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Joan Brooks, HB04034


The Member admitted that she engaged in professional misconduct. At the time of the incident, the Member was working a night shift in a geriatric psychiatry unit (the “Unit”). The Member and three nursing colleagues transferred an elderly patient with moderate to advanced dementia, who appeared calm, from a wheelchair to a Broda chair in the Unit’s dining room. The Member and a colleague applied a pelvic restraint to the patient without a physician’s order. Neither the Member nor her colleagues documented the application of the restraint or the rationale for applying the restraint. The patient was left restrained in the Unit’s dining room for approximately 5.5 hours. During this time, the Member and her colleagues failed to appropriately observe and monitor the patient, or continually assess the ongoing need for restraints.

Upon observing the patient in the early morning, the Member believed that the patient was deceased. The Member did not call a Code Blue, take the patient’s vital signs, or ensure that her colleagues did so per the facility’s protocol. Instead, the Member’s colleague wheeled the patient to his room. The Member and her colleagues placed the patient in his bed with the collective intention to make it appear as though the patient had died in bed or more recently than the Member and her colleagues suspected. The Member’s colleague falsely documented that the patient was in bed during the time that he remained restrained in the Broda chair. The Member later provided inaccurate information during the facility’s investigation into the patient’s death.

The Member had been assigned to a different patient that evening. Between approximately 12:30 am and 5:30 am, this patient was sitting in a Broda chair in the Unit’s dining room. Despite expressing distress, including removing her gown and exposing herself, the Member did not observe or provide care to the patient. The Member falsely documented that the patient had fallen sleep and was transferred to her bedroom despite remaining in the Broda chair in various states of distress in the dining room.

Discipline Committee’s Findings

Based on the Member’s admissions, a panel of the Discipline Committee of the College of Nurses of Ontario (the “Panel”) found that the Member:

  • contravened a standard of practice of the profession or failed to meet the standards of practice of the profession;
  • abused a patient physically and emotionally;
  • failed to keep records as required;
  • falsified a record relating to the Member’s practice; and
  • engaged in conduct, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable and unprofessional.

Discipline Committee’s Order

The Member signed an undertaking to permanently resign as a member of the College of Nurses of Ontario (“CNO”) and agreed not to apply for membership with CNO at any time in the future.

In light of the Member’s undertaking, the CNO and the Member jointly sought an order requiring the Member to appear before the Panel for an oral reprimand.

The Panel accepted the Joint Submission on Order, concluding that the proposed penalty was reasonable and in the public interest.

Page last reviewed May 05, 2023