How Short-Staffing and Unsafe Patient Ratios Led to the Sentencing of Former Nurse Christann Gainey
On March 28, former nurse Christann Gainey pleaded guilty to misdemeanor neglect of a care-dependent person and tampering with records. The plea is for the 2018 death of 84-year-old Herbert R. McMaster Sr.
The unwitnessed fall occurred at Cathedral Village senior living in Philadelphia's Upper Roxborough neighborhood. McMaster was the father of Trump's former national security advisor.
Although Gainey was responsible for the care of McMaster, short-staffing, high patient-to-nurse ratio, and the lack of administrative support are also to blame. The systems for nurses to provide safe care to patients are flawed and dangerous. As a result, instead of correcting the system, nurses are being tried as criminals.
Portia Wofford is a nurse, writer, and content marketer. Upon hearing the story of Gainey, her initial thought was sadness for the patient. In her opinion, McMaster was placed in an unsafe environment. Then, she felt empathy for the nurse.
Wofford has first-hand experience working as a nurse in long-term care, long-term acute care, and a skilled nursing facility.
"These facilities are dangerously understaffed," Wofford says. "The nurses are held responsible for taking care of the residents while still completing their duties."
McMaster's Passing, Policies, and Sentencing
Here are the events leading up to the unfortunate death of McMaster in 2018:
- On April 9, McMaster was admitted to Cathedral Village's rehabilitation program after suffering a recent stroke.
- On April 12, he was transferred to Cathedral Village senior living facility.
- Around 11:30 p.m., a staff member from the facility found McMaster on the floor in his room. His fall was unwitnessed.
- On April 13, just after 7:00 a.m., McMaster was found dead in his wheelchair in the facility's lobby.
- McMaster died from a subdural hematoma or brain bleed.
According to the 141-page report, his fatal fall wasn't his first. It was McMaster's fifth fall during his four-day stay at the Cathedral Village senior living facility.
According to the Center for Medicare and Medicaid Services (CMS) report, "any resident with the potential for head trauma injury or having an acute change in level of consciousness will receive 72 hours of neurological evaluation, following notification of the physician."
The policy also states that the neurological assessments should be completed as follows:
- Every 15 minutes for the first hour
- Every hour for the next three hours
- Every two hours for the next four hours
- Every four hours for the next 16 hours
- Every eight hours for the next 48 hours
Gainey admitted to falsely documenting neurological checks on McMaster. She missed a total of eight neurological checks. Neurological assessments include:
- Taking vital signs
- Assessing for mental status
- Checking pupils
- Checking motor function
- Checking reflexes
Gainey's sentencing included:
- Six months of house arrest
- Four years of probation
- The inability to reinstate her nursing license or work in a care facility during this time
Gainey was charged with additional counts of felony neglect and involuntary manslaughter. Charges were dropped as part of a plea bargain.
Short-Staffed and Unsafe Nurse-to-Patient Ratios
Long-term care facilities, also known as nursing homes or skilled nursing facilities, are known for having sicker patients. They are a mixture of residents with:
- Behavioral issues
- Psychiatric diagnosis
- Medically complex conditions
- Those receiving therapy
A single nurse can have anywhere from 30-60 patients. It is reported Gainey was caring for 37 patients at one time, including McMaster, on the morning of his passing.
"It's a lot of work for one person," Wofford says. "Throw in an admission or discharge, and you've set the nurse up for failure."
Evidence repeatedly shows low nurse staffing levels lead to:
- Nurse burnout
- Nurses leaving the profession
- Increased job dissatisfaction
Evidence repeatedly shows disproportionate patient-to-nurse ratios result in:
- Poorer monitoring
- Care being neglected
- Decreased quality of care
The impact of disproportionate patient-to-nurse ratios and low staffing has on quality of care and monitoring are clear, as seen in the incident involving McMaster's fall under Gainey's care.
Abandoned by Administration
Similar to the case of RaDonda Vaught, the nursing administration failed to put systems in place to support and protect nurses from legal action. In the case of Gainey, it is reported:
- The director of nursing and the nursing home's administration team were in violation of providing adequate supervision and interventions to prevent falls.
- According to the CMS report, the facility "neglected to monitor and assess a resident for change in condition."
- The 141-page report noted staff neglected to develop a fall prevention plan even though they were required for McMaster.
"The facility and the administration should be accountable and held liable for the unsafe working conditions for their staff and the unsafe living conditions for their residents," Wofford says.
In this case, Wofford suggests administration should have offered one-on-one care by increasing staff.
"Someone should have been assigned to that resident 24 hours per day, and that person should have been extra staff," Wofford says.
Nurses are responsible for protecting their own nursing licenses, but nursing organizations like the American Nurses Association (ANA) believe nurses should not automatically be punished after a medical error.
In 2010, the ANA put out a position statement supporting Just Culture. Just Culture is a concept where mistakes and errors made by nurses should not be an automatic punishment but a way to evaluate what caused the error.
In the case of Gainey, she was found guilty, sentenced, and stripped of her nursing license, while the facility was only issued a fine for the death of McMaster.
Creating a Culture of Safety
Especially now, after the COVID-19 pandemic where nurses are leaving the profession in droves, nurses are working short-staffed every day. How can nurses create a culture of safety for their patients while feeling they too are protected?
Prevention is key, says Wofford. She advises getting involved in the care plans for your residents.
"If something is unsafe, then speak to the administration about it," Wofford says. "If administration is not acting, I've gone as far as calling the provider and the family to let them know what is going on."
If a resident has an unwitnessed fall or hits their head, think of safety. Send them out to be evaluated. If you know you don't have the adequate time or resources to care for a resident after an incident, advocate for the resident and yourself.
"This is your license," Wofford says. "I'd rather face the consequences from my facility than the [board of nursing] or a courtroom."
4 Ways to Create a Culture of Safety
Hospital administrators need to be more transparent when systems aren't working and errors occur. They must treat it as a way to improve patient quality while supporting their staff. This transparency should also be extended to the caregivers and family members of the patients.
Demand Safer Staffing
The former governor of New York, Andrew Cuomo, made it a law that hospitals and nursing homes must have safe staffing. A clinical staffing committee will create guidelines and submit them to the Department of Health by July 1 each year. Since 2004, California has mandated staffing ratios. Other states should follow.
"Involve staff in decision-making," Wofford says. "Involve one staff member for each role in care plan meetings and quality assurance performance improvement meetings." This involves staff members in the decision-making process and empowers them to speak up if system errors occur.
Civil Court vs. Criminal Court
When appropriate, nurses should be tried in civil court, not in criminal court. When tried in civil court, nurses will not face such a heavy burden of responsibility compared to facilities when it comes to medical errors. Civil cases are not about breaking a criminal law.
If a nurse is tried in civil court, they will be charged but not sent to jail. This would improve the culture of nursing by sending a message to nurses and administration that they do indeed support Just Culture.
Meet Our Contributor
Portia Wofford is an award-winning nurse, writer, and content marketer. She dedicated over a decade of her nursing career to creating solutions, programs, and education for her employees. Wofford owns and operates a health and nursing content marketing agency, The Write Nurse. She's also the cofounder of the Healthcare Influencer Network, where they empower brands to promote health equity, diversity, and increased access to care through social media.
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