Critical Incident

Joseph J. Sabia Jr.

Dr. Alice McDonnell Managerial Decision Making in HAS-537

There are always going to be unforeseen happenings that occur whether it is in your personal or professional life and one must always be prepared to handle these issues head on. Health care administrators are always faced with obstacles that they need to overcome within the facility they work in. I chose to interview Michael Semian, from the Gino Merli Center in Scranton, Pennsylvania. Michael is the Commandant and Head Administrator.
Background
The Gino Merli center is dedicated to providing their patients with compassionate and high quality care to Veterans of Pennsylvania. The home is a State run VA nursing home open to all honorably discharged Veterans and their spouses. All applicants must be a bona fide resident of the Commonwealth of Pennsylvania. The can move from out of state to be eligible as well. The Gino Merli Center is the first VA nursing home in NEPA. It’s located on the same site where the old State Hospital once was. Typically the Commandant of a VA nursing home is a prior Military but it’s not a requirement. Michael is the first Non-Veteran to serve as Commandant but this hasn’t hindered him in anyway and he has the respect and admiration of all residents and staff. The Center provides 196 beds, including 156 for full nursing care and 40 for dementia. The major difference in the types of residency is the level of care: the Personal Care Unit provides food and shelter, medical and nursing care, ancillary therapeutic services, and recreational activities. These residents receive a supervised and protected environment. When needed, assistance is provided for eating, bathing, shaving, and other activities of daily living which do not require constant nursing care. The Nursing Care Unit provides 24-hour care, seven days a week. Residents receive a complete range of clinical services under the direction of physicians and other licensed health care professionals. The Dementia Care Unit provides long-term care in a safe and secure environment. The focus is to provide specialized care tailored to meet the needs of these unique residents in an atmosphere that promotes sensory stimulation. There are 196 rooms, 12 of which are private rooms, and 92 double rooms. Each room has a private TV and a common bathroom. The total square feet of the facility is 123,067 and there are 4 floor. The first floor has one wing dedicated for administration and volunteer services. The south wing on the first floor is for residents. Floors 2 and 3 are dedicated for residents. All floors are approximately 30,000 square feet and the basement is dedicated for maintenance, laundry, housekeeping and food services which approximately 8,000 square feet.
The center opened as the Northeastern Veterans Center in January 1994. Through requests of local veterans’ organizations it was petitioned that the home be renamed after a hero from the local community. It was a long process to vet all the names that were nominated but in July 2002 Governor Mark Schweiker authorized the new name and it was renamed the Gino J. Merli Veterans Center, in honor of the noted World War II hero and Medal of Honor recipient. I cannot think of anyone else the center could have been named after. He was a strong and humble man throughout his life and really didn’t pay much attention to his Medal of Honor status. His citation speaks volumes of the man that he was and became. The follow is his actual Metal of Honor citation:
He was serving as a machine gunner in the vicinity of Sars la Bruyere, Belgium, on the night of 4 September 1944, when his company was attacked by a superior German force. Its position was overrun and he was surrounded when our troops were driven back by overwhelming numbers and firepower. Disregarding the fury of the enemy fire concentrated on him he maintained his position, covering the withdrawal of our riflemen and breaking the force of the enemy pressure. His assistant machine gunner was killed and the position captured; the other 8 members of the section were forced to surrender. Pfc. Merli slumped down beside the dead assistant gunner and feigned death. No sooner had the enemy group withdrawn then he was up and firing in all directions. Once more his position was taken and the captors found 2 apparently lifeless bodies. Throughout the night Pfc. Merli stayed at his weapon. By daybreak the enemy had suffered heavy losses, and as our troops launched an assault, asked for a truce. Our negotiating party, who accepted the German surrender, found Pfc. Merli still at his gun. On the battlefield lay 52 enemy dead, 19 of whom were directly in front of the gun. Pfc. Merli's gallantry and courage, and the losses and confusion that he caused the enemy, contributed materially to our victory.
What isn’t said in the write up is that Gino played dead while German soldiers were seeing if anyone survived the fire fight, when one German soldier was inspecting Gino to see if he was alive or dead he stabbed him twice in the buttock, Gino didn’t move a muscle. The German soldier satisfied he was dead moved on.
The mission of Gino Merli’s center is, “to provide individualized quality care to the Veterans of PA and their spouses. A holistic approach to care guides specially trained staff in care. Preventive and rehabilitative service while encouraging residents’ self-choice, well-being and dignity.” The Gino Merli’s purpose statement “The purpose of QAPI at GMVC is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to identify, solve and prevent problems holistically.”
Michael Semian received his BHSA from Marywood University – (1986-1991).
Before he became an administrator he worked for free to get his thousand hours to sit for the NHA exam. While he was working for free he learned every job in a nursing home which helped shape his leadership style. His first job was as an administrator for the Diocese of Scranton, Little Flower Manner for over 10yrs.
When I asked Michael what his Leadership Style is he answered “I would have to say I follow a management style of Management by walking around and servant leadership. I will do anything in the organization (including taking out the garbage).”
The Administrative Leadership Team:

The Nursing Leadership Team:

Michael stressed numerous times that Gino Merli is dedicated to providing their resident with compassionate and high quality of care. Because of this he has compiled a team of experts who believe in the mission and purpose statement. Each one of the staff has been involved in long term care for a number of years and they have all experienced what long term care brings to both the patients and their families. Gino Merli is constantly running on help from volunteers they provide both direct patient and family assistance. Some of the services include sitting with patients, taking them to activities, handing out mail and organizing all the donations the facility receive. They have a full time volunteer staff of approximately 5 and about 20 people volunteer on a weekly basis. In 2014 the center had 102 volunteers and from January to May they have had 112 volunteers. Their volunteer population keeps growing each year.
Critical Incident
I first asked Michael what his definition of a “critical incident” would be. He answered:
“A critical incident can be defined as anything that can put a resident’s life in danger, an unforeseen happening that causes damage and has the potential to interrupt the care and services provided to resident and/or their families. The incident could specifically occur in a resident’s room, on the floors outside the building or it can be a natural disaster affecting roads and the staff’s ability to reach the residents safely”.
Mr. Smith’s name is fictitious. This is a brief history of Mr. Smith. Mr. Smith had an elopement in the past. He was sitting outside waiting on a family member to take him to church. He got impatient and walked to St Mary’s Church, which was just three blocks from the Gino Merli Center. He was found at the church by staff and family members and when asked why he was there he said “this is where I was signed out to.” He was on 15 minute checks because of this incident. The night of the incident Mr. Smith had a fall and hit his head without trauma. Policy states staff conduct neurological checks every hour for the first three hours and every two hours the next eight hours. Mr. Smith told the nurse after the first check he didn’t want to be checked anymore so the nurse didn’t check him anymore.
On July 18, 2014 at 8:50 PM, Mr. Smith was observed outside of the facility near the front of the main entrance in an employee’s car. The nurses’ aide, who was assigned to this resident, stated that she had seen the resident from an upstairs window and immediately went to the resident to bring him inside the facility. The staff member stated that she knew of the resident's whereabouts all evening up to the time he was observed outside because Mr. Smith was on 15 minute checks. This staff member was responsible for observation of the resident and documenting his whereabouts. The nurses’ aide stated that she had observed the resident at 8:45 PM in the sitting area. At 8:50 PM, the staff noted that she observed the resident sitting in a staff member’s car. A review of video surveillance on July 22, 2014 revealed that on July 18, 2014 at 8:50 PM, Mr. Smith was observed outside of the facility near the front of the main entrance. This staff member was responsible for observation of the resident and documenting his whereabouts. The nurses’ aide stated that she had observed the resident at 8:45 PM in the sitting area. At 8:50 PM the staff noted that she observed the resident sitting in a staff member’s car. Mr. Smith’s whereabouts were unknown for approximately 30 minutes. The nurses’ aide form noted that she knew the whereabouts of Mr. Smith every 15 minutes and documentation was shown that the resident was in sight of the staff member every 15 minutes throughout the day at the time the resident was on the first floor of the facility. It was observed through the surveillance video of Mr. Smith was outside the facility. The video showed that at 8:04 PM on July 18, 2014 the resident was seen walking around the enclosed area outside the facility's multipurpose room. At 8:09 PM the video showed the resident by the gate that was secured with a zip tie. The resident was pushing on the gate to try to open it. The resident then walked over to an unlocked shed (on the facility grounds) and then walked back to the gate with clippers in hand and cut the zip tie that secured the gate closed. At 8:24 PM, the resident walked out of the gate and closed it behind him. At 8:25 PM the resident opened a second gate, which was unsecured, to the ambulance entrance. The next sighting of the resident on the surveillance video was at 8:55 PM. From staff statements to facility staff the resident walked along the street, and entire side of the building, and then turned right onto another street, before he entered the facility parking lot, when security staff observed an older man rummaging through another staff member's car. The security staff member was seen on the video going into the facility to inform facility staff that someone was in a car in the parking lot. Evidence on the video showed the staff member that was scheduled to observe Mr. Smith was not at the scene at 8:50 PM as she had stated. The facility failed to report the resident's elopement in a factual manner. The resident's whereabouts had not been discovered by the facility staff member assigned to observe the resident every 15 minutes but by another employee who was returning to the facility from a break. The event indicated that the Nurse and Nurses’ aide was unaware of Mr. Smith’s whereabouts for 30 minutes, but after viewing the facility's surveillance video, it revealed that the staff was not aware of the resident's whereabouts for nearly an hour. The night of the critical incident, staff was dealing with a Nurse who stole Morphine from a patient and was using the drug on the premises. When Management was notified about the misuse of drugs the local police, AAA and DOH were called. As police and others from the local agencies were going in and out management believed Mr. Smith walked out with the “crowd” and believed he was only in the parking lot for just a few minutes. Once the review of the tapes revealed what really happened, they fired the Nurse’s aide for falsifying official documents and suspended the Nurse for 5 days without pay for not following policy for falls with head injury. The Nurse appealed the suspension and won through collective bargaining and received his 5 days back with pay because it was shown that he would have violated the patients’ rights if he insisted on doing the neurological checks after Mr. Smith refused after the first check. The nurse’s aide was brought back after a year but without pay. The review of policy showed that it was impossible for the Nurse’s aide to perform 15min checks due to patient ratio. It also showed that Management left the shed open allowing Mr. Smith to have access to tools to help in his aid of escaping the grounds and only using a zip tie as means of securing an exit from the facility. New policies that arise from this incident were that if a patient refuses neurological checks nursing shall still put eyes on the resident every hour for the first three hours and every two hours for the next six hours. The front door can only be opened by security unless an emergency arises then they will automatically open. The Ambulance gate is now secured by a magnetic lock so it can only be open by a code. The shed is locked at all times when it’s not in use and all exit doors will be locked at 7:00 pm unless a specific event is happening that staff will be present.
Behavioral Theory The behavioral theory in which I chose to use was Theory X and Theory Y. I applied this to the management style of Michael. According to this theory, individuals who take on the role of “Theory X” are looked at as being lazy and not happy or satisfied with the work they are doing. Because of this, an “authoritarian” style of management is then needed to be used to ensure that the employees are fulfilling their roles and the goals that they are required to meet. In this type of management style, employees are constantly needed to be supervised on a consistent basis. I do not feel that Michael in the least bit possesses this type of management style. The management style that Michael exuberates can best be compared to “Theory Y.” This type of management style proves the management to be ambitious and self-motivated. These managers enjoy what they do on a daily basis and do not look at work as being work but more of them fulfilling the passion that they have. Michael is constantly stressing how much he enjoys what he does on a daily basis and does not wake up every day feeling as if he is going to work but more so that he is going to do what he loves to do – help others. These types of managers accomplish the goals they set out and are committed to their work. In this case, Michael was determined to make sure his patient’s needs were met and that they were safe and because of his drive and passion, he did just that.

Analysis: When I approach my Critical incident I was looking for something juicy and cool to report on because I believed it was what the class wanted to hear. As they say in journalism if it bleeds it leads. I sat down and asked my Head Administrator if he had any critical incidents that would measure up to the hype I was hoping for. He said it’s not about what happened but how well everyone handled the critical incident. It was a profound statement because no matter what happens it’s all about how good or bad your staff is trained to handle the scenario that is before them. Everyone in the class brought all different types of critical incidents and I did learn a lot from each of my classmates. There were a few critical incidents I favored and it made me research them more to further my knowledge on their topic because I didn’t necessarily agree with how either the outcome was or how it was handled and I would have done things a bit different.
The first one was from Bri, I didn’t agree with how Jim, her Administrator caved to DOH, and allowed the resident to have full visitation rights. With the events that happened the previous four months he had enough evidence to challenge any deficiency that DOH would have handed down. To put his staff and residents in harm’s way isn’t doing him due diligence to his facility. I believe because his facility is on a “Special Focus Facility” Initiative that he was scared to make the wrong move for fear of getting more fines or being shut down. I believe after I presented this scenario to DOH when they visited my facility they said if he told DOH he would not amend the visitation restrictions he imposed on the family member the worst scope severity code that they would receive a “D” on F172, which according to the “SFF”, if on their next survey they found no deficiencies in which there was actual harm to any resident, and no deficiency in which there was systemic potential for harm, meaning no deficiency above an “E” level they would of not received any other fines of prolonged “SFF” status. Although I didn’t agree with Jim’s final decision I do like the fact that it made me research and ask question to the right people. In no way am I arm chair quarterbacking his decision I just believe that I would have handled it differently. Natasha’s Incident made all of us think systematically when she presented her incident of a 73 year old male that went in for bowel surgery and ended up brain dead due to the ambu connection disconnecting form the intubation tube. When we went around asking our one question not one of us asked if the equipment was defective until Dr. McDonnell suggested it, her type of out of the box thinking comes with experience. We all jumped on the nurse who accompanied the gentlemen in the elevator and faulting the respiratory therapy for not accompanying them to the recovery room, we focused on human error. We neglected to think out of the box to see if the equipment was to blame and in the end the hospital found that a few of the ambu bags didn’t click onto the intubation tube. When trying to place blame quickly on an employee for being negligent or impaired, a good administrator needs to think outside the box and look at any incident from all angles to make the proper decision. This incident will be in my mind as an example of what to look at first before placing blame on anyone. Madiha’s incident is something that isn’t seen every day. It had domestic violence, international students, college policy, domestic law and their embassy DC. This had to be approached with kid gloves because one wrong decision and it can cause an international incident and possibly two students being sent back to their country, jail time and all sorts of bad press. The way it was handled I believe was flawless, the administration made sure the wife and children were safe and the husband got the help he needed for his addiction to alcohol. If she would have contacted the embassy like I asked, both students would have been sent home. I learned that handling things at the lowest level is the best course of action not only in this incident but with every incident. The one thing that is very evident after listening to everyone’s incident is that you must be prepared for everything. If you get comfortable in your job you’re going to fail as an administrator. Training your staff and running drills is key to having a successful home or hospital. A key training tool that I’m going to take away from this class is running scenario based drills to see how my staff will react. As we in the Military say you fight like you train, most get caught up in the day to day running of a home, business or department and forget that the unthinkable can happen. Every smart administrator will know that training your staff is the backbone to running a successful home. This class, I feel has prepared me to manage people better especially when we studied the different types of behavioral theorist and how to deal with change. Change is always happening and I believe that is a good thing because change makes people not be stagnant and grow. Change is a hard thing for most to handle and we get comfortable in our little box and any interruption in our box makes for disgruntled employees unless you manage the transition of change diligently. A good leader will recognize how change will affect his people and change his management style accordingly. If your leadership style follows Theory Y you may need to change it to Maslow's Hierarchy of Needs to attack the physiological and safety needs of employees to get them to self-actualization and back to a productive employee.

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