Reference no: EM133543381

Tim Wagner worked as a physical therapy assistant (PTA) for 17 years and for a year tried the position of director of sales and marketing at a 120-bed skilled nursing facility (SNF). While holding a full-time PTA position, Tim also enrolled at a local university and completed a bachelor's degree in health services management. Upon graduation, Tim accepted the position of clinical liaison for special projects with Lippert Healthcare Inc., a privately owned multifacility chain that operated 10 skilled care facilities. Tim's main responsibilities included assisting the 10 nursing homes with recruitment of therapy staff; development of therapy staff; optimizing utilization of therapy services to maximize revenues, clinical outcomes, and staff productivity; and assisting in the development of programs such as fall prevention, restorative care, and wound care. The nursing home corporation also used Tim as interim rehab manager whenever a need arose in one of the chain's facilities. Tim used his clinical background to his advantage and applied what he learned in his health services management program. He performed exceptionally well in this position. However, his main ambition after graduating with a bachelor's degree was to become a nursing home administrator (NHA). His goal was realized when Lippert Healthcare appointed Tim to be the administrator of Cloverleaf Nursing Center, a 90-bed SNF located in a small town of approximately 33,000. Lippert's corporate officers told Tim, "Because you want to be an administrator, we will put you at Cloverleaf. The management staff here is stable. It will be a place where you can learn and grow."

Previous Administrators

Joe Atkins

At Cloverleaf, Tim replaced Joe Atkins, who had managed the facility for approximately a year and a half. The vacancy at Cloverleaf was created when Joe was transferred within the chain to manage another nursing home that needed an experienced administrator. During the interim period of 2 months after Joe was moved to another city and Tim came to Cloverleaf, the director of nursing (DON), Claudia Moore, functioned as the interim administrator. Claudia had been employed at Cloverleaf for 9 years. She had been the DON for a year and a half, and was a charge nurse for more than 7 years before that. She had no desire to become a licensed NHA.

Joe was in his mid-40s. He had a master of science degree in community health nursing, had been a DON, and had 5 years of experience as NHA. Although Joe was regarded as a people-oriented person, he would become confrontational if he disagreed with a subordinate and would assign personal blame when something did not go well. From time to time, he would have mood swings. As one department manager described it, "One day he would be all happy and everything would go well; the next day he would be chewing people out." At times, he would burst out, "I say you finish this, and you will do it now." Apart from periodic episodes like these, Joe had given a free rein to most of his department managers, but he also favored some managers over others. He had formed an "inner circle" of his favorite managers that included the DON, the dietary manager, the human resource director (who worked 3 days a week), and the maintenance man. Not part of this inner circle were the business office manager, the social worker, the activity director, and the rehabilitation manager (who worked part-time). People in the inner circle generally assembled for lunch in the DON's office, would go out to eat together, or go for a drink or two after work; on some occasions, they would be invited to Joe's home for some partying.

Margaret Bond

Before Joe, Cloverleaf's administrator was an older female, Margaret Bond. She had managed this facility for a number of years. Ms. Bond had a passive personality. She spent most of her time in her office and was not seen much out on the floors.

Before coming to Cloverleaf, Ms. Bond was the administrator of a 35-bed facility, where she had fostered a family-like working environment with her staff. This facility closed down, and she was hired as the administrator at Cloverleaf. She brought with her the business office manager, the DON, and the facilities manager who was in charge of all plant and environmental services. Those who had worked with Ms. Bond described her as "motherly" and "cliquish." The assistant director of nursing (ADON) sometimes felt that the DON received preferential treatment from Ms. Bond for things such as requests for time off. The facilities manager would spend an inordinate amount of time in Ms. Bond's office while the work often did not get done. Ms. Bond had a pet name for the facilities manager, but other staff sometimes felt demeaned by her.

One day Ms. Bond sustained a broken hip in the nursing home. She took a long leave of absence and subsequently went on permanent disability leave. During her absence, Lippert's corporate officers visited the facility after a negative annual inspection by the state's Department of Health, and they terminated the DON and the facilities manager for unsatisfactory performance. This is when Joe Atkins was brought in as the administrator.

The Upset DON

Thirty-one-year-old Tim obtained his NHA license and was so glad to have gotten a foot in the door at this 90-bed facility. But shortly after settling into his new position, Tim felt as if there was a tug-of-war between him and Claudia Moore, the DON. Tim thought that this situation was prompted by some recent incidents.

Ruffie Jacob

A patient, Ruffie Jacob, was admitted from the local hospital at around 6 p.m. on a Thursday. The hospital's policy did not allow them to send medications with a discharged patient. Intravenous Vancomycin (prescribed for severe infections) to be administered twice daily was one medication the patient was on. Cloverleaf had a contract with a local pharmacy, but the pharmacy did not have IV Vancomycin in stock. The patient had to miss a dose Thursday night. Tim learned about it the next morning and found that even at that time the medication had not arrived. Tim became concerned and went to check with Claudia, who responded, "I have got it under control, don't worry about it. I am dealing with the pharmacy." That afternoon Tim felt that he had to transfer the patient back to the hospital, but Claudia overruled his decision. The medication came in at around 5 p.m. on Friday. On Sunday, the patient expired. Tim was very uncomfortable that it could become a potential legal issue. He informed the corporate officers, including the legal officer, who advised Tim to contact the medical director and explain the circumstances. On Monday morning, the medical director asked Claudia about the incident. After her meeting with the medical director, Claudia approached Tim and said, "Why did you make such a big deal of it? I had it under control." Tim explained that he had to inform the corporate officers about the potential liability, and the corporate officers had asked him to contact the medical director.

The Supply Clerk

Nancy was both the central supply clerk and the van driver for Cloverleaf. She filled out a request for a day off and presented it to Tim in person. Tim granted her the time off. The day Nancy was off, Claudia approached Tim and asked, "Where is Nancy?" Tim explained that since Nancy reported to him, he had granted her request for a day off. Claudia was not pleased, and asked, "Why are you doing this to me? Nancy is my employee."

The Night Rounds

Tim realized that it was important for him to make rounds of the facility unannounced on some weekends and nights. Once he dropped in at 2:00 a.m. for a surprise visit. Claudia told Tim the following day that a CNA, whom she did not name, felt that people were not being trusted, and that the CNA was going to turn in her resignation. "Why don't you trust us? Why do you have to check up on us?" Claudia demanded. Tim replied, "It is not a question of trust. I just need to get to know the operations and the night people." The next time Tim came in during the night shift, he told the staff, "I am not here to check up on you. I am just here to check the building."

The PPS Meeting

Responsibilities in the nursing department were shared by three managerial personnel: the DON, the ADON, and the resident assessment coordinator. Corporate policy required the facility to have a daily PPS (prospective payment system) meeting in the morning. The meeting was meant to serve several purposes: review the clinical condition of patients; agree on the resource utilization group (RUG) categories; and share information on clinical progress, therapies, and discharge planning. During this period, the facility was in the process of filling the resident assessment coordinator's position. In the interim, Claudia was handling the minimum data set (MDS). She had a lot of catching up to do. Tim was concerned about the annual survey, which could take place any day. He was not sure whether Claudia had a firm grip on keeping the assessments and care plans current. In the PPS meetings, Tim noticed that information was often missing. Tim thought that Claudia was perhaps overwhelmed with the increased workload. Tim had also observed that certain clinical systems were getting neglected. So, one day Tim decided to take over the PPS meetings. He thought he could help relieve some of the pressures Claudia was experiencing. Claudia, however, was not pleased. She approached Tim and asked him, "Am I not doing my job here? Am I not meeting your expectations?"

Assignment

1. Using the leadership models described in Chapter 14, describe the leadership styles of Joe Atkins, Margaret Bond, and Tim Wagner.

2. Was it appropriate for Tim Wagner to intervene in the situation concerning Ruffie Jacob? Explain why or why not.

3. Did the DON have Mr. Jacob's situation under control? What should have been done?

4. Was it appropriate for Tim to grant Nancy the day off? Explain why or why not.

5. Should a nursing home administrator visit the facility on weekends and nights? How should such visits be approached?

6. Was it appropriate for Tim to take over the PPS meetings? Explain why or why not.

7. Why do you think the tug-of-war existed? How should Tim manage the conflict he has with the DON?