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: Assigning Tasks to Un-Regulated Health Providers
Allegation
The patient attended the clinic for an Emsella Chair consult with an unregulated health professional, a kinesiologist. The Emsella Chair is a modality designed to stimulate the pelvic floor muscles. The patient requested a physiotherapist be involved in their care plan when this was offered by the clinic. The physiotherapist performed an assessment and delegated the provision of physiotherapy services to the kinesiologist. The physiotherapist is on the General Register and does not have the authority to perform pelvic health internal examinations. The patient’s condition worsened with the treatment provided and the patient submitted a written complaint to the College.
The College investigated four allegations:
- The physiotherapist assigned the assessment and treatment planning to an unregulated health provider, the kinesiologist.
- The physiotherapist failed to perform a thorough assessment and treatment plan prior to assigning tasks to their supervisee, the kinesiologist.
- The physiotherapist failed to re-evaluate or monitor the patient’s response to treatment.
- The physiotherapist prescribed a treatment, the Emsella Chair, which resulted in the patient’s prolapsed bladder becoming worse.
Investigation
The investigator interviewed the patient, the physiotherapist, and the kinesiologist.
The investigator also interviewed the physiotherapist that provided physiotherapy services to the patient after the investigated physiotherapist did.
The patient’s physician was contacted and the patient’s medical records were reviewed.
The patient’s physiotherapy records and the records kept by the kinesiologist were reviewed.
Documents relating to the Emsella Chair were reviewed.
Decision
The Complaints Director determined there was sufficient evidence of unprofessional conduct to refer the complaint for a hearing.
The Complaints Director, under the authority of section 55 (2) (a.1) of the Health Professions Act, obtained consent from the patient and the physiotherapist to attempt resolution of the complaint by facilitated resolution as an alternative to referring this matter for a hearing.
The physiotherapist agreed that they failed to meet the following College Standards of Practice while providing physiotherapy services to the patient:
Supervision
- Specifically, the physiotherapist performance expectation: the physiotherapist refrains from assigning the interpretation of assessment findings and determination of treatment procedures and treatment goals and the planning, development or modification of treatment plans to unregulated health providers in supervisee roles.
Client Assessment, Diagnosis, Interventions
- Specifically, the following two physiotherapist performance expectations:
- The physiotherapist applies appropriate assessment procedures to evaluate clients’ health status using standardized measures as available.
- The physiotherapist re-evaluates and monitors clients’ responses throughout the course of interventions, making adjustments and discontinuing services that are no longer required or effective.
Evidence-Informed Practice
- Specifically, the physiotherapist performance expectation: the physiotherapist incorporates current physiotherapy-related evidence into client-centered care by reviewing relevant research/information and integrating findings into assessment and intervention plans.
The physiotherapist agreed to review and reflect on the following College documents:
- The Code of Ethical Conduct
- The Consent Guide for Alberta Physiotherapists
- The Pelvic Health Guide for Alberta Physiotherapists
- The following Standards of Practice
The physiotherapist agreed to provide proof of this review and reflection via an original reflection paper, not generated from Artificial Intelligence or ChatGPT in any way to the Complaints Director. This reflection paper should apply the reviewed documents to this case and demonstrate that the physiotherapist has learned from this experience and will ensure this behavior does not occur again. Particular attention should be paid to the responsibilities of a physiotherapist in managing and providing physiotherapy services in different practice settings.
The physiotherapist will, at their own expense, complete the following course that is approved by the Complaints Director, specific to health-care professional ethics:
- Center for Personalized Education for Professionals (CPEP) Medical Ethics Course PROBE: Ethics & Boundaries Program – Canada
The following condition is placed on the physiotherapist’s practice permit:
- May not offer any pelvic health services until proof of education is provided to the College.
The physiotherapist was an active participant in this facilitated resolution.
Key Message
Physiotherapists need to consider the impact of business arrangements on patients and whether the decisions they make regarding provision of services and delegation of services align with the Standards of Practice and Code of Ethical Conduct.
This case highlighted how a decision that was seemingly made in the best interest of a patient, to allow physiotherapy services to be billed to a third-party payer, became a case of unprofessional conduct with ramifications to the patient and physiotherapist. Thankfully, the patient’s condition has since improved and the physiotherapist has modified their practice.
All physiotherapists must ensure that assessments are appropriate and thorough, that they only assign appropriate tasks and those tasks that they are competent to perform to supervisees with clients’ consent, and that they re-evaluate, monitor, and document clients’ responses throughout the course of treatment. In this case, not only was the physiotherapist not authorized in pelvic health, but they also assigned activities they were not competent to perform.
Physiotherapists are also reminded of the following when it comes to providing pelvic health services:
- Individuals who do not possess the competence to perform internal examinations may not claim that they provide treatment of pelvic health conditions.
- If a physiotherapist is not authorized to perform restricted activities, the physiotherapist may still provide general information to patients and the public about pelvic health concerns, incontinence, or pelvic pain and inform patients of the treatment options available to address these concerns.
Case 2: Communicating Risks and Benefits to Patients
Allegation
The patient, who was the complainant, attended physiotherapy intermittently over a six-month period with several physiotherapists at the same clinic. Intake paperwork, including a needling consent form, was completed by the patient at their first attendance. Needling was not performed on the date the forms were completed. Needles were used as an intervention, specifically anatomical acupuncture, on several occasions. On the patient’s final attendance at the clinic, acupuncture was again utilized by the physiotherapist as an intervention. The patient experienced worsening pain and reduced function after this appointment, sought medical attention at a health-care centre and was diagnosed with a pneumothorax.
Investigation
The investigation focused on the use of needles, specifically anatomical acupuncture, as a physiotherapy intervention, the education provided to the patient about the risks and benefits of anatomical acupuncture as an intervention, as well as the consent discussions had with the patient.
The patient and the physiotherapist provided written submissions and were interviewed by the investigator.
The patient’s physiotherapy record was reviewed, as were clinic policies and procedures relating to informed consent and using needles in practice. The clinic’s consent forms were also reviewed.
The investigator also referred to the Health Quality Council of Alberta (HQCA) document, “The Safe Practice of Dry Needling in Alberta,” a webinar entitled “Adverse Events Associated with Dry Needling in Physiotherapy Practice” and the College publication “Understanding Dry Needling Risks and Consent.”
Decision
A review of the HQCA document revealed that certain acupuncture points and muscles needled with other dry needling techniques carry a greater risk of pneumothorax than others. According to this document, “… the risk of a pneumothorax is very small (very rare) if proper needling techniques are employed.”
The investigation determined the following:
- Needles were inserted into acupuncture points at sites that carry a higher risk of pneumothorax according to the HQCA document.
- There was insufficient evidence to support that the physiotherapist had detailed discussions about the increased risks involved with needling these areas with the patient.
- There was no evidence that ineffective or unsafe needling practices resulted in the patient suffering a pneumothorax.
- That there were deficiencies in the education provided to the patient about the risks and benefits associated with using needles as a physiotherapy intervention, the documentation of consent discussions and education provided to the patient, and, given the needles were retained in the patient’s body for 12 minutes, the importance of instructing the patient not to move while the needles were in place.
Ultimately, the Complaints Director determined that the conduct did not rise to the level of unprofessional conduct as defined by the Health Professions Act. However, several deficiencies were identified in the physiotherapist’s practice. Several recommendations were made to the physiotherapist to improve their practice:
- Review and reflect on the following:
- Informed Consent Standard of Practice.
- Education and consent discussions they have with patients, particularly involving acupuncture in anatomical areas associated with increased risk of patient safety events.
- Risk Management and Safety Standard of Practice, with particular attention paid to the safety considerations when leaving patients unsupervised with needles in situ, and the fact it is up to the physiotherapist to properly consider all risks of chosen interventions.
- Provide greater detail in their documentation of the risks and benefits of physiotherapy interventions and patient safety discussions.
- Ensure all documentation is completed and signed contemporaneously to ensure the authenticity of the physiotherapy record.
- Review the Consent Guide for Alberta Physiotherapists
- After reviewing the Consent Guide for Alberta Physiotherapists, incorporate the following processes:
- Obtain written informed consent from the client after having the informed consent discussion with the client, not as part of the general intake process for clients.
- Document the nature and content of that consent discussion as part of the treatment record.
Key Message
All physiotherapists must consider the risks and benefits of any interventions proposed and communicate those risks and benefits to the patient. Documentation of this communication must occur. Special attention should be given to topics the physiotherapist considers having been covered or be so standard they do not warrant documenting or reviewing with the patient. When considering the use of needles in practice, these include but are not limited to, the patient not moving while the needles are in place.
The topic of informed consent has been covered recently in College communications and College-Selected Activities. Physiotherapists must continue to document consent discussions and the content and details of those discussions. Consideration must be made for gaps in treatment dates. While reviewing each and every risk and benefit of an intervention is not necessary at every session, this case demonstrates that extra care should be taken when a gap in treatment sessions occurs and when a patient has a lot of experience with an intervention. Familiarity with patients who have attended for a long time or patients with experience with certain interventions, may cause assumptions to be made on the part of the physiotherapist. It is important for physiotherapists to consider the importance of reminding patients about the risks and benefits of physiotherapy interventions, especially with interventions with a higher risk of a patient safety event.
Case 3: Timely Documentation
Allegation
The complainant alleged that a modality was used on them prior to them being assessed by the physiotherapist. The allegation investigated by the College was:
- The physiotherapist prescribed physiotherapy treatment before conducting an assessment.
The allegation related to the following physiotherapist performance expectation from the Client Assessment, Diagnosis, Interventions Standard of Practice. The physiotherapist:
- Applies appropriate assessment procedures to evaluate clients’ health status using standardized measures as available.
Investigation
The complainant withdrew their allegation approximately six weeks after it was submitted to the College. Written consent is required by the College to withdraw from participating in the complaint an individual initiated. The party must agree to waive their rights as a complainant which includes the right to be informed of the Complaints Director’s decision and their right to appeal that decision if the matter is dismissed. The complainant was informed of this and did withdraw their complaint. However, the Complaints Director has the carriage of the complaint. This means, once the Complaints Director is aware of possible unprofessional conduct, the Complaints Director must decide whether to proceed with an investigation and the conduct process. In this case, the Complaints Director determined there was sufficient evidence within the written complaint to warrant continuing with the investigation.
Without a complainant, the investigation was brief and consisted of written submissions and an interview with the physiotherapist, an interview with an administrative staff member who worked at the physiotherapy clinic when the complainant attended for their assessment, and a review of documents including the complainant’s physiotherapy record.
Decision
There was no evidence collected during the investigation to support the allegations.
The physiotherapist denied the allegations and described the assessment, education and consent processes utilized prior to the application of the modality.
The physiotherapy record supported the physiotherapist’s version of events. A complete assessment was documented in a contemporaneous way. This added weight and credibility to the physiotherapist’s version of events.
The complaint was dismissed with no evidence of any unprofessional conduct.
Key Message
This case highlights the importance of timely documentation relative to the weight of the evidence considered during an investigation and decision. Given that much of the evidence is contained in the physiotherapy record, it is critical that timely and complete documentation is completed by each physiotherapist after each patient encounter.
Case 4: Mandatory Employer Reported Incompetence
Allegation
This was a mandatory employer report following the termination of the physiotherapist’s employment secondary to incompetence.
Investigation
The investigation focused on the differences between employer expectations for performance and the College’s Standards of Practice.
Documents were reviewed and interviews occurred including the physiotherapist, their co-workers, and the employer.
Decision
The investigation determined that, while the physiotherapist did not meet the employer’s performance expectations, there was insufficient evidence to suggest that the physiotherapist demonstrated unprofessional conduct as defined by the Health Professions Act.
Physiotherapists should recognize that very different processes exist between employment agreements and expectations and the College’s Standards of Practice.
A secondary issue in this case is that the physiotherapist disclosed to the investigation that there were health issues that may have related to the complaint being filed. All physiotherapists are reminded that it is the physiotherapist’s obligation to ensure that they consistently and fully meet all the Standards of Practice, meet the Code of Ethical Conduct in its entirety, and meet all legislative requirements of the College of Physiotherapists of Alberta.
Specifically, I highlight the following sections of the Code of Ethical Conduct relating to this case:
Responsibilities to the Client
15. Practice the profession of physiotherapy according to their own competence and limitations, referring the client to others as necessary
Responsibilities to the Public
8. Take responsibility for their own physical and mental health and refrain from practicing physiotherapy while their ability to provide appropriate and competent care is compromised.
Responsibilities to Self and the Profession
7. Attend to their own health and well-being.
Case 5: Documentation Errors
Allegations
- Following the patient’s pedestrian motor vehicle collision (MVC) of June 2017, the physiotherapist failed to provide a complete assessment and diagnosis of the patient’s injuries according to the DTPR (Diagnosis and Treatment Protocols Regulation).
- Following the patient’s pedestrian MVC of June 2017, the physiotherapist failed to develop an appropriate physiotherapy treatment plan for the patient.
- The physiotherapist did not allow the patient to participate in the management and decision-making of their own health.
- The physiotherapist inaccurately documented that the patient had fibromyalgia, which resulted in irreparable harm to the patient.
- The physiotherapist failed to clearly communicate and explain the fees and billing practices to the patient in relation to receiving physiotherapy services under the DTPR.
Investigation
The investigation focused on the documentary evidence within the patient record and recollections of the physiotherapist. The patient did not participate in the complaint process despite the best efforts of the investigator. Given significant time had passed between the complaint being made and the period in which physiotherapy services were provided, the recollections of the physiotherapist were given less consideration than what was documented in the physiotherapy record.
The physiotherapy record documented an appropriate assessment and diagnosis relating to the DTPR.
The physiotherapy record documented a treatment plan was developed that was appropriate to the diagnoses and there was signatory evidence that this plan had been reviewed with the patient.
The physiotherapy record documented a medical diagnosis of fibromyalgia and that, when the patient made a request to correct this documentary error, the physiotherapist complied with this request. The patient alleged this error caused them irreparable harm. Because the patient did not participate in the investigation, a definition of irreparable harm was not made.
There is insufficient evidence collected in the investigation to show that the physiotherapist had clearly communicated and explained the fees and billing practices to the patient in relation to receiving physiotherapy services under the DTPR. The physiotherapist recalled that they had had a conversation about their billing practices during the initial encounter with the patient. There was no documentary evidence to support this. The physiotherapist did not produce the standard letter that the DTPR states must be mailed to the patient when generating the final invoice to the insurer.
Decision
There was no evidence to support allegations 1, 2, and 3.
The evidence showed the physiotherapist’s behaviour did not rise to the level of unprofessional conduct as defined by the Health Professions Act for allegation 4.
There was insufficient evidence to support allegation 5. The Complaints Director did not believe there was a reasonable prospect of establishing unprofessional conduct as defined by the Health Professions Act relating to this allegation.
Key Message
Physiotherapists should be aware of what they are documenting and how errors may impact patients and the therapeutic relationship.
Physiotherapists should consider documenting discussions relating to Fees and Billing practices.
Physiotherapists are reminded that, according to the DTPR Interpretive Guide, the following applies to physiotherapists:
When generating the final invoice to the insurer, a copy of the invoice shall be mailed to the patient with a standard letter that indicates the following: "your insurer has been billed in the amounts shown for all goods and services listed. Please review the invoice and report any errors to the signatory or your insurer."
Case 6: Dry Needling Communication
Allegations
The patient attended physiotherapy four times in six weeks. Dry needling was used as a physiotherapy intervention each attendance. The patient experienced a sharp pain during dry needling. The patient felt this was done without proper education or explanation by the physiotherapist.
The College investigated one allegation and that was that the physiotherapist failed to effectively communicate to promote the patient’s understanding of what to expect during a dry needling treatment.
The allegation related to the following physiotherapist performance expectation from the Communication Standard of Practice. The physiotherapist:
- Communicates effectively with clients to promote their understanding of proposed services.
Investigation
Both the patient and the physiotherapist were interviewed during the investigation.
Consent forms and the entire physiotherapy record were reviewed.
The patient stated that they were provided with written and verbal information about what risks are associated with dry needling but did not recall specifically being told that the insertion of the needle could result in a sharp pain experience.
The patient stated that they experienced a sharp pain with needle insertion, that there was not the expected response, and that the physiotherapist removed the needle as soon as they made the physiotherapist aware of the sharp pain response.
The physiotherapist provided their standard verbal explanation, or script, for what patient’s should expect during a dry needling intervention, including symptoms such as pain, bleeding, bruising, and numbness. The physiotherapist also stated that they reviewed the risks involved with dry needling as an intervention.
The consent form utilized by the physiotherapist reviewed possible complications associated with dry needling but did not comment on the possibility of a sharp pain experience with needle insertion.
Both the patient and the physiotherapist confirmed that written and verbal consent for the intervention was obtained on the first attendance and verbal consent on the remaining attendances.
The patient and the physiotherapist both agreed that dry needling continued following the sharp pain experienced by the patient.
The physiotherapist did not document any adverse events following the intervention.
The physiotherapy record did not reflect the depth of education provided to the patient as part of the consent discussion.
Decision
After reviewing the submissions of both parties and examining the physiotherapy record, it is reasonable to conclude that as soon as the physiotherapist was aware that the patient was experiencing a sharp pain response, the physiotherapist stopped inserting the needle and removed it. There was no evidence collected that the physiotherapist continued to advance the needle through the sharp pain response. The physiotherapist acted appropriately once the patient informed the physiotherapist they were experiencing sharp pain with needle insertion.
The Complaints Director found that while the patient experienced a sharp pain with needle insertion, there was no evidence that the physiotherapist failed to communicate with the patient to promote their understanding of the intervention, dry needling. The physiotherapist provided a reasonable description given to patients of what occurs and what should be done if a sharp pain is experienced during needle insertion. There was no evidence presented that this was or was not communicated to the patient.
Given there was no evidence to support the allegation, the complaint was dismissed.
Case 7: Documentation and Transfer of Responsibility
Allegations
The patient was assessed and a treatment plan was developed by physiotherapist #1. A physiotherapy support worker was utilized during the provision of physiotherapy services. Physiotherapist #1 went on vacation and transferred responsibility of the patient’s care to physiotherapist #2. The patient experienced pain following the application of an electrical modality by the physiotherapy support worker. The patient submitted a written complaint about physiotherapist #1. Two allegations were investigated:
- Physiotherapist #1 assigned delivery of the patient’s treatment to an unregulated health-care provider who caused the patient pain by negligently increasing the electrotherapy intensity.
- Physiotherapist #1 failed to address the patient’s reported right arm injury.
Investigation
The patient was attending physiotherapy under a Workers’ Compensation Board – Alberta claim for a left arm injury. The patient clearly identified on intake that they had issues with their right arm as well as their left arm.
Both the patient and physiotherapist #1 were interviewed to provide clarity relating to the allegations.
Relating to allegation #1, the investigation focused on whether tasks or activities were assigned to the physiotherapy support worker, what those tasks/activities were, and when they were assigned.
Relating to allegation #2, the investigation focused on a review of the physiotherapy record to determine if an assessment had occurred for the right arm.
Decision
It is important to note that physiotherapist #1 was the physiotherapist responsible for the patient’s care for a portion of the episode of care. Only this portion of the episode of care was considered in the decision.
Allegation #1
The investigation produced evidence that physiotherapist #1 developed a treatment plan that included the use of exercise and potentially therapeutic ultrasound. There was no evidence that physiotherapist #1 planned for electrical modalities to be utilized. There was also evidence that physiotherapist #1 believed that the physiotherapy support worker was competent to provide the physiotherapy services outlined in the treatment plan. There was contradictory evidence that the patient was aware of the role of the physiotherapy support worker, but the patient was aware that the physiotherapy support worker could not alter the treatment plan without consulting with the responsible physiotherapist.
There was no documentary evidence of a transfer of responsibility of care from physiotherapist #1 to physiotherapist #2.
Electrotherapy was introduced as a treatment during the time period that physiotherapist #2 was the physiotherapist responsible for the care of the patient.
Based on the collected evidence, the Complaints Director found that while physiotherapist #1 did assign responsibility for the patient’s care to the physiotherapy support worker, this did not involve the use of an electrical modality. For the physiotherapy support worker to have used this modality, the physiotherapy support worker should have communicated with the physiotherapist responsible for the patient’s care before or at the time of use. In this case, physiotherapist #2 was the physiotherapist responsible for the patient’s care, not physiotherapist #1. There was no evidence of unprofessional conduct, and the complaint was dismissed.
Take Away Message
Physiotherapists should ensure that they document when transfer of responsibility for patient care occurs.
Physiotherapists should ensure that patients know what tasks/activities physiotherapy support workers may and may not perform.
Physiotherapists should ensure that physiotherapy support workers are not altering treatment plans or introducing new treatments without the authorization of the physiotherapist responsible for the patient’s care.
Allegation #2
The physiotherapy record showed that subjective and objective data was collected regarding the left and right arm of the patient. A physiotherapy impression was made that could have been applicable to the left arm, the right arm, or both arms. The side was not clearly documented in the record. There was evidence collected that the patient knew that the exercises prescribed by physiotherapist #1 were to be done on both sides and that this would impact the condition of both arms. While the patient might not have been satisfied with the way their right arm condition was being addressed, the evidence supported an assessment occurred and appropriate exercises were prescribed by physiotherapist #1. There was no evidence of unprofessional conduct, and the allegation was dismissed.
Take Away Message
Be sure to document which side of the body subjective reports, objective findings, and physiotherapy impressions are made to provide clarity to the reader and to avoid confusion for all parties reviewing the physiotherapy record.
Case 8: Infection Prevention Best Practices and Responsibility
Allegation
A coworker of the physiotherapist experienced a needle stick injury after emptying the garbage can from the treatment room utilized by the physiotherapist.
The allegation investigated was:
- The physiotherapist failed to maintain the health and safety of their colleagues when they disposed of sharps in an unsafe manner, failing to abide by routine practices in the handling of sharps.
Investigation
The physiotherapist admitted that, on occasion, they temporarily stored used needles in a tissue box and then transferred the needles to a sharps container. This was because the sharps container available in the clinic was in another treatment room and was not always readily accessible to the physiotherapist.
The physiotherapist admitted that this activity did not adhere to best practices of infection prevention and control.
However, the physiotherapist did not admit to disposing of used needles in a garbage can, thus not admitting to being the cause of the needle stick injury suffered by their coworker.
The evidence collected in the investigation showed that there was a four-day period between garbage collection for the garbage can in the physiotherapy treatment room. The evidence also showed that the investigated physiotherapist was the only professional to use the physiotherapy treatment room. The investigator found that one patient had needles used as part of their physiotherapy treatment during this four-day period.
The physiotherapist denied placing the used needles in the garbage can and maintained the needles used on this occasion were placed in an approved sharps container.
There was no direct evidence collected that the physiotherapist placed used needles in the garbage can.
Decision
The evidence supported two distinctly different versions of events and did not support the Complaints Director’s decision to refer for a hearing as there was not a reasonable prospect of establishing the facts that the physiotherapist placed used needles in the garbage can, thus leading to a needle stick injury.
The admission by the physiotherapist that they did not adhere to best practices of infection control in physiotherapy practice was considered by the Complaints Director.
The physiotherapist also described measures they had taken to ensure that they have a suitable sharps container with them at all times and stated they knew they had failed to meet the Standards of Practice of the College regarding Infection Control.
The Complaints Director was mindful of the impact of this event on the physiotherapist’s coworker.
The investigation uncovered areas of the physiotherapist’s practice that required improvement. The College’s Professional Conduct Process exists to determine what if any, corrective action or restrictions must be put in place to ensure it is safe for the physiotherapist to continue working.
The physiotherapist was reminded that they must ensure that sharps are disposed of properly and adhere to best practices of infection prevention and control in physiotherapy practice.
The Complaints Director recommended that the physiotherapist review and reflect on the following College documents to improve their practice:
- Infection Control Standard of Practice
- Performance of Restricted Activities Standard of Practice
- Risk Management and Safety Standard of Practice
- Infection Prevention and Control Guide
- Patient Safety and Risk Management Practice Guideline
Take Away Message
It is the responsibility of the physiotherapist to ensure that they always adhere to best practices of infection prevention and control in physiotherapy practice according to applicable legislation, regulatory requirements, standards, and guidelines.
Physiotherapists must ensure that they have the appropriate equipment available to meet their Standards of Practice. If their employer is not providing this equipment, the physiotherapist must obtain the equipment necessary and educate their employer of the need for this equipment.
