Quarterly report of all closed conduct files from April 1 to June 30, 2025.
Disclaimer: Decisions may vary depending on the circumstances. The reasons for a decision must be considered in light of the evidence and the actual issues pertaining to the allegation.
Case 1
Allegations
The patient was fitted for orthotics as part of the physiotherapy services provided by the physiotherapist.
The patient stated in their written complaint that the orthotics were not fitted properly, and that the physiotherapist did not do any re-evaluation of the orthotics after providing them.
The College investigated two allegations:
- The physiotherapist improperly fitted orthotics for the patient.
- The physiotherapist failed to re-evaluate and monitor the patient's response to the orthotics fitted by the physiotherapist.
Investigation
The investigator focused on the submissions of the patient and the physiotherapist. Both parties provided the investigator with written and oral recollections of events.
The physiotherapist’s curriculum vitae was reviewed, and the physiotherapist was asked what steps they take to ensure that they maintain their competence in the provision of orthotics as part of providing physiotherapy services.
The physiotherapy record was reviewed in detail.
Decision
The investigation uncovered insufficient evidence for the Complaints Director to consider referring the allegations for a hearing.
The physiotherapist was able to provide evidence that an assessment occurred. The physiotherapist was also able to describe their competencies in the area of orthotics fitting and provision.
There was no documentation that a re-assessment occurred after the orthotics were provided to the patient.
However, there was evidence that the physiotherapist’s documentation of the interactions between the patient and the physiotherapist did not support the physiotherapist’s version of events and fell below the expected Standard of Practice regarding Documentation.
The physiotherapist was provided with the following recommendations to improve their future practice:
- Review the 2025 Standard of Practice “Assessment, Diagnosis, Treatment” and reflect on how it applies to the physiotherapy services they provide when considering the provision of orthotics as one part of their physiotherapy services.
- Review the 2025 Standard of Practice “Documentation” and ensure that all [emphasis added] documentation meets the minimum requirements identified in the Standard.
It was strongly recommended that the physiotherapist undertakes each of the recommendations.
Finally, given that both allegations in this complaint came with recommendations, the Complaints Director provided the physiotherapist with a formal caution regarding this matter.
All physiotherapists are reminded that a complaint may result in a referral for a hearing if sufficient evidence exists to support the allegations and there is a reasonable prospect of establishing the facts necessary to prove the allegations.
Key Message
Orthotics are only one part of a physiotherapy treatment plan and should be considered as such.
If you are considering providing orthotics as part of a physiotherapy treatment plan, ensure you have met your practice requirements regarding assessment, consent, and communication surrounding the provision of orthotics.
Remember that physiotherapists are responsible for ensuring they have the competence to
provide the interventions to the populations they serve and for pursuing appropriate
education/training to obtain and maintain this competence. Be able to communicate this training to patients and funders that may ask.
Finally, contemporaneous documentation is crucial in an investigation and a professional conduct decision. Be sure to document all interactions with patients, even those that may seem inconsequential. If the worst should happen, and your conduct is investigated, your documentation may add or subtract from your version of events.
Case 2
Allegation
The complainant, the patient, injured their right ankle in July of 2024. The patient had surgery on their right ankle in mid-September of 2024. The physiotherapist provided physiotherapy services for the patient in early October of 2024.
The allegation investigated by the College was that the physiotherapist failed to meet the expected outcome of the Client Assessment, Diagnosis, Interventions Standard of Practice in their interaction with the patient in October of 2024.
Investigation
The investigator interviewed the patient and the physiotherapist and reviewed the physiotherapy record to determine what assessment, diagnosis, and interventions were performed and whether that met the expected outcome and performance expectations of the Standard of Practice.
The investigation revealed that the patient had a ligament repair surgery, and the patient was aware of this. It also revealed that, at the time of the assessment, the physiotherapist was unable to determine from the patient or other sources what kind of surgery was performed and whether any post surgical protocol was in place.
Decision
The key evidence in this decision was that the physiotherapist did not know what surgical restrictions or post-surgical protocol was in place for the patient following their ankle surgery. Based on this limited information, the physiotherapist performed an assessment and provided education about range of motion exercises, gait patterns, and the use of thermal agents.
The patient believed the physiotherapist erred by not asking for more detail about their surgery and, had the physiotherapist asked more detailed questions, would have learned more about the surgery and would have been better able to assess, diagnose and begin interventions and treatment planning for the patient.
There was no evidence within the physiotherapy record that the physiotherapist knew the type of surgery performed or any post surgical restrictions for the patient. There was also no evidence within the record that the physiotherapist made any attempt to obtain this information. There was no evidence within the record that the physiotherapist assessed range of motion prior to prescribing range of motion exercises. There was no evidence within the record that the physiotherapist assessed thermal sensation prior to recommending the use of thermal agents for self management. There was evidence within the record that the physiotherapist assessed the patient’s gait while in an air cast and provided education about appropriate gait patterns.
Ultimately, there was insufficient evidence to support the allegation and the complaint was dismissed.
Key Message
The evidence revealed the complaint was primarily about communication and the patient/physiotherapist therapeutic relationship. The patient did not feel heard and felt the physiotherapist did not ask enough questions with enough depth to fully understand their reasons for attending physiotherapy when they did. The physiotherapist felt they provided physiotherapy services the best they could given the information they had before them and erred on the side of patient safety when it came to the assessment and interventions they performed.
All physiotherapists are reminded to engage in active listening to ensure that the client’s perspective, needs, and preferences are heard and understood.
Case 3
Allegation
The physiotherapist failed to apply physiotherapy interventions effectively resulting in increased symptoms and reduced function for the patient, the Complainant.
Investigation
The investigation focused on a review of the physiotherapy record and interviews with the physiotherapist and the patient.
Decision
There was enough evidence of unprofessional conduct collected in the investigation for the Complaints Director to consider referring the matter for a hearing.
The Complaints Director chose to proceed with facilitated resolution as an alternative to referring a matter for a hearing. Facilitated resolution is only an option if deemed appropriate by the Complaints Director and agreed to by both the individual reporting the incident and the physiotherapist. The patient was open to proceeding with facilitated resolution and so was the physiotherapist.
Facilitated resolution results in a formal and binding agreement between the physiotherapist and the College. The terms of the agreement are similar to orders the College would seek if the matter was referred for a hearing and the physiotherapist was found guilty of unprofessional conduct.
The key evidence in this case was divergent evidence between what was documented in the treatment record for assessment and treatment and what physiotherapy services were actually performed by the physiotherapist. Also noteworthy was the patient attended the clinic on an “as-needed basis” and saw multiple practitioners at the clinic for the same condition.
The physiotherapist acknowledged that the physiotherapy record was not an accurate reflection of what occurred on the date in question. The physiotherapist relied heavily on “copy and paste” from prior chart notes and did not confirm previous assessment results and instead relied on prior documented responses from the patient to guide their treatment interventions on the day in question. This led to choices in treatment interventions that, in the opinion of the Complaints Director, likely resulted in increased symptoms and reduced function for the patient, that did not align with the physiotherapist’s and patient’s expectations. Further, regarding manual therapy, there was a lack of specificity regarding the spinal level that was mobilized and the manner in which the spinal level was mobilized. There was no evidence to guide the Complaints Director in their decision regarding the appropriateness of the manual therapy performed on the day in question. This, too, may have resulted in the adverse response of the patient to the interventions chosen by the physiotherapist.
The physiotherapist agreed to write a self-reflection paper incorporating topics relevant to the complaint to demonstrate reflection on this case and show learning for future cases. The patient agreed to this course of action.
Key Message
Electronic medical records offer many conveniences for physiotherapists, including “copy and paste” options for prior chart notes. This can lead to more efficiency and less time spent on documentation by physiotherapists.
However, documentation must accurately reflect what occurred during each patient interaction. If a test was not performed, do not document it was. Be specific in your documentation so that a colleague can carry on your treatment plan. Does documenting “Grade 3 flexion / extension mobilizations bilateral cervical spine” provide your colleague with enough information to appropriately manage the patient in your absence? If there has been a gap in appointments or if there is a different treating physiotherapist, does the documentation support that re-assessment was done, or that the case was reviewed by the physiotherapist?
The professional conduct process relies heavily on the physiotherapy record and expects it to be an accurate representation of what occurred during a physiotherapy interaction.
Good documentation should be comprehensive, well organized, and done in a timely manner that is consistent with the Standards of Practice.
Is your documentation going to support you if you are engaged in the professional conduct process?
Case 4
Allegation
On or about August 8, 2024, the physiotherapist failed to apply physiotherapy intervention procedures safely and effectively resulting in increased pain and dysfunction for the patient.
Investigation
The investigation focused on interviews with the patient and the physiotherapist, a review of the physiotherapy record, and a review of the interventions utilized on the date in question.
Decision
There was insufficient evidence of unprofessional conduct for the Complaints Director to refer this matter for a hearing.
The evidence showed that the physiotherapist discussed the indications for the interventions used, had the patient’s informed consent to use the interventions, applied the interventions safely and effectively, and discontinued use of the interventions when the patient withdrew their consent due to increased symptoms.
The evidence also showed that the physiotherapist may have erred in determining the acuity of the patient’s condition and managed the case as a chronic case rather than a sub-acute case. This may have led the physiotherapist to select an intervention that was not indicated for an acute or sub-acute condition, and this may have resulted in an unexpected and significant increase in the patient’s symptoms and a lengthy reduction in function for the patient.
The Complaints Director recommended that the physiotherapist review and reflect on their choices of interventions for acute, sub-acute, chronic and acute-on-chronic conditions and reflect on their use of manual muscle testing in painful conditions.
Case 5
Allegations
- The investigated member failed to maintain professional boundaries when providing treatment to the patient.
- The investigated member engaged in sexual misconduct when providing treatment to the patient.
Investigation
The investigation focused on five areas during the patient’s episode of care.
- Sharing of personal information by the physiotherapist.
- Positioning of the physiotherapist at the end of treatment sessions that was interpreted by the patient to prevent them from leaving the appointment.
- Exposing the patient’s buttocks more than necessary for the provision of treatment.
- Adjusting clothing inappropriately for the provision of treatment.
- Resting of the physiotherapist’s hand on the patient for no therapeutic purpose.
There was little evidence available to be gathered in this case other than the patient and physiotherapist’s submissions and the treatment record.
Decision
The complaint made by the patient and the subsequent investigation raised concerns about the physiotherapist’s ethics and actions.
The Complaints Director had to consider whether the physiotherapist’s conduct met the minimum requirements or fell below the required standards. The Complaints Director did not find the concerns raised to be significant enough to meet the definition of unprofessional conduct and warrant referral for a hearing.
This was a thorough investigation which provided conflicting evidence as the allegations related to interpretation of events that were not captured or recorded in real time and are, thus, “they said / they said” situations. The Complaints Director is permitted to perform a limited weighing of credibility in assessing the evidence when making their decision.
Within the decision to dismiss this complaint, and considering the ongoing importance of all physiotherapists maintaining appropriate professional boundaries, the following recommendations were made to the investigated member to improve their practice and avoid any concerns relating to professional boundaries in the future:
- Review and reflect on the College’s Code of Ethical Conduct
- Review and reflect on the College’s Boundary Violations Standard of Practice
- Review and reflect on the College’s Protecting Patients from Sexual Abuse or Misconduct Guide for Alberta Physiotherapists
- Complete and reflect on the College of Physiotherapists of Ontario’s Ethics E-Learning Module
- Pursue other independent education on maintaining boundaries, such as from post-secondary institutions
- Continue ongoing professional development as a physiotherapist in all areas of practice
The complainant exercised their right under section 68 of the Health Professions Act for a review of the Complaints Directors decision in this case. The College’s Complaint Review Committee met, reviewed the complaint, investigation, and decision, and using the authority granted under section 68(c)(ii) confirmed that “the complaint is dismissed if in the opinion of the complaint review committee there is insufficient evidence…of unprofessional conduct.”
Key Message
Physiotherapists are involved in multiple therapeutic relationships each day. Each and every client relationship includes a process of building a therapeutic relationship and then maintaining that relationship through the ups and downs of clinical care. It takes dedicated time, energy, and skill to consistently build positive therapeutic relationships. Physiotherapists should regularly reflect on the distinctions between personal and therapeutic relationships and be attentive to maintaining professional boundaries.
Case 6
Allegations
- The physiotherapist touched the patient’s left buttock for no clinical reason.
- The physiotherapist utilized electrotherapy, cupping and handheld massager, without the patient's informed consent.
Investigation
Allegation #1
The patient recounted that the physiotherapist placed their hand on the patient’s left buttock for no clinical reason while using a handheld massager. The physiotherapist offered written and oral evidence regarding their standard practice when using a handheld massager and offered explanations for why their hand was in contact with the patient during its use. The physiotherapist denied their hand was on the patient’s buttock and was, instead on the patient’s lower back to stabilize a towel that was used between the handheld massager and the patient. Because the patient and the physiotherapist were the only individuals in the treatment area while physiotherapy services were provided, their recollections of events were the key pieces of evidence.
Allegation #2
The investigation focused primarily on the documented consent discussions in the physiotherapy record. Both the patient and the physiotherapist were interviewed and provided written submissions regarding their recollections of consent discussions.
Decision
The Complaints Director is responsible for determining whether there is a reasonable prospect of proving the allegation before a hearing tribunal.
Allegation #1
The physiotherapist was able to offer evidence that supported the need to place one of their hands on the patient while using a handheld massager as part of the provision of physiotherapy services. When weighed against the evidence provided by the patient, the Complaints Director determined that there was insufficient evidence to support referring this matter for consideration by a hearing tribunal.
Allegation #2
The physiotherapy record documented that consent was obtained by the client for the use of the handheld massager as well as other components of the physiotherapy services provided, including communication with the patient’s physician and accessing diagnostic imaging reports, the physiotherapy record did not document specific consent for the use of electrotherapy or cupping.
While the physiotherapist erred in these omissions and there were technical breaches of the Standard of Practice, not every breach of a standard rises to the level of unprofessional conduct as defined by the Health Professions Act. A documentation error or omission must be distinguished from unskilled practice that arises from a lack of knowledge. Given this, the Complaints Director did not believe there was sufficient evidence to support a finding of unprofessional conduct as defined by the Health Professions Act by a hearing tribunal. This allegation was not referred for a hearing.
Key Message
All physiotherapists should ensure that consent discussions are ongoing and informed.
Consent discussions are physiotherapy service and provider-specific. When a person consents to receive a physiotherapy service, there is an implication that the consent is to a particular person providing that service. If a colleague receives consent to use electrotherapy, the physiotherapist should not assume that they too have consent to use electrotherapy.
If you are going to place a hand on a patient, particularly in an area that a patient may consider sensitive, or in a manner that is new to you and the patient, the physiotherapist should explain the rationale for doing so and obtain consent to do so.
Physiotherapists rely on regular check-ins with patients during the provision of physiotherapy services, such as “are you OK?” and “how are you doing?” While these check-ins are essential and important, of equal importance in the Professional Conduct Process is the documentation of these check-ins. Consider documenting all aspects of consent at least on your first interaction with the patient and documenting the patient’s response to treatment, particularly if there was anything out of the ordinary that occurred during the provision of physiotherapy services. Remember that documentation is a cornerstone of safe, effective, and legally-sound health-care practice. It provides a detailed record of the care provided, which can be used to demonstrate that appropriate procedures were followed and is relied upon heavily in the Professional Conduct Process.
Case 7
Decision
The College received a complaint under section 57 of the Health Professions Act (the “HPA”) after the employer suspended the physiotherapist for unprofessional conduct.
The physiotherapist appealed and grieved the suspension.
The College’s Professional Conduct Processes were placed in abeyance (paused) while the appeal and grievance processes played out.
After the appeal processes and grievance processes were concluded, the employer changed the suspension to a letter of warning.
Given this development, the Complaints Director, pursuant to section 55(2)(f) of the HPA determined there was insufficient evidence of unprofessional conduct and dismissed the complaint.
The reason for this decision was that, if the suspension never occurred, the employer would not have been mandated to report the physiotherapist’s conduct under section 57 of the HPA.
Given a letter of warning was issued instead, it was as if the suspension never happened.
Key Message
The College’s Professional Conduct Process exists in parallel with other administrative bodies and decision-makers. There are times when the Professional Conduct Process defers to these other bodies and then determines the appropriate steps for the College to undertake.
