The Discipline Committee of the College of Nurses of Ontario has suspended the registration of a Registered Practical Nurse for two months after he admitted to falsifying patient records while working as a manager at an Ottawa retirement home1. The nurse, Bernard Koudjo Guetaba, appeared before the disciplinary panel via videoconference on February 11, 2025, where he was unrepresented. He admitted to all allegations of professional misconduct brought against him, which involved altering the dates on patient care plans and assessments over a one-year period.
The events in question occurred between January 2018 and January 2019 at Chartwell Rideau Place, a retirement home in Ottawa that has since permanently closed. Mr. Guetaba had been employed at the facility since March 2017, holding the position of Health and Wellness Manager. In this role, he was responsible for ensuring that all patient care plans were kept up to date. This responsibility was mandated by the Retirement Homes Act, which requires that each resident be assessed and have a care plan developed upon admission, and that this plan be reassessed and revised at least every six months, or more frequently if a resident’s care needs changed. Mr. Guetaba was responsible for either conducting these assessments himself or assigning their completion to the nurses he supervised. At the time, the facility maintained all its care plans as hardcopy documents stored in binders at the nursing station.
The misconduct was discovered on February 27, 2019, when a regional Chartwell nurse visited the facility to conduct a routine audit of its documentation. During this audit, the regional nurse found expired care plans that had been visibly altered to change their dates. The investigation revealed that these alterations were made using white-out and, in other cases, by editing the existing dates on the documents by hand. The facility’s subsequent investigation identified unauthorized changes to numerous care plans and associated assessments. As the Health and Wellness Manager, Mr. Guetaba was required to, and did, sign all of these documents, even those originally drafted by other nurses.
The altered documents included records for at least four different patients, whose identities are protected by a publication ban. For a resident identified as Patient A, assessments and a care plan had dates whited out and altered by hand to state they were completed and consented to on November 30, 2018. For Patient B, a care plan was altered with both white-out and by hand to change the completion and consent date from January 22, 2017, first to January 22, 2018, and then again to January 22, 2019. Similarly, records for Patient C were whited out and altered to reflect completion dates in January 2019. For Patient D, documents were altered by hand to change a date of June 28, 2018, to January 28, 2019.
When initially confronted by the facility about these alterations, Mr. Guetaba stated that he did not know how they had occurred. However, he later admitted to having altered the care plans and assessments himself. He claimed to his employer that he had done so for his own personal research purposes. During the disciplinary proceedings, Mr. Guetaba acknowledged that it is never appropriate to alter patient documentation. His employment at Chartwell Rideau Place was terminated on March 20, 2019, as a result of these incidents.
The College of Nurses of Ontario issued a Notice of Hearing dated January 6, 2025, alleging that Mr. Guetaba had committed four separate acts of professional misconduct. The allegations stated that he contravened a standard of practice of the profession, falsified records relating to his practice, signed or issued documents in his professional capacity that he knew or ought to have known contained false or misleading statements, and engaged in conduct that would reasonably be regarded by members as disgraceful, dishonourable, or unprofessional. All four allegations stemmed from the same set of facts involving the alteration of dates on care plans and assessments for the four patients. Mr. Guetaba admitted that his conduct breached several CNO standards, including the Code of Conduct, Professional Standards, Ethics Standard, and Documentation Standard, which obligate nurses to act with integrity, honesty, and truthfulness, and to ensure all documentation is accurate.
At the February 2025 hearing, the panel received Mr. Guetaba’s written plea and conducted an oral plea inquiry, satisfying itself that his admissions were voluntary, informed, and unequivocal. Based on his admissions and the Agreed Statement of Facts, the panel formally found Mr. Guetaba guilty of committing all the alleged acts of professional misconduct. In its reasons, the panel specified that it found his conduct to be both dishonourable and unprofessional. The panel noted that the deliberate falsification of documentation demonstrated dishonesty and deceit, which directly impacts the integrity of the nursing profession. It stated that documentation is a fundamental aspect of nursing, and by altering records, Mr. Guetaba compromised patient care and misled colleagues, violating the trust placed in nursing professionals.
Following the finding of guilt, the College and Mr. Guetaba presented a Joint Submission on Order, which the panel accepted. The penalty includes an order requiring Mr. Guetaba to appear before the panel within three months to be orally reprimanded. The panel also directed the Executive Director of the College to suspend Mr. Guetaba’s certificate of registration for a period of two months.
In addition to the suspension, the panel imposed several terms, conditions, and limitations on Mr. Guetaba’s registration. He must attend a minimum of two meetings with a CNO-approved Regulatory Expert at his own expense, to be completed within six months. Before the first meeting, he is required to review the CNO’s Code of Conduct and Documentation standards, complete associated Practice Reflection Worksheets, and provide these to the expert. The sessions with the expert will focus on the misconduct, its potential consequences, strategies for preventing recurrence, and the development of a formal learning plan. The expert must then submit a report to the CNO assessing Mr. Guetaba’s insight into his behavior.
Furthermore, for a period of 12 months after he returns to nursing practice, Mr. Guetaba must notify any employer of the panel’s decision and provide them with copies of the hearing documents. He can only practice for an employer who agrees to specific oversight conditions. This includes the employer performing three random spot audits of his documentation practices at four-month intervals over the 12-month period. Each audit will involve reviewing at least five of his patient charts to ensure they meet CNO and employer standards, with the employer reporting the results of each audit to the CNO. Finally, Mr. Guetaba is prohibited from practicing independently in the community for 12 months.
In accepting the joint submission, the panel considered aggravating and mitigating factors. The aggravating factors included the repeated nature of the misconduct over a significant period, the potential risk to patient safety from falsified records, and Mr. Guetaba’s initial failure to take accountability. Mitigating factors included his cooperation with the College, his admission of guilt by agreeing to the facts, and his lack of any prior disciplinary history. The panel found the proposed penalty was in line with similar past cases and satisfied the goals of specific and general deterrence, rehabilitation, and public protection. The panel concluded that the suspension and oral reprimand send a clear message that such conduct is not tolerated, while the remedial measures and employer oversight provide for rehabilitation and ensure public safety.
