Long-term care homes and agency didn't properly check fake nurse's credentials, Ontario documents show

One long-term care home in Hamilton that hired a fake nurse didn't properly check her credentials and two other care homes in Ontario didn't check them at all, according to provincial inspection reports.

The agency the purported nurse belonged to also didn't properly check her records, the reports say.

Without that check, they didn't see the 29-year-old Mississauga woman, who now faces criminal charges, was already named on the College of Nurses of Ontario's (CNO) list of unregistered practitioners, according to the reports.

"I am very surprised and that is very concerning," said Doris Grinspun, chief executive officer of the Registered Nurses' Association of Ontario. "That would be considered negligence." 

On March 8, Hamilton police announced charges against the woman, who's accused of forging a real nurse's credentials.

The woman worked at Arbour Creek Long-Term Care Centre and Heritage Green Nursing Home, both in Hamilton, and Eatonville Care Centre in Toronto between late October 2022 and mid-May 2023. At one of the care homes, her work involved administering drugs to 17 residents, according to inspection reports.

Heritage Green Nursing Home, a non-profit, is its own licensee. Responsive Management Inc. is the licensee for Arbour Creek and Eatonville.

A person who is pretending to be a medical practitioner, having access to medication and being expected to administer them if they have no qualifications, could become a dangerous scenario. We're just fortunate that doesn't appear to be the case here.- Sgt. Ben Adams, Hamilton police

Responsive Management Inc. was also one of six for-profit long-term care providers recently named in a class action lawsuit, claiming gross negligence that led to illnesses and deaths during the COVID-19 pandemic.

After employing the fake nurse, all three homes were issued provincial orders, which they have complied with, says Ontario's Ministry of Long-Term Care.

The woman's case is still before the courts. She's charged with fraud over $5,000, false pretence over $5,000 and four counts of using forged documents.

Hamilton police Sgt. Ben Adams told CBC Hamilton the woman was working with an agency and it was the first to notify police.

Adams and the long-term care homes refused to name the agency. However, CBC has confirmed through court documents that it's Dumelum Care Ltd. based in Hamilton.

Adams said he's not aware of any residents being harmed by the fake nurse, but said the situation is concerning.

"A person who is pretending to be a medical practitioner, having access to medication and being expected to administer them if they have no qualifications, could become a dangerous scenario. We're just fortunate that doesn't appear to be the case here," he said in a phone interview.

How did the woman get into the LTC homes?

Court documents obtained by CBC Hamilton and public inspection records from the Ministry of Long-Term Care from June 2023 outline how the fake nurse got into the homes.

The court documents alleged the woman forged her CNO certificate, a diploma from Georgian College, a first-aid certificate and a criminal record check. Police said the woman also used a real nurse's CNO registration number.

They note the homes used Dumelum Care to fill positions due to staffing shortages during the pandemic.

An inspection at Arbour Creek in Hamilton states Dumelum Care checked the woman's registration number through the CNO website "and they thought their name had been listed."

The fake registered practical nurse worked three shifts in a row at Arbour Creek and administered drugs to three residents, the report says.

Only after those shifts did staff inspect her records and find the woman's name on the CNO's list of unregistered practitioners. CNO wasn't able to confirm to CBC News when the woman was first added to the list.

Arbour Creek notified Dumelum Care, which led the agency to realize the woman wasn't registered.

The inspection at Arbour Creek also found the home didn't follow its own policies about checking nurses' credentials and noted the home's executive director waited too long — 10 days — to file a critical incident report about the situation.

An inspection at Heritage Green in Hamilton found she worked there for five shifts in November 2022, but only learned the nurse was fake in May 2023 after the province notified the home.

The woman administered medicine to 17 residents, the report says.

"The home did not have a process in place to ensure the validity of the staff at the time of the incident," it notes.

An inspection at the Eatonville Care Centre in Etobicoke in suburban Toronto found the fake nurse worked there for six months.

It doesn't specify how many residents received medicine from the woman, but the home has roughly 247 beds.

The report says the home received the woman's forged documentation but never reviewed it.

It adds that the home's executive director waited too long — eight days — to file a critical incident report about the fake nurse.

Nursing homes, agency say they've made changes

The province sent all three homes a list of compliance orders and written notifications, all of which were complied with, according to the ministry.

Responsive declined an interview. But Paula White and Janette West, executive directors of Arbour Creek Care Centre and Eatonville Care Centre, respectively, told CBC Hamilton they have "reinforced our practices surrounding credential investigation, regardless of if the individual is hired directly by us or is temporary through an agency."

Scott Kozachenko, administrator at Heritage Green, also declined an interview but said the home "fully co-operated" with the province and police.

Stephen Emeka Akposionu, Dumelum Care's chief executive officer, declined an interview, but said in an email the agency has implemented prevention measures to "leave no stone unturned."

That includes triple checking the CNO website on different days to verify a nurse's credentials and contacting schools to confirm their degrees.

CNO spokesperson Kristi Green said employers have an obligation to confirm that nurses they employ directly or through an agency are entitled to practise nursing.

The Registered Practical Nurses Association of Ontario also declined an interview. But Tiff Blair, chief strategy officer for the association, said in an emailed statement it's "distressing" to see people pretending to be nurses and noted the College of Nurses has a "simple process" to help employers verify someone's credentials.

Grinspun said nursing homes and agencies need to do a better job of checking nurse certifications. She also said there's no oversight over agencies right now and a system or body should be in place to do such work.

Adams, from Hamilton police, said officers are still investigating to see if anyone helped the Mississauga woman fake her credentials.