Mandatory

Reporting-CNO
http://www.cno.org/Global/docs/ih/42006_fsMandReporting.pdf
Mandatory Reporting
What is the purpose of
mandatory reporting?
• ensures that the College is alerted if
there is a concern that a nurse is not
practising safely.
• it allows the College to take action to
protect the public and
• use innovative approaches to help
rehabilitate the nurse when necessary.
Mandatory Reporting
A report does not constitute a finding of professional
misconduct, sexual abuse, incapacity or incompetence
against the member who is the subject of the report.

Only a Panel of the College’s Discipline Committee

or Fitness to Practise Committee can make such a
conclusion *

All regulatory health professionals are subject to

mandatory reporting. The Ontario government has
legislated a mandatory reporting framework in its
Regulated Health Professions Act, 1991.
What does the College do when it
receives a report?
What does the College do when it receives a report?

1. The College’s Executive Director

reviews the report along with any
information about the nurse that the
College may have previously received.

2. The Executive Director assesses the

level of risk posed to the public and
determines an appropriate regulatory
response.
Not every report will require the College to make a formal investigation and
hearing.

For example;
• an investigation may not be necessary if the
facility has imposed ongoing monitoring and
restrictions on the nurse’s practice, and these
measures provide sufficient public protection
• an investigation may be unnecessary if the
nurse is participating in activities that
demonstrate improvement in her or his
practice, and the employer is closely
monitoring the member’s progress
If the College initiates an investigation:
The nurse will be asked to provide a written response
to the College’s Inquiries, Complaints and Reports
Committee.

If the Committee is sufficiently concerned about risk

to the public: The nurse will be referred to a hearing
before a Discipline or Fitness to Practise Committee
panel.

*The panel will make a formal determination of

professional misconduct, incompetence or incapacity
only after a hearing in which the nurse has had a fair
and full opportunity to participate.*
Nurse committed Professional
Misconduct

May be required to pay a fine or attend for a

reprimand.

They may be monitored while practising or be

suspended from practice.

In the most serious cases, a panel has the

authority to revoke a nurse’s Certificate of
Registration.
Nurse found to be Incapacitated or
Incompetent:
May be required to comply with
appropriate medical treatment before
returning to practice.

Nurse found to be incompetent:

• May be required to complete additional education

or training.
• In both situations, it is likely that the nurse will
have restrictions on her or his practice, and will
require monitoring upon returning to practice.
Who is required to report?
1. Facility operators
2. Employers
3. Nurses
4. Health Information Custodians
Facility operators (Nurse employer)
- as the individual who operates a facility where one or more
nurses practise.
- are required to report to the College when there is reason to
believe that a nurse has sexually abused a client, or is
incompetent or incapacitated.
Example:
If Nurse A is employed by an acute care hospital.
Nurse B practises at the same hospital but is
employed by a nursing agency.
• The College expects the acute care hospital, as
the facility operator, to report Nurse A or Nurse
B to the College if either nurse seems
incapacitated or incompetent, or may have
sexually abused a client.
• The reporting obligation is not based on the
employment relationship. Rather, it’s based on
the facility operator’s direct knowledge of the
concern.
Facility operators (Nurse employer)

The person who operates the facility – not staff members – is

required to make the report.

The College encourages facilities to develop procedures and

guidelines so staff members can support the facility in meeting its
reporting obligations.

The report must be made to the College’s Executive Director in

writing within 30 days. The report must be filed immediately if
there is a concern that the nurse poses a continued risk.

http://www.cno.org/protect-public/employers-nurses
Employers

are required to report the termination of a nurse’s employment or

privileges for reasons of professional misconduct, incompetence or
incapacity.
 By alerting the College of An employer must also
concerns about a member’s file a report if he or she
practice, employers support intended to terminate the
the College’s mandate of nurse’s employment, but
protecting the public interest. the nurse resigned first

The employer continues to have a legal obligation to report to the College.

Reports must be made within 30 days of the termination or resignation of
the nurse, and must contain the:
reason(s) for the termination; or
reason(s) for intending to terminate if the member resigned before the
employer could take action.
Nurses
A nurse is a member of the College.
A nurse is required to file a report to the appropriate
regulatory college if she or he believes that another health
care professional has sexually abused a client.
A nurse must self-report to the College if she or he:

 has been found guilty of an offence in any jurisdiction;

 has a finding of professional negligence and/or malpractice;

 has been charged with any offence in any jurisdiction;

Nurses

 has a finding of professional misconduct, incompetence

or incapacity, or any similar finding in relation to the
practice of nursing or any other profession in any
jurisdiction

 is the subject of a current investigation, inquiry or

proceeding for professional misconduct, incompetence or
incapacity or any similar investigation or proceeding in
relation to the practice of nursing or any other profession
in any jurisdiction
Nurses
self-report a finding within 30 days.
Self reporting form : www.cno.org/sr_form.pdf
by phoning the Customer Service Centre at
416 928-0900 or 1 800 387-5526.
Mail or fax the completed form along with any supporting
documentation to the College.
Health information custodians
The Personal Health Information Protection Act (PHIPA)
sets out mandatory reporting obligations for health
information custodians.
A “health information custodian” is defined as anyone
who is authorized to collect, use, retain and disclose a
patient’s personal health information
- must file a report to the College when a nurse who is
under their employ resigns or is terminated, suspended or
subject to disciplinary action as a result of the unauthorized
collection, use, disclosure, retention or disposal of a
patient’s personal health information
Health information custodians
Reports must be made within 30 days of the termination,
resignation or disciplinary action. They must contain:
■ details of the privacy-related incident; and
■ details of the suspension, disciplinary action,
termination or resignation, as applicable.
What is the purpose of mandatory
reporting?
Mandatory reporting ensures that the College is alerted
when there is a genuine concern that a nurse is not
practising safely.

It allows the College to take action to protect the public,

using innovative approaches that help the nurse return to
safe nursing practise

.*
Required Reports
1. Sexual Abuse 6. Finding of professional
2. Incompetence negligence or malpractice
3. Incapacity 7. Proceeding in any
4. Charged with an jurisdiction
offence 8. Finding in any jurisdiction
5. Guilty of offence
Sexual abuse
Sexual abuse in the regulatory context occurs when a
health care professional:
■ has physical sexual relations with a client;
■ touches, in a sexual manner, the client's genitals,
anus, breast or buttocks;
■ touches a client in a sexual manner;
■ behaves in a sexual manner with a client; and/or
■ makes remarks of a sexual nature to a client
Sexual abuse
Even if consensual, is considered abusive because a
health care professional is in a position of power by virtue
of their professional knowledge and skill.
When health care professionals meet their personal needs
in what should remain a professional relationship, clients
are vulnerable to harm
Sexual abuse
The facility operator or nurse who reports an incident of
suspected sexual abuse must make his or her best effort to
inform the client of the need to notify the appropriate
regulatory college.

The report can include the name of the client only if the
client (or the client’s representative, if the client is
incapable) has consented in writing.

If the client has not consented in writing, the client’s name

must not be included in the report.
Sexual Abuse
The report must contain:
■ your name;
■ the name of the nurse who is the subject of the
report; and
■ a description of the alleged sexual abuse
Fines may be imposed if a person or a facility fails to
make a mandatory report relating to sexual abuse.
Individuals may be fined up to $50,000 while
corporations may be fined up to $200,000
What help does the College provide to
patients who have been sexually
abused?
Sexually Abuse

Patients who were sexually abused by a nurse may apply for

funding from the College to help pay for therapy or
counseling.

The funding can only be used for therapy or counseling

required as a result of the sexual abuse. It is paid directly to
the therapist or counselor.

The College will contact all victims of abuse who are

identified after a finding of sexual abuse has been made and
inform them of their eligibility for financial assistance.
Incompetence
Three key components:
1. must relate to the nurse’s professional care of a client;
2. the nurse must display a lack of knowledge, skill or
judgment; and
3. any deficiencies must demonstrate that the nurse is unfit to
continue to practise, or that practice should be restricted.

*A nurse - is incompetent if her or his client care shows such

significant and repeated deficiencies in knowledge, skill or
judgment that the nurse’s practice must be restricted to ensure
client safety*.
Incompetence is demonstrated:
- by poor insight, or gaps in comprehension or application of
basic nursing principles.
- A lack of appreciation for the seriousness of potential outcomes
for clients who receive substandard care
Incompetence
If there are concerns, the facility operator typically:
 initiates close monitoring
 restrictions on practice and remedial activities to ensure client
safety.
For example, a nurse may not be allowed to practise without
direct supervision until the deficiencies are addressed. In
such a situation, the College expects the facility operator to
make a report.
When you make a report of incompetence to the College,
include the following information:
your name;
the name of the nurse who is the subject of the report; and
a description of the alleged incompetence.
Incompetence
The description should include:
• the nature of the concerns that gave rise to
the report;
• a list of any restrictions that are in place or
that are the basis for the facility operator’s
belief that restrictions are warranted; and
• any learning or performance improvement
plans to address the concerns.
Incapacity
CNO
Incapacity
The definition of incapacity consists of the following two
essential components:
1. the member must have a physical or mental condition; and
2. the condition must warrant that the member not be permitted to
practise, or that her or his
practice be restricted.

*A nurse is incapacitated when she or he has a health condition that

impairs her or his ability to provide care*.
Most commonly arises when a member is affected by a mental
health or addiction disorder.
Conditions can cloud judgment and impair the individual’s ability
to recognize that she or he has a health condition and that it’s
affecting her or his practice
*Only the College’s Fitness to Practise Committee can conclude
whether a nurse is incapacitated.*
Incapacity
Most nurses recognize when a health condition affects their practice
and take appropriate action.
E.g. a nurse may decide to take time off from work to deal with
personal issues, and there is no concern about client safety. In such a
situation, the College does not expect the facility operator to file a
report.
When you report a case of suspected incapacity, include the following
information:
 your name;
 the name of the nurse who is the subject of the report; and
a description of the alleged incapacity, including:
the nature of the condition or disorder;
any behavioural observations made by clients, colleagues and/or
supervisors; and
a list of any restrictions you have placed on the nurse’s practice (or
the basis for your belief that restrictions are warranted.
What does the College do when it
receives a report of incapacity?
If a nurse found to be incapacitated, the Executive Director,
a Panel of the Inquiries, Complaints and Reports
Committee (ICRC) conducts an inquiry.

The nurse may be directed to attend an independent health

assessment with Health care professionals specializing in
mental health or addiction disorders

Will refer the nurse to the Fitness to Practise Committee.

The Panel may also direct the Executive Director to impose
an interim order of suspension or restrictions until the
Fitness to Practise Committee concludes the matter.
What happens after a referral to the
Fitness to Practise Committee?
Nurse will be notified. There are two routes for addressing
Fitness to Practise referrals:
a) agreement or
b) formal hearing.

 The majority of matters are resolved by agreement.

 The nurse acknowledges that she or he is incapacitated.
 The College will then work with the nurse and health
providers with an agreement that includes appropriate
restrictions on the nurse’s practice.
 If the matter is not resolved by an agreement, the nurse will
have a full and fair opportunity to participate in a formal
hearing before a Fitness to Practise Panel.
What happens if a nurse is found to be
incapacitated?
Nurse be required to comply with appropriate medical
treatment before returning to practice

The nurse is responsible for abiding by the restrictions

that have been ordered.

The College will be in regular contact with the nurse, the

nurse’s health care team and the nurse’s employer(s) to
meet the ultimate objective of the incapacity process: the
nurse’s healthy return to safe nursing practice
 Required Report
Charged with an offence
• An offence is a breach of law that is prosecuted in a court.
• This includes any offence in any jurisdiction.
Guilty of offence
• The requirement includes all findings of guilt for any
offence, including but not limited to offences under the
Criminal Code, the Food and Drugs Act, and the
Controlled Drugs and Substances Act, as well as offences
under provincial laws
• Even if a nurse has been pardoned, or received an
absolute or conditional discharge instead of a conviction,
the nurse must still self-report to the College.
Required Reports
Finding of professional negligence or
malpractice
 Professional negligence or malpractice findings arise
from circumstances in which clients sue health care
professionals to receive compensation for substandard
care

 A nurse is required to self report if a civil court has made

a finding that the nursing care she or he provided was
professionally negligent.
Guilty of offence
Proceeding in any jurisdiction
 This term refers to circumstances in which a nurse is also a
member of any other profession (e.g. midwife, lawyer) in
Ontario or any other jurisdiction, and is involved in a current
investigation, inquiry or proceeding for professional
misconduct, incompetence or incapacity or any similar
investigation or proceeding, and that matter is not yet
decided.
Finding in another jurisdiction
 This term refers to circumstances in which a nurse is also a
member of another profession in Ontario or any other
jurisdiction, and a disciplinary or incapacity or similar
proceeding has determined that they have committed
professional misconduct, or is incompetent or incapacitated,
or made any similar finding
Self-report a finding
When you self-report a finding in another jurisdiction, the
report must contain:
your name;
the nature and a description of the offence or finding;
 the date the proceeding began and the finding was made;
 the name and location of the court or regulatory body that
is holding the proceeding or made the finding; and
 the status of any appeal initiated about the finding made
against you.

Nurses are required to file an additional report to the College if an

appeal changes the status of a finding.
This report must not contain information that violates any
publication ban that a court imposed during the proceedings
A summary of mandatory reporting obligations
Facility operators must report:
the sexual abuse of a client by a health care professional;
and
a health care professional who is:
Incompetent,
Incapacitated. 

Employers must report:

The termination of, or the intent to terminate, privileges or
the employment of a nurse.
A summary of mandatory reporting
obligations
Nurses must report:
Health Information Custodians:
• The sexual abuse of a
client by a health care
professional.  • The termination,
• a finding of guilt for an resignation, suspension
offence; or other disciplinary
• a finding of professional actions in response to the
negligence or malpractice unauthorized collection,
if they are currently the use, disclosure, retention
subject of a proceeding or disposal of personal
in any other health health information.
professional jurisdiction;
and/or
• A finding in any other
health professional
jurisdiction
Mandatory gunshot wound reporting-
CNO
I just started working in the emergency
room of a rural hospital. My manager
informed me of legislation that requires
hospitals to inform police when a client
suffering from a gunshot wound comes into
the ER. I have serious ethical concerns that
this will prevent clients from seeking care as
they will be afraid of being reported to
police. What can I do to ensure that this
legislation doesn’t affect my ability to care
for clients?
Mandatory gunshot wound reporting CNO
The Mandatory Gunshot Wounds Reporting Act, 2005
requires hospitals and other prescribed health care facilities
to report to police, as soon as is practical, the following
information about an individual with a gunshot wound:
the name of the client, if known; and
the location of the reporting facility.

The legislation does not indicate who is responsible for reporting the
information. Refer to your facility’s and/or unit policy for who on the
team is responsible for reporting the information. You may want to
refer to your facility’s policies for other mandatory reporting
obligations, such as those for suspected child abuse, to determine how
nurses have met reporting obligations while maintaining therapeutic
relationships with their clients.
REPORTING INCAPACITY: SCENARIO #1
A nurse on a unit, is suspected by her colleagues of
having a drug abuse problem. This nurse frequently
asks co-workers to co-sign for wastage they have not
witnessed. Her clients are treated with higher
dosages of PRN pain medication than other nurses’
clients on the unit. She primarily works night shifts,
takes lengthy breaks and has taken above-average
sick time. Her manager has noticed that the nurse is
loud one moment, and withdrawn the next. When
asked by colleagues if she is ok, nurse denied that
she has any health issues. Does the facility operator
have an obligation to report the manager’s concerns
to the College?
REPORTING INCOMPETENCE: SCENARIO #2
The supervisor in a unit in an acute care hospital,
recently hired a new nurse, who has extensive
experience in long-term care settings. This nurse has
therapeutic skills are extremely strong, but struggles
with certain aspects of medication administration.
Educator meets with the nurse and together they
develop a learning plan to address the areas of
concern. Unfortunately, the nurse near-miss errors
continue. Educator decides that the nurse must be
paired with a more senior nurse on the unit, and
informs the facility operator of the steps she has
taken to have the nurse supervised. The facility
operator then reports the nurse situation to the
College.
REPORTING SEXUAL ABUSE: SCENARIO #3
The manager was informed by one nurse that a
patient had told her that the night nurse, had
touched her inappropriately while providing care.
The nurse was immediately put on leave pending an
investigation. The nurse has been with the facility
for close to a decade and this is the first complaint a
patient has ever made about his practice or conduct.
Nurse most recent performance reviews even note
that he is an excellent nurse who is a strong advocate
for his patients. Does a report have to be made
before the employer’s investigation is completed?
What if the employer’s investigation finds no cause
for concern?