A Registered Practical Nurse in Ontario has been suspended for three months after admitting to locking an 85-year-old patient with dementia in his room for approximately nine hours overnight1. The nurse, Sarah Emmanuel, also admitted to falsifying the patient’s monitoring records during the time he was confined. The decision was released by a panel of the Discipline Committee of the College of Nurses of Ontario, or CNO, following a hearing held by videoconference on May 28, 2025. Ms. Emmanuel, who was terminated from her position as a result of the incident, admitted to all allegations of professional misconduct. These allegations included contravening standards of practice, failing to keep records, and engaging in conduct that would reasonably be regarded by members of the profession as dishonourable and unprofessional.
The incident occurred during a 12-hour night shift from 19:30 on November 29 to 07:30 on November 30, 2021. Ms. Emmanuel was working on Unit 3C, a mental health unit at the Scarborough Health Network, Birchmount Campus. According to the Agreed Statement of Facts, the patient was an 85-year-old man who had recently been admitted for a psychiatric assessment and was exhibiting symptoms of dementia. At the time of the shift, the patient had no physician’s orders for any form of restraint. Early in the shift, the patient was observed wandering the hallway immediately outside his room, which was across from the nursing station. Ms. Emmanuel’s own clinical notes from 20:13 described the patient as “calm and cooperative” and noted “No concerned.” At 22:00, she again documented that he was walking around the unit, socializing, and was compliant with his medication. The facts state that at 22:01, Ms. Emmanuel administered medications to the patient in his room. At approximately 22:08, she left the patient’s room, closed the door, proceeded to the nursing station to obtain the room key, and returned to lock the patient inside.
The patient was environmentally restrained by being locked in his room for approximately nine hours, from 22:08 until the next morning. Video surveillance showed the patient approaching the door of his room on numerous occasions throughout the night. During this entire nine-hour period of confinement, Ms. Emmanuel approached the patient’s door on only two occasions: once very briefly after locking it, and not again until around 06:20 the following morning. The panel found that she “failed to conduct adequate monitoring, observation, and assessments” of the patient while he was restrained. She spent the majority of her shift in the nursing station or on break. The Agreed Statement of Facts notes that the confinement was discovered on the morning of November 30, when Ms. Emmanuel’s supervisor arrived early, walked the unit, and “observed that the Patient was locked in his room,” which immediately commenced an investigation by the facility. Ms. Emmanuel’s employment was terminated on January 20, 2022, as a result of these events.
The nurse’s actions were in direct violation of multiple facility policies. The facility’s Mental Health-Least Restraint for Mental Health Patients policy clearly stated that restraint is a “method of last resort” reserved for emergency situations where a patient demonstrates a “risk of bodily harm to self or others.” The policy required all non-restraining methods, such as redirection, to be considered or attempted first. It also explicitly required a physician’s order to specify the type of restraint and the behaviors requiring it, which Ms. Emmanuel did not have. Furthermore, the policy mandated rigorous monitoring for any patient in environmental restraint, including assessing the patient for readiness to discontinue the restraint “at least every hour” and offering fluids “at least every 2 hours” and bathroom access as needed. Documentation was also required for all interventions, the rationale for the restraint, de-escalation attempts, and the patient’s response. Ms. Emmanuel failed to adhere to any of these requirements.
The facility’s Levels of Observation for Mental Health Patients policy was also breached. This policy required “close observation” for a patient in this situation, which is defined as “direct monitoring of the patient once every 15 minutes” with documented evidence on a “Periodic Observation Form.” The Agreed Statement of Facts clarified that while the nursing station had a monitor for CCTV feeds, the screens were small and reviewing them “is not a replacement for physical rounding and does not provide adequate supervision to constitute ‘direct monitoring’.” Although Ms. Emmanuel stated she monitored the patient via this CCTV footage, she admitted this did not meet the “direct monitoring” standard.
The discipline panel found Ms. Emmanuel’s conduct to be not only unprofessional but also “dishonourable,” a finding based on her deliberate falsification of clinical records. At 03:05, Ms. Emmanuel entered a progress note claiming the patient had slept between midnight and 03:00 and was now “awake, walking in his room, when writer did q15 round.” Evidence showed that at this time, she only glanced towards the patient’s door from the hallway and did not approach it or conduct any direct monitoring. Later, at 06:50, she documented that the patient had “slept for another 4 hours,” again without having performed direct observation. The handwritten “Periodic Observation Record,” which tracked the 15-minute checks, also contained false entries. Ms. Emmanuel documented that she had completed these Q15 checks for three separate time blocks during her shift, but she admitted in the Agreed Statement of Facts that she “did not complete any of these checks by direct observation as documented or required by the Observation Policy.”
By admitting to the allegations, Ms. Emmanuel acknowledged she had contravened numerous CNO standards. These included the Code of Conduct, by failing to treat the patient with respect, provide safe and competent care, and maintain “complete, accurate and timely documentation.” She also breached the Professional Standards, which require nurses to be accountable and take “action in situations in which patient safety and well-being are compromised.” The panel noted her actions violated the Therapeutic Nurse-Client Relationship standard, which is “built on trust, respect, empathy,” and requires nurses to recognize the “potential for patient abuse.” The Documentation standard was breached by failing to provide an “accurate, clear and comprehensive picture” of the patient’s care. Finally, the Decisions About Procedures and Authority standard was breached, as it requires nurses to ensure they have the “proper authority,” such as a physician’s order, before performing an act like a restraint, and to ensure the rationale is based on “achieving the best outcomes for the patient.”
The discipline panel accepted a joint submission on penalty from the College and Ms. Emmanuel’s counsel. The penalty includes, first, a requirement for Ms. Emmanuel to appear before the panel for an oral reprimand within three months of the order becoming final. Second, the panel ordered a three-month suspension of her certificate of registration.
Beyond the suspension, the panel imposed several remedial terms, conditions, and limitations on Ms. Emmanuel’s registration. She is required, at her own expense, to attend a minimum of two meetings with a CNO-approved Regulatory Expert within six months. The purpose of these sessions is to review her misconduct, its potential consequences, and develop strategies to prevent recurrence. Before this meeting, she must complete a review of CNO standards on conduct, documentation, restraints, and the nurse-client relationship, and complete several Practice Reflection Worksheets. The subject of the sessions with the expert will specifically include “the acts or omissions for which the Member was found to have committed professional misconduct,” “the potential consequences of the misconduct,” and “the development of a learning plan.” The expert must then submit a report to the CNO confirming the dates of attendance and providing “the Expert’s assessment of the Member’s insight into the Member’s behaviour.”
To ensure public protection, Ms. Emmanuel will also be subject to employer notification for a period of 12 months from the date she returns to nursing practice. She is required to inform any employer of the discipline decision before commencing or resuming employment in any nursing position. She must provide the employer with copies of the panel’s order, the Notice of Hearing, the Agreed Statement of Facts, and the decision. The employer must then provide a report to the CNO confirming they have received these documents and agreeing to “notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession.”
In accepting the joint submission, the panel weighed several factors. The aggravating factors included the “extremely vulnerable” nature of the 85-year-old patient with dementia, the “significant risk” posed by failing to monitor him for nine hours, and the “fundamental breach of trust and disrespect for the Patient.” Mitigating factors included Ms. Emmanuel’s lack of any prior disciplinary history with the College, her cooperation throughout the proceedings, and her admission of the facts, which avoided a contested hearing and preserved College resources. The panel concluded the penalty was reasonable, in the public interest, and in line with previous similar cases. A publication ban remains in effect protecting the name of the patient and any information that may tend to identify him.
