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Done In By A Contract Nurse . . . Lessons Learned

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By Steve Moran

The story was big because of the association with the Trump administration . . .

H.R. McMaster, Sr. is the father of H.R. McMaster who was, for about 5 minutes, (actually February 2017 until March 22, when he resigned) Trump's national security adviser.

What Happened

McMaster, Sr. was a resident at Cathedral Village, a Presbyterian Village community, located in the Philadelphia area for about 13 days following a stroke. On April 12, 2018, he had an unwitnessed fall and was found laying on the floor in his room at about 11:30 PM with a small cut on the side of his head. The charge nurse, Christann Gainey, had him put in a wheelchair and taken to the lobby. The next morning (April 13) at around 7:30 AM, he was found dead by a staff member.

Nurse Charged

The charge nurse, Christann Gainey, age 30, who worked for an agency and not the community, was found not to have done the 8-point neurological check and to have falsified the records. On May 10, 2018, she was charged with felony neglect, manslaughter, and tampering with records.

A Word about Presbyterian Village -- Lessons Learned

They are a great organization that cares about residents and team members. They have 30 campuses and serve around 6,000 residents. And yet this happened.

Some thoughts . . .

  • Perhaps the most important is that it can happen to any community. We are in a rewarding, but tough, business that is often not very forgiving. It only takes one employee or contractor who doesn’t care or makes a mistake, or things just go very wrong.  

    This does not mean we should stop doing what we are doing, or become so defensive that it degrades the way we serve residents, families and team members.

  • Culture matters, this is a general statement and not a specific commentary on Presbyterian Village or Cathedral Village. But we know, the better the culture the easier it is to recruit and retain team members; which also means those team members will care more and do a better job. It also means less agency staffing.

  • If a disaster hits, hire a disaster management firm to help you do the very best job of serving your community, residents, family members and staff. These firms do not help you hide but ultimately help you be more transparent. And at the same time that transparency is the right kind and amount of transparency.  

  • Know that while at the time it will feel like the world is falling in around your head, hardly anyone really knows or is paying attention. Several years ago when Emeritus was pounded by PBS and ProPublica, it felt to Emeritus and the whole industry like the world was falling down around us. Yet if you had gone out on the streets and asked 100 people what they thought of the story, 98 or 99 would have had no idea what you are talking about.

    At least for otherwise great communities and organizations, time almost always takes care of the reputation problem.

Finally, I give great kudos to the organization and the community for great transparency and the willingness to address the problem head-on. Go to the Cathedral Village website, right there at the top of the Home Page is this:  

 

You can click on the image above to see their statement and updates. This is the way to handle these things. Don’t think it will never happen to you. Maybe not, but then again maybe so.

They will survive and continue to serve their communities in a caring and compassionate fashion.

A Final Note of Sadness -  I hope this does not sound too weird

I have thought a lot about this young woman, nurse Christann Gainey, just 30 years of age and her life is most likely ruined. It was more than an accident and she needs to pay the appropriate price for her inaction in the first place and attempted cover-up in the second. She likely will end up in prison for some number of years. She almost certainly will never again work as a nurse.

Somehow I suspect she forgot what her profession was all about. It drives me to continue to tell the story of how we change lives and to help organizations tell that story to their teams. It is the single best way to prevent this thing from happening.

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