Another Nurse Prosecuted For The Death of a Patient

Image: Christann Gainey

Christann Gainey. 

LPN. 

39 patients.

Guilty of neglect of a care-dependent person. 

It was recently announced that Gainey, 34 of Philadelphia, pleaded guilty to misdemeanor neglect of a care-dependent person and tampering with records in the 2018 death of Herbert R. McMaster Sr. at the Cathedral Village senior living facility in Philadelphia's Upper Roxborough neighborhood. McMaster Sr. was the father of former Trump national security advisor H.R. McMaster Jr.

According to records, 84-year-old McMaster fell and struck his head in April 2018 in the lobby of the nursing home and died hours later due to a subdural hematoma. Gainey, who was assigned to the facility through a staffing agency, as required by facility medical policy to perform neurological and vital sign checks on McMaster after the fall. 

“When a family selects a senior living facility, they do not expect their loved one to be found dead in the lobby of a place that was supposed to be caring for him,” Attorney General Josh Shapiro said. “This nurse ignored her job responsibilities, falsified paperwork, lied to her supervisors and neglected Mr. McMaster, who died. We’re holding her accountable and today, the court ordered the nurse held for trial on all charges.”

Prosecutors argued that Gainey documented frequent neurological checks; however, camera footage at the nursing home showed that she in fact did not check on the patient at those times and was elsewhere. It’s important to note that while she wasn’t near the deceased at the time - she was with her other patients. 

Gainey was originally charged with felony neglect and involuntary manslaughter but pleaded down. 

“The defendant has now been held accountable for her actions that led to the tragic death of Mr. McMaster,” said Attorney General Shapiro. “We have several active and ongoing investigations into long term care facilities and nursing homes across Pennsylvania, and will hold anyone who knowingly neglects a care-dependent person in Pennsylvania accountable.”

Court records indicate that Gainey was sentenced to six months under house arrest, with another four years of probation. She will also be barred from seeking reinstatement of her license or working in a care facility during that time.

While this case hasn’t made national headlines like RaDonda Vaught, Gainey’s case is just as distressing to the nursing profession. This case took four years to come to a conclusion. Defense attornies repeatedly argued that the nursing home itself was short-staffed, and Gainey was essentially a substitute nurse who was left on her own to care for dozens and dozens of patients overnight.

In fact, Gainey was responsible for 39 patients on the overnight shift. Her team argued that at the time she was supposed to be doing neurologic checks on McMaster she was with other patients. Unfortunately, this did not matter to prosecutors. 

While falsifying records is NEVER acceptable, this nurse felt like she had no other option at the time. Interestingly, records indicate that a report released by the  Pennsylvania Health Department officials also placed blame for the incident on administrators at the facility who investigators said had failed in their essential duties and responsibilities. 

The 141-page report said the last and fatal fall was McMaster Sr.'s fifth during his four-day stay at the facility, where he was admitted for rehabilitation following a stroke.

But why is the facility still open? Why did none of the administrators get fired? Or legally held accountable? Because it was far easier to place the blame on one single person than on an entire system despite what the report indicated. 

Just Culture

The American Nurses Association (ANA) supports the position of Just Culture. According to the 2010 position statement, Just Culture is a “concept that establishes an organization-wide mindset that positively impacts the work environment and work outcomes in several ways. The concept promotes a process where mistakes or errors do not result in automatic punishment, but rather a process to uncover the source of the error.”

The case against Gainey is another prime example of how Just Culture has been tossed aside in favor of securing a guilty verdict. Does McMaster’s death deserve attention? Yes. Should someone be held accountable for his death? Yes, but the entire system needs to be. From the top to the bottom. 

The report from the Pennsylvania Health Department reported that, 

• Staff failed to develop a fall prevention plan even though his medical records indicated it was required
• Failed to complete the required neurological checks after his falls
• Did not attempt to perform CPR to resuscitate McMaster when he was found unresponsive
• The director of nursing and facility administrators failed to provide adequate supervision or implement interventions to prevent accidents and falls

The death of McMaster does not lie solely with Gainey. Did she falsify records? Absolutely. And this is something that no nurse will ever support but as indicated by the report - there were multiple system failures. 

Systems need to change. Nurses can’t be the only ones held accountable. 

Until then, reporting of incidents will continue to decrease as nurses worry about their own future and fate within the profession.