A Winnipeg nurse has been suspended and fined after a critically ill patient died in her care at Grace Hospital in 2022. Tammy Wolfe, a registered nurse at Grace Hospital’s medicine unit, pleaded guilty last year to multiple charges brought by the College of Registered Nurses of Manitoba over professional misconduct. A panel of the college’s inquiry committee found the misconduct occurred during a single 12-hour night shift between April 18 and 19, 2022, when Wolfe was responsible for a 68-year-old patient admitted days earlier showing worsening shortness of breath. According to the panel’s written decision from January, the unit was short-staffed that night, with nurses caring for eight patients each instead of the usual six or seven. The patient died at approximately 5:50 a.m. after coding roughly 30 minutes earlier when a remote oxygen monitor alarmed. The panel found Wolfe failed on multiple fronts over the course of the shift, in a decision published online earlier this year. When the patient was admitted to the unit at approximately 10 p.m. on April 18, Wolfe noted in her progress notes that the patient was “lethargic and confused”—but recorded the patient as alert on the National Early Warning Score vital signs form, understating the patient’s deterioration score. A correct calculation on the form, which is part of a standardized track and trigger system to assess patient illness severity and risk of deterioration, would have produced a score of seven, according to the decision. That would have required immediately notifying the attending physician and considering a higher level of care or intensive care unit transfer, the panel wrote. However, Wolfe did not notify the medical team. The decision also documents that Wolfe recorded no vital signs between 11:15 p.m. and 6:05 a.m., and there is no record of any patient assessment between 10:15 p.m. and 3 a.m. or between 3 a.m. and 6:05 a.m. At midnight, Wolfe recorded that a dose of an opioid was withheld because of the patient’s reduced level of consciousness—but she did not consult the prescribing physician before doing so and provided no explanation for the change in the patient’s condition since admission. The panel also found Wolfe failed to document several prescribed antibiotic medications on the medication administration record, though withdrawal records confirmed she had retrieved them. The panel noted Wolfe maintained the patient was too ill for the ward and should have been in the intensive care unit — but that she never documented that concern. The panel weighed Wolfe’s 23-year discipline-free record, her early guilty plea and expressed remorse as mitigating factors. She was suspended for three weeks and ordered to pay $8,000 in costs — a penalty jointly recommended by Wolfe’s lawyer and the college’s Complaints Investigation Committee. Wolfe must also complete three courses within four months, including medication management, nursing documentation and a critical-thinking course. “Undocumented work cannot be proven and cannot be part of RN practice,” the panel wrote, noting the “overall dramatic neglect of documentation and charting” as an aggravating factor. “The panel had some sympathy for the fact this was conduct by an RN with an unblemished record on one shift on an understaffed unit, but ultimately finds that the registrant failed in their continuity of care for the patient,” it reads. The panel concluded the penalty was consistent with comparable decisions in other provinces and appropriately serves deterrence while protecting public confidence in the profession. CTV News has reached out to Wolfe’s lawyer, Jeff Smorang, for comment and is awaiting a response.
