During the two days of Herbert R. McMaster Sr.'s fatal stay at Cathedral Village's nursing home last month, the facility was using seven different temporary nurses, including one who made seven medication errors while being observed by a surveyor, a new Pennsylvania Department of Health report says.
The 108-page licensing report indicates that state health department officials completed their survey of the nursing home on April 12, the day Herbert R. McMaster Sr. fell and hit his head. He died the next morning.
The state health department did not respond to a request for additional information, such as what time the surveyors left the building that day. Such reports are not released to the public until 41 days after the survey is completed.
The Pennsylvania Office of Attorney General on May 10 charged a licensed practical nurse, Christann S. Gainey, 30, with neglect of a care-dependent person, involuntary manslaughter, and tampering with records in the death of McMaster, the father of former national security adviser H.R. McMaster, Jr.
After announcing the charges against Gainey, Attorney General Josh Shapiro brushed off questions about the potential for management's share in the responsibility for McMaster's death and laid the blame squarely on Gainey, who was employed by an outside agency.
"Gainey could have saved Mr. McMaster's life had she simply done her job. Instead, she intentionally ignored her job responsibilities, falsified paperwork, and lied to her supervisors to cover up this inexcusable conduct," Shapiro said at a May 10 news conference.
The report from the licensing survey, however, suggested that Cathedral Village, which is part of a continuing-care retirement community in the Upper Roxborough section of Philadelphia, was not properly managing some agency staff.
Cathedral Village's acting administrator told surveyors on April 10 that seven different agency nurses from three different agencies worked at the facility on April 9 and April 10, but could not prove during the interview with surveyors that management had evaluated the skills of four of the seven outside nurses.
Regulations say that nursing homes must "ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs."
One of the outside workers, a licensed practical nurse, made seven medication errors on the morning of April 10, contributing to the facility's 19.44 percent medication error rate, far above the regulatory limit of 5 percent. The LPN told surveyors that she "never received an orientation" before working at the facility.
"Obviously to me, from a compliance side, the most important thing is, before you let anybody on the floor you have orientation for staff that have not been in your building before, because your processes may be very different than others," said David R. Hoffman, a nursing home consultant and former federal prosecutor, speaking generally.
It's not clear whether Gainey's skills had been evaluated before she worked at Cathedral Village. Gainey's preliminary hearing is scheduled for Thursday morning. Her employer was General Healthcare Resources, of Plymouth Meeting.
The Attorney General's office declined to comment on the health department's findings. "Our focus is on the criminal charges our office filed this month against Ms. Gainey for her role in causing Mr. McMaster's death," said spokesman Joe Grace.
Cathedral Village, which is owned by Presbyterian Senior Living, did not respond to a request for comment on the licensing inspection.
Among the other problems cited in the survey were failures to develop comprehensive care plans for residents, to ensure that residents' desires regarding advanced directives were reflected in physicians' records, and to accommodate residents' preferences for call-bell access and showering.
A resident who requested two showers a week had received just one shower during the 2½ weeks between his admission on March 22 and April 9. The resident told surveyors that "when he asks for a shower that he is provided with a basin of water." The one shower was provided by an occupation therapist aid.
"This is a disturbing survey, although in line with what we have been seeing from this nursing home," said Sam Brooks, a senior lawyer at Community Legal Services of Philadelphia.