The Discipline Committee of the College of Nurses of Ontario has ordered a three-month suspension for a registered nurse who physically and verbally abused a highly vulnerable patient at a specialty mental health hospital1. Maribel Sanqui-Penaflor, a registered nurse since 2004, admitted to allegations of professional misconduct stemming from a September 2022 incident at the Waypoint Centre for Mental Health in Penetanguishene, Ontario. The patient involved was blind, non-verbal, diagnosed with a severe intellectual disability and autism, and was symptomatic with COVID-19 at the time of the altercation. In a hearing held via videoconference on June 2, 2025, the disciplinary panel accepted Ms. Sanqui-Penaflor’s plea and a joint submission on penalty, which also includes an oral reprimand and extensive remedial education.
Ms. Sanqui-Penaflor faced three primary allegations: that she contravened a standard of practice of the nursing profession, that she verbally, physically, and emotionally abused a patient, and that she engaged in conduct that would be reasonably regarded by her peers as disgraceful, dishonourable, and unprofessional. By admitting to the facts and allegations, the panel was satisfied that her plea was voluntary, informed, and unequivocal. The disciplinary panel issued an order prohibiting the publication of the patient’s name or any information that could reveal their identity.
The incident occurred during the evening shift on September 13, 2022. Ms. Sanqui-Penaflor was the assigned nurse for Patient 1, a resident of the Bayview Program for Dual Diagnosis. This program provides specialty care for inpatients with developmental disabilities and mental health needs. Patient 1 was a highly vulnerable individual with a history of severe self-injurious behaviours that had resulted in blindness. She was non-verbal and required 1:1 nursing care during the day shift. Ms. Sanqui-Penaflor had been assigned as Patient 1’s primary nurse since March 2020 and had cared for her as she transitioned from requiring hard restraints to living in the regular inpatient area.
The patient’s care was guided by a Recovery Plan of Care, which set therapeutic goals and behavioural interventions. This plan involved encouraging the patient to be physically active, including taking walks before meals. Staff were instructed to use prompts like turning on lights, removing the blanket, and using verbal cues. The plan specifically stated that staff were not to physically assist the patient to get up or use force, and were to allow the patient time to process requests.
This established routine was complicated by a COVID-19 outbreak at the facility in August 2022. On September 13, Patient 1 tested positive for COVID-19 and was symptomatic. When Ms. Sanqui-Penaflor began her 7:00 p.m. shift, the charge nurse informed her that there was a change to the patient’s routine and a physician had ordered that Patient 1 be permitted to rest in her room. Prior to the shift change, the patient had been resting and had accepted her supper in her room.
According to the Agreed Statement of Facts, when Ms. Sanqui-Penaflor arrived at the patient’s room, she was “visibly upset” and said, “this is ridiculous.” A Personal Care Attendant, identified as Colleague B, was seated in the hallway and observed the subsequent interaction. Colleague B reported that Ms. Sanqui-Penaflor turned on the light in the patient’s room, stood in the doorway, and yelled “get up, you are lazy I cannot believe you ate in your bedroom,” or words to that effect. The Member then walked over and “ripped” the patient’s blanket off, yelling “get up.” She proceeded to grab the patient by the leg, turn her body, and tip her mattress in an attempt to remove her from the bed. As this happened, Patient 1 began screaming and crying “no, no, no.” Ms. Sanqui-Penaflor then returned to the doorway and stated, “I am not wasting the past two years.” Later, from a computer near the door, she yelled to the patient, “if you want [a] snack you need to get up, no way you are eating in your room, no one eats in their room, get up.”
Colleague B perceived the nurse’s actions as “rude and forceful” and her tone as inappropriate. Another colleague, a Registered Practical Nurse identified as Colleague A, also overheard and observed the interaction and felt the Member’s tone and actions were “not right” and “not therapeutic.”
In the Agreed Statement of Facts, Ms. Sanqui-Penaflor acknowledged that her tone of voice came across as aggressive and inappropriate. While she did not recall using the word “lazy” or some of the other specific phrases, she acknowledged that any shaming or judgmental language of that nature is inappropriate for a nurse to use. She further stated that while removing the blanket was an acceptable cue under the patient’s normal care plan, she acknowledged doing so in an “unacceptably abrupt or rough manner.” Ms. Sanqui-Penaflor also stated she did not recall pulling the patient’s leg or tipping the mattress, but admitted that using physical force in any way to prompt the patient was contrary to the care plan and was unacceptable conduct. She also agreed it was not acceptable to complain about “wasting the past two years” in the patient’s presence.
As part of the agreed facts, Ms. Sanqui-Penaflor offered context for her actions. She stated that as the patient’s primary nurse for over two years, she had witnessed her progress greatly from the consistent therapeutic routine of daily walks. She was concerned about the length of time the patient had been isolated during the COVID-19 outbreak and was worried that continuing to isolate her would cause her to regress. She described the incident as an “isolated lapse” and cited several contributing factors, including feeling heightened emotions, being fatigued from working long hours and overtime shifts during the outbreak, and experiencing a difficult time in her personal life while grieving the anticipated loss of a close family member with a terminal illness. She affirmed that these reflections were not intended as an excuse for her conduct, for which she took full accountability and expressed deep and sincere regret.
The Discipline Panel found that Ms. Sanqui-Penaflor’s actions constituted clear professional misconduct. The panel ruled that she contravened the profession’s standards of practice, including the Code of Conduct, which requires nurses to treat patients with dignity and respect. She also breached the Professional Standards related to accountability and the Therapeutic Nurse-Client Relationship Standard by misusing the power imbalance in the nurse-patient relationship and failing to protect a vulnerable patient from harm. The panel affirmed that her actions constituted verbal, physical, and emotional abuse. Furthermore, the panel found her conduct to be disgraceful, dishonourable, and unprofessional. It described the conduct as dishonourable because it showed a “lack of integrity, compassion, and ethical judgment, amounting to a moral failing.” It was deemed disgraceful because the “mistreatment of a profoundly vulnerable patient, and the fundamental betrayal of the trust inherent in the nurse-client relationship, shames the Member and brings disrepute to the profession.”
Both the College and Ms. Sanqui-Penaflor’s legal counsel presented a joint submission on penalty, which the panel accepted. The panel ordered that Ms. Sanqui-Penaflor must appear for a formal oral reprimand within three months. It also directed the College’s Executive Director to suspend her certificate of registration for a period of three months.
Following the suspension, Ms. Sanqui-Penaflor will be subject to several terms, conditions, and limitations on her registration. She must, at her own expense, attend a minimum of two meetings with a CNO-approved Regulatory Expert within six months. The expert, who must have expertise in nursing regulation, will assess whether additional sessions are required. Before the first meeting, Ms. Sanqui-Penaflor must review the CNO’s “Code of Conduct” and “Therapeutic Nurse-Client Relationship” standards, completing the associated Practice Reflection Worksheets. She must also complete the CNO’s self-directed learning package “One is One Too Many” and its workbook.
These completed worksheets and workbooks must be provided to the expert, who will then review the misconduct, its potential consequences, and strategies for preventing recurrence with Ms. Sanqui-Penaflor. The expert will collaborate with her to develop a learning plan and will ultimately submit a report to the CNO assessing the Member’s insight into her behaviour.
Finally, for a period of 12 months from the date she returns to nursing practice, Ms. Sanqui-Penaflor must notify any employer of the panel’s decision. She is required to provide her employer with copies of the Notice of Hearing, the Agreed Statement of Facts, and the panel’s decision and reasons. The employer must then send a report to the CNO confirming they have received the documents and agreeing to notify the CNO immediately if they receive any information that the Member has breached the standards of practice.
In accepting the joint submission, the panel noted the high legal threshold required to reject such an agreement. It found the penalty was not contrary to the public interest. The panel weighed aggravating factors, such as the extreme vulnerability of the patient and the physical and emotional nature of the abuse, against mitigating factors. These included the Member’s lack of any prior disciplinary history, her cooperation with the College, her early admissions, and her expressed remorse. The panel concluded the penalty was reasonable, achieving general deterrence by signaling that abuse of vulnerable patients is not tolerated, while also addressing specific deterrence and rehabilitation through the suspension and educational requirements.
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