Nurse suspended, fined for professional misconduct

A nurse who pleaded guilty to professional misconduct after a 68-year-old critically ill patient died while in her care at Grace Hospital in 2022 has been suspended and fined.

The College of Registered Nurses of Manitoba issued its decision on Tammy Wolfe’s conduct earlier this year after a hearing in the fall.

The college disciplinary panel said it had sympathy for the nurse, given her otherwise clean record and the fact the death occurred when her unit was short-staffed, but concluded she failed in caring for the patient.

“This failure would not only have impaired the ability of the registrant’s team to work together to provide proper nursing care but also had lasting impacts on the patient’s family and for the reputation of the nursing profession,” reads the decision, made public this week.

Wolfe was working as a a charge nurse in the acute medicine unit, which treats patients with illnesses such as heart attacks, congestive heart failure or chronic obstructive pulmonary disorder.

The 68-year-old patient was admitted on April 18 around 10 p.m. when the unit was short-staffed, leaving it with a ratio of one nurse for eight patients.

Wolfe was supposed to record the patient’s vital signs on a form that outlines how frequently a patient should be monitored, but failed to assess the patient properly and scored them incorrectly on the form.

Wolfe wrote that the patient was alert when they were actually lethargic and confused, the decision said.

Lethargy and confusion would have prompted a higher score on the form, which would have required Wolfe to inform the medical team to review the patient’s care plan.

The decision indicates the 68-year-old’s condition required monitoring at least every hour.

Wolfe recorded a partial assessment of the patient at 10:15 p.m., but did not document any vitals again until 3 a.m. Afterward, nothing else was documented.

Wolfe also failed to document whether she gave several medications to the patient, though she said she had administered the drugs.

At midnight, Wolfe wrote that she withheld a hydromorphone dose, due to the patient’s reduced level of consciousness, but did not explain the change in consciousness from 10:15 p.m. to midnight in the written record and did not consult with a doctor.

The patient had a urinary catheter but Wolfe failed to monitor whether the patient was urinating sufficiently.

At around 5:20 a.m., the patient’s oxygen levels dropped. The patient died thirty minutes later.

Wolfe maintained to regulatory officials that the patient was “too ill to be on the unit” and should have been in intensive care, the decision said, but did not document her concern about it when the 68-year-old was in her care.

Wolfe, who has been a registered nurse since 2003, hadn’t faced a disciplinary action in the past.

Her lawyer, Jeff Smorang, said her clean record and her guilty plea show she has taken responsibility.

Wolfe has expressed sincere remorse and regret over the “isolated incident” that occurred during one shift, with one patient, at a time when the unit was understaffed, argued Smorang.

She was fined $8,000, suspended for three weeks and ordered to complete courses in medication management, documentation in nursing, and critical thinking in nursing, said the decision.

The sanctions were jointly recommended by the college lawyers and Wolfe’s lawyer.

erik.pindera@freepress.mb.ca