation report with a receiver’s signature for initial disclosure sent in June 2024. Satisfied that Ms. Hirsi had received adequate notice, the panel proceeded with the hearing in her absence, as permitted under the Statutory Powers Procedure Act. A publication ban was ordered to protect the identities and personal health information of the patients involved.
The allegations against Ms. Hirsi all stemmed from her employment as a Registered Practical Nurse at the Humber River Hospital (Church Site) in York, Ontario, during a single night shift on April 22 and April 23, 2020. At the time, Ms. Hirsi was working full-time on the Nursing Resource Team and was assigned to an Acute Care Floor with a patient ratio of one nurse to five patients, though she was assigned four patients that night. The College alleged that she committed professional misconduct by failing to meet the standards of practice, failing to keep required records, falsifying records, and engaging in conduct that would be regarded by members of the profession as disgraceful, dishonourable, or unprofessional. Because the Member was not present, she was deemed to have denied all allegations.
The panel heard testimony from three witnesses. Cindy Lee, an Advanced Practice Consultant with the College, testified about the nursing standards in effect in April 2020, including the Documentation Standard, Professional Standards, Code of Conduct, and Ethics Standard. The panel also heard from two fact witnesses from the hospital: Nancy Raponi, the Manager of Nursing Resources and the Member’s supervisor at the time, and Cindy DiFilippo, who was the Member’s clinical practice leader in 2020 and is now a Risk Manager at the facility. Both Ms. Raponi and Ms. DiFilippo testified about the hospital’s internal investigation following the death of one of the Member’s patients, Patient [A], who passed away at 0745 hours on April 23, 2020, just 15 minutes after Ms. Hirsi’s shift concluded.
The hospital’s investigation, which led to Ms. Hirsi’s termination for cause, relied heavily on electronic medical records and security video footage from the unit. Ms. Raponi and Ms. DiFilippo testified about hospital policies, including “Purposeful Rounding,” which requires nurses to check on patients every hour and as needed, documenting these rounds. They also explained the facility’s use of the National Early Warning Score 2, or NEWS 2, a tool to identify patient deterioration. A high score requires specific escalation steps. For instance, a NEWS 2 score greater than seven requires continuous patient monitoring, escalation to the Most Responsible Physician and the Critical Care Response Team, and informing the Team Lead.
The evidence regarding Patient [A] was central to the case. Ms. Raponi testified that Patient [A] was unstable, alert and confused, and receiving 100 percent oxygen. The Member’s own documentation showed that she assessed Patient [A]’s oxygen level at 84 percent even with 100 percent oxygen support, resulting in a NEWS 2 score of 10. According to hospital policy, this required immediate and continuous monitoring and escalation. Ms. Raponi testified that the Member did not take any of the required steps. The records showed Ms. Hirsi took only one set of vital signs for Patient [A] during her entire 12-hour shift and never informed the physician or Team Lead of the patient’s critical state.
The security footage review provided a stark timeline. Ms. Raponi testified that the footage confirmed Ms. Hirsi spent a total of only 13 minutes with Patient [A] during the entire shift. There was a gap in time between 2130 hours and 0545 hours where the Member did not enter Patient [A]’s room at all. Despite this absence, Ms. Hirsi documented multiple assessments that required her to be in the patient’s room. At 2319 hours, she documented a Pain 1, Respiratory Assessment, and Safety Assessment. At 2320 hours, she documented a Restraint/Seclusion Assessment. At 0444 hours, she documented a Corporate Safety Check, Pain Assessment, and a Short CAM Assessment. At 0715 hours, she documented a Transfer of Accountability and another Restraint/Seclusion Assessment. Ms. Raponi testified that based on her review of the security footage, the Member did not enter Patient [A]’s room at any of those times. Ms. DiFilippo’s testimony was consistent, noting that multiple required assessments, including focused respiratory and neurological assessments, were not completed.
This pattern of falsification and lack of care was repeated with the Member’s other three patients. For Patient [B], Ms. Hirsi documented a Pain Assessment, Respiratory Assessment, Safety Assessment, and Short CAM Assessment at 1930 hours. Ms. Raponi testified that the security footage showed the Member did not even arrive on the unit until 1935 hours, and that she was not in Patient [B]’s room at 1930. Later, at 0441 hours, Ms. Hirsi documented a Corporate Patient Safety Check, Pain Assessment, and Genitourinary Assessment. The video footage again confirmed she was not in the patient’s room at that time. Ms. Raponi testified that the Member did not enter Patient [B]’s room at all between 2124 hours and 0536 hours.
For Patient [C], the Member documented a Pain Assessment and Safety Assessment at 1940 hours. Ms. Raponi testified that while this room was in a “blind spot” for the camera, it was visible from certain angles, and the footage confirmed the Member was not in the room at that time. She entered the room later, at 2018 hours. At 0450 hours, Ms. Hirsi documented a Corporate Patient Safety Check and a Short CAM Assessment, both of which required her to be present, but the footage showed she was not.
For Patient [D], Ms. Hirsi documented a Pain Assessment and a Safety Assessment at 1924 hours. The security footage confirmed she was not in the patient’s room at that time. At 0452 hours, she documented a Corporate Patient Safety Check, Pain Assessment, and Short CAM Assessment, and again, the footage showed she was not in the room. Ms. Raponi testified there was a gap in care for Patient [D] between 2016 hours and 0452 hours. Ms. DiFilippo added that required Physical Assessments and Focus Assessments for this patient were never completed.
In total, Ms. Raponi’s review of the security footage concluded that Ms. Hirsi spent approximately 36 minutes in total providing care to all four of her patients during her 12-hour shift.
Based on this evidence, the panel found Ms. Hirsi committed professional misconduct as alleged in all paragraphs of the Notice of Hearing. The panel found the testimony of Ms. Raponi and Ms. DiFilippo to be forthright, honest, clear, cogent, and convincing. The panel concluded that the Member’s conduct was a clear breach of the College’s standards. They found she failed to provide required nursing care, failed to document care, documented medical assessments she did not complete, and failed to escalate Patient [A]’s deteriorating condition.
In its decision, the panel made a specific finding that the Member’s conduct was not only unprofessional and dishonourable, but also disgraceful. The panel stated it was “very concerned by the Member’s failure to provide care to her patients as required, as the Member spent 36 minutes with them over the course of a 12-hour shift.” The panel noted that when questioned during the hospital’s internal investigation, the Member did not demonstrate any accountability for her failures. The panel concluded, “The Member’s conduct shames the Member and by extension the profession and casts serious doubt on the Member’s moral fitness and inherent ability to discharge the higher obligations the public expects nurses to meet.”
In determining the penalty, the College’s counsel submitted that the Member’s conduct was serious, dishonest, and intentional, breaching the trust of the facility, her colleagues, and her patients. The College highlighted the potential for harm, noting that Patient [A] did not receive the appropriate level of care and passed away. The only mitigating factor was the Member’s lack of a prior disciplinary history.
The panel accepted the College’s submission on penalty. Ms. Hirsi is required to appear before the panel for an oral reprimand within three months of the order becoming final. The panel ordered a five-month suspension of her certificate of registration. Following the suspension, Ms. Hirsi will be subject to terms, conditions, and limitations on her registration. She must attend a minimum of two meetings with a CNO-approved Regulatory Expert at her own expense to review her misconduct, its potential consequences, and the CNO standards for Code of Conduct and Documentation. For a period of 18 months after she returns to nursing, she must notify any employer of the panel’s decision and provide them with a copy of the reasons. Finally, for that same 18-month period, she is prohibited from practicing independently in the community. The panel found this penalty satisfied the principles of specific and general deterrence, rehabilitation, and public protection.
