Preview
FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022
EXH IBIT B
FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019
NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022
File No. 115311-0 1
SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF ROCKLAND
----------------------------------------------------------------X Index No. 0 330 87/ 20 19
MARION FAYO, Deceased, by an d through, Hon. Rolf M. Thorsen
KATHLEEN FAYO, as Adm inistrator of the
Estate of MARION FAYO
AFFID AVIT IN
Plaintiff, SU PPORT OF
JOELLE C. MARGREY,
-against- D N P, MSN , CN L,
RN , CLN C
NORTHERN RIVERVIEW HEALTH CARE
CENTER, INC.,
Defendant.
----------------------------------------------------------------X
STATE OF NEW YORK }
} SS:
COUNTY OF ONONDAGA }
J OELLE C. MARGREY, D N P, MSN , CN L, RN , CLN C, a licen sed Registered
Nurse in the State of New York, being duly sworn and deposed, states and affirm s the
following under the penalty of perjury:
1. I am currently the Vice President of Skilled Nursing Operations at
Loretto Health & Rehabilitation in Syracuse, New York, where I have direct oversight
over 719 skilled nursing beds and 20 4 sub-acute nursing beds in m ultiple facilities
located across two counties in Central New York. I was previously the Director of
Nursing at Loretto, where I was directly responsible for the operation of the facility’s
nursing departm ent com prised of 8 0 0 em ployees who cared for 583 residents daily.
My experience an d educational background are set forth in m y Curriculum Vitae,
which is attached as Exhibit 1.
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2. I am very fam iliar with federal an d state regulations and associated
guidelines for the operation, care, and services provided in various Nursing/ Medical
settings, including Nursing Hom es and Skilled Nursing facilities. I also have extensive
knowledge of the standards of care applicable to facilities such as Northern Riverview.
3. I have reviewed Marion Fayo’s records from her residence at Northern
Riverview Health Care Center, including Care Plans, Clinical Assessm ents, Clinical
Monitoring, CNA Accountability Records, Diagnostics an d Labs, Min im um Data Sets,
Nutrition Evaluation and Docum entation, Physician Orders, Progress Notes, Risk
Assessm ents, Therapy Records, Medication Adm inistration Records, and Treatm ent
Adm inistration Records. I have also reviewed Ms. Fayo’s records of care at Orange
Regional Medical Center.
4. Based upon m y records review an d the facts of this m atter, it is clear that
the care, skill, and/ or knowledge exercised or exhibited in the treatm ent, practice, or
work perform ed by Northern Riverview’s staff in its care and treatm ent of Ms. Fayo fell
outside of acceptable professional standards or treatm ent practices. It is equally clear
that Northern Riverview violated Ms. Fayo’s rights as a nursing hom e resident under
state and federal regulations.
5. Ms. Fayo was 63 years old when she was adm itted to Northern
Riverview on Decem ber 22, 20 16 following an inpatient hospitalization. H er
adm itting diagn oses included cardiom yopathy, hyperten sion, Type 2 Diabetes,
COPD, vitam in D deficien cy, hyperlipidem ia, dem entia without behavioral
disturbance, acute ischem ic heart disease, m uscle weakn ess, unsteady on feet, and a
history of falls.
6. Upon adm ission, Ms. Fayo was assessed as requirin g supervision assist
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of one staff for transfers, assist of on e staff for am bulation, assist of one staff for
bathing, som e assistance for hygiene and toilet transfers, independent for feedin g,
and was in continent of bowel an d bladder. Ms. Fayo was approxim ately 65 in ches
tall, weighed 151.2 pounds, and had a BMI of 25.95. She was also free of infection ;
that is, she did n ot have either urin ary tract infection or sepsis. She was placed on a
diet of regular, thin liquids, consistent carbohydrate, an d n o added salt.
7. Ms. Fayo was also assessed as having severe cogn itive im pairm ent.
Non-com pliant behavior was not am ong Ms. Fayo’s diagnoses, however. In fact, the
adm ission assessm en t reflected that she was alert and respon sive with periods of
confusion, did n ot have an y m ood or behavior con cern s such as resistive/ refusal of
care, and appeared happy to be at the facility. But on Decem ber 29, 20 16, it was
docum ented that Ms. Fayo was hitting, had poor self-care, was un cooperative,
displayed self-isolation, was sad and irritable, had a decreased appetite and weight
loss, and lacked interest in activities.
8. On J anuary 5, 20 17, Ms. Fayo was transferred to Orange Regional Medical
Center due to decreased intake and vom iting; she was returned to the nursing hom e that
sam e day. By J anuary 12, 20 17, she was showing signs of dehydration and kidney
failure as she still had decreased intake and vom iting, and she had lost m ore than 16
pounds since her adm ission. There is a physician order to obtain a urine culture and to
catheterize if needed, but this was only attem pted one tim e. At her fam ily’s insistence,
Ms. Fayo was transferred to Orange Regional Medical Center on J anuary 15, 20 17 where
she was diagnosed with sepsis and dehydration, am ong other conditions.
9. It is m y professional opinion, within a reasonable degree of nursing
certainty, that the care and treatm ent rendered by Northern Riverview fell below
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m inim um acceptable standards of care, were in violation of the nursing hom e residents’
rights of care and treatm ent, and m ay also constitute abuse, neglect, and m istreatm ent.
Below is a sum m ary of events that supports this conclusion. I have categorized this
sum m ary with sub-headings.
a. Docum entation:
• On 12/ 29/ 16, an Interdisciplinary Behavior/ Psych Assessm ent
indicated that the patient was hitting, had poor self-care, was
uncooperative, displayed self-isolation, was sad and irritable,
had a decreased appetite and weight loss, and lacked interest in
activities. This assessm ent w as com pleted by an LPN , w hich is
out of the scope of practice for licensure.
• The plan of care im plem ented by the LPN indicated they would
encourage, refer to unit activities, and offer alternate m eals, all
of which the patient refused. There is no further docum entation
to indicate the interventions that w ere put in place to assist
w ith the behaviors and refusals, let alone an explanation as to
w hy Ms. Fay o w as refusing care or m eals.
• On 1/ 5/ 17, the patient was sent to the hospital at 1720 due to
vom iting and decreased intake. Upon return on 1/ 5/ 17, there is
no RN assessm ent of the patient or any docum entation of the
course of treatm ent in the hospital.
• On 1/ 13/ 17, an Interdisciplinary Behavior/ Psych Assessm ent
indicates the sam e behaviors as the assessm ent on 12/ 19/ 16 and
is com pleted by an LPN .
• There are m any entries in the m edical record that the patient
refused supplem ents and m edications, but there is no indication
that the m edical providers were m ade aware. This is a N YSDOH
regulation and best practice as a review of phy sician orders,
w ith consistent refusals, is indicated for changes in the
treatm ent regim en. There are also no interventions indicated
for a change in the plan of care due to the refusals or alternate
attem pts by the staff except an occasional re-approach.
• There are m any notes throughout the m edical record that
indicate the patient required skilled needs as she was presently
being treated for an infection. There w as no indication that the
patient had an infection, how ever, or that there w as a
phy sician order for antibiotics.
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b. Failure to Institute Tim ely Nursing Interventions:
• There is very lim ited docum entation throughout the record by
RNs or indications that an RN was notified in situations that
would constitute an RN assessm ent per best practice standards.
Som e exam ples include refusals of m edications 12/ 23/ 16,
12/ 26/ 16, 1/ 2/ 17, 1/ 3/ 17, 1/ 8/ 17 and 1/ 9/ 17. On 1/ 2/ 17, a note
by an LPN indicates the patient had vom iting and was placed on
a clear liquid diet; a 1/ 5/ 17 a note by an LPN indicates
hydralazine was held due to a low blood pressure; and on 1/ 5/ 17
a note by an LPN indicates the patient was sent to the hospital
due to vom iting and decreased intake. Any of these instances
would have indicated the need for an assessm ent by an RN. It
appears throughout the record that the LPN s w ere com pleting
assessm ents and m aking decisions that w ere out of their scope
of practice.
• On 1/ 12/ 17 there is a physician order to obtain a urine culture
and to straight catheterize if needed. The docum entation
reflects this w as attem pted one tim e, and there is no further
docum entation about attem pts or a discontinuation of the
phy sician order.
c. Physician Services
• On 1/ 15/ 17 at 1323 a n ote indicates the fam ily is upset with the
care. The NP is called to the room and the fam ily is told they
were going to initiate intravenous fluids, the fam ily declined an d
requested hospitalization. There is no docum entation in the
record that there w as a discussion of initiating intravenous
fluids or rationale for such prior to the fam ily reporting they
w ere upset w ith the care.
• The patient was adm itted with a diagnosis of diabetes, and
laboratory values in the m edical record dated 10 / 24/ 16 (prior to
adm ission) and signed 12/ 27 / 16 by the physician in the STR
facility indicate that the patient’s glucose level was 10 1 (norm al
range 65-99) and the HgAlC was 1.46 (normal range 0 .50 -1.30 ).
There w ere no phy sician orders to m onitor the blood glucose
levels. There is a notation in the LPN progress notes of a blood
glucose level of 166 on 12/ 22/ 16 at 2155. There is no follow up
indicated and no indication that the MD w as m ade aw are.
Furtherm ore, this blood glucose reading of 166 taken on
12/ 22/ 16 at 2155 is carried through on m any of the progress
notes. This indicates the sam e blood glucose reading w as used
on an ongoing basis and there w as no regard to the signs and
sy m ptom s that the patient w as having and the likelihood that
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untreated diabetes w as contributing. The research indicates
that signs and sy m ptom s of uncontrolled diabetes include
w eight loss, infections, kidney problem s, and confusion.
d. Care Plans
• The inconsistencies listed below in the care plans were not
docum ented as initiated and, if they had been initiated, the
patient m ay have had an im proved transition to the facility and
an im proved quality of life. Per NYSDOH regulations, any
interventions noted on the care plan are to be im plem ented, but
there is no docum entation of this. The care plans are not
updated with treatm en t orders, m edication changes, changes in
condition or hospitalization, and are not person centered per
NYSDOH regulations.
• The behavior care plan indicates that an attem pt will be m ade to
identify patterns of behaviors to target interventions. There is
no indication in the record that this w as com pleted, and this
care plan w as initiated on 1/ 28/ 17 after the patient had been
discharged to the hospital.
• The noncom pliance care plan in dicates that the patient refuses
m edications, food, labs, and diagnostics, and the plan of care is
to recognize the right to refuse treatm ent and accept choices
without judgem ent. There is no indication of other
interventions trialed for the patient’s refusals or assessm ents as
to the reason w hy the patient refused. Essentially , the plan of
care is to allow her to refuse, even though it w as detrim ental to
her health outcom e and quality of life.
e. Activities of Daily Living (ADL) Docum entation
• There are om issions in the following docum entation, concluding
that the care was not provided: Am bulation; Bathing; Bed
m obility; Bladder/ Bowel Incontinence; Bowel Movem ents;
Dressing; Pain Checks every shift; Hygiene; Skin Observation;
Transfers; Dining/ Intake by m outh – food; Dining/ Intake by
m outh – fluids.
f. Nutrition
• On 12/ 27/ 16, a progress note by an RD indicates that the patient
had an 8 .3-pound weight loss in 5 days an d is on furosem ide,
intake was 50 -75% and Hi-Cal 60 cc four tim es a day will be
added. There is no indication in the nursing assessm ent that
the patient had edem a present on adm ission to indicate such a
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w eight loss in 5 day s.
• On 1/ 2/ 17, there is a progress note in dicating that a care plan
m eeting was held with the patient’s sister, at which tim e they
discussed decreased in take and weight loss. They discussed
high interest foods and added ½ sandwich, offering snacks and
would discuss with the MD to liberalize diet. The Hi-Cal and
HCS supplem ent was discontinued due to refusal. There is no
indication in the docum entation that it w as discussed w ith the
MD to liberalize diet and there is no MD order for such. There
is no further docum entation of snacks that w ere trialed and
offered to the patient to increase intake. Since adm ission, the
patient had decreased intake and had continual w eight loss,
totaling 16.6 pounds in approxim ately 5 w eeks, and the
docum entation reflects the only attem pts to increase intake
included Hi-Cal and HCS supplem ents and offering a ½
sandw ich.
g. Medication Adm inistration Records (MARs) and Treatm ent
Adm inistration Records (TARs)
• There are m any om issions on the MARs/ TARs, and there is no
docum entation as to the reason why or that the resident refused.
The patient was sent to the hospital on 1/ 5/ 17 at 1720 and was
returned to the facility on 1/ 5/ 17. The records do not indicate
that on 1/ 5/ 17 the patient's m edications and treatm ents were
not given as she was in the hospital, nor does it reflect that the
MD was notified upon hospital return as to adm inistering the
m issed m edications or withholding them . Exam ples include:
• 12/ 20 16 - Donepezil 5m g at HS on 12/ 22/ 16, Lipitor 20 m g at
HS on 12/ 22/ 16, Check ID qs for DNR (11-7 shift) on
12/ 22/ 16, Pain scale qs (11-7 shift) on 12/ 22/ 16, HCal 120 cc
QID on 12/ 27/ 16 at 170 0 and 210 0 , and on 12/ 28/ 16 at 0 90 0
and 130 0 , antifungal to perineal on 12/ 25/ 16 at 0 90 0 , an d
siderails for bed m obility (11-7 shift) on 12/ 22/ 16 and
12/ 27/ 16.
• 1/ 20 17- Carvedilol 25m g at 170 0 on 1/ 5/ 17, Colace 10 0 m g at
170 0 on 1/ 10 / 17, Check ID bracelet for DNR on 1/ 5/ 17 (3-11
shift), Vital signs on 1/ 2/ 17 (11-7 shift), Vital signs on 1/ 3/ 17
(7-3 shift), Vital signs on 1/ 5/ 17 (3-11 shift), Antifungal to
sacrum / peri-area on 1/ 5/ 17 at 170 0 blank.
h. Minim um Data Sets (MDS)
• On 12/ 29/ 16, the adm ission MDS was com pleted and indicated
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that the BIMS was 99; therefore, unable to com plete an
assessm ent of cognition. Throughout the record, the patient is
noted to be alert and oriented w ith periods of confusion. W as
the patient re-approached to com plete this assessm ent, w hich
w ould have assisted in form ulating the plan of care for the
patient and triggered pertinent care area assessm ents (CAAs)
on the MDS.
10 . Ms. Fayo was showing signs of dehydration and kidney failure due to
septicem ia from an untreated infection on J anuary 15, 20 17. As discussed above, she
had decreased intake, vom iting, and weight loss without appropriate interventions/ care
plan m odifications for com pliance per NYSDOH regulations. She was adm itted to
Orange Regional Medical Center on J anuary 15, 20 17 as septic, with a rectal
tem perature of 10 0 .6, and a urine sam ple that was thick, yellow and brown. The urine
culture showed a turbid appearance and revealed m oderate bacteria, which are
indications of a positive result, and she was given an antibiotic. She was also
dehydrated, as eviden ced by the Basic Metabolic Panel findings of Sodium level of 133
(related to kidney failure), BUN level of 56 (indicates kidney failure due to dehydration),
and Creatinin e level of 2.97 (indicates im paired kidney function due to dehydration,
vom iting). Had the nursing hom e obtained the urine culture as ordered on 1/ 12/ 17
and/ or follow ed up w ith the MD if they w ere unable to obtain it, Ms. Fay o’s outcom e
w ould not have been a negative one.
11. Furtherm ore, even though Ms. Fayo had a history of noncom pliance with
eating, taking m edications, and not allowing laboratory and diagnostics to be
com pleted, the noncom pliance m ay have im proved if the nursing hom e had evaluated
the reasons for such and attem pted alternative interventions. The care plans were not
person-centered as NYSDOH requires and reflect only generic interventions such as
accept choices without judgem ent, encourage the fam ily to support, and re-offer, which
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clearly did not work. Im plem enting a non-com pliance care plan does not relieve the
facility from the requirem ents to continually trial and care plan alternate interventions
to prevent weight loss and dehydration. I would also question whether Ms. Fayo was
truly being non-com pliant or whether she was having a worsening of her dem entia
which would lead to a reduction in intake. Either way, the facility should have
continually trialed and docum ented alternative m easures.
12. Alternative interventions that could have been attem pted include but are
not lim ited to: super potatoes, super pudding, high calorie ice cream , sm all frequent
m eals, an d finger foods; trial of an appetite stim ulant; evaluation of past history of
eating routines and favorite foods; discussion of insertion of a gastronom y tube;
evaluation of m edications to determ ine whether any were contributing to a reduction in
intake (som e m edications contribute to a reduction in appetite, and som e contribute to a
reduction in appetite because they leave a m etallic taste in the m outh); and assess for
dehydration, which can suppress appetite.
13. The nursing hom e should also have evaluated Ms. Fayo to determ ine
whether she had an untreated depression, given the change in physical status and
environm ent in which she was residing. As n oted in Paragraph 7 above, Ms. Fayo did
not have an y m ood or behavior con cerns upon her adm ission but, within one week,
she was hitting, had poor self-care, was uncooperative, displayed self-isolation, was
sad and irritable, had a decreased appetite and weight loss, and lacked interest in
activities. These changes can correlate to depression.
14. There is also no m erit to the claim that Ms. Fayo’s fam ily was hin dering
the nursing hom e’s efforts by bringing in food that she was not supposed to have. Ms.
Fayo was not eating, and her fam ily was sim ply trying to provide her with nourishm ent.
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The fact that Ms. Fayo’s diet consisted of no added salt did not change the fact that she
was not taking in enough to sustain her needs. It also did not lead to the hospital
adm ission and diagnosis of urinary tract, infection, dehydration, acute kidney failure,
and sepsis.
15. In m y opinion, within a reason able degree of nursing certainty, Ms. Fayo
did not receive adequate and appropriate healthcare services, preventative care, or care
within best practice standards at Northern Riverview. It is also m y opinion, within a
reasonable degree of n ursing certainty, that Northern Riverview violated Ms. Fayo’s
right to adequate an d appropriate m edical an d nursing care as m andated by state an d
federal law. These failures include:
• Failu re to tre at an d care fo r th e p atie n t w ith e vid e n ce -bas e d
p ractice an d w ith in be s t p ractice gu id e lin e s (10 NYCRR §§
415.3, 415.5, 415.11, 415.12, 415.26, 415.27; 42 CFR §§ 483.10 , 483.25,
483.34, 483.70 )
• Failu re to accu rate ly d o cu m e n t an d m o n ito r th e p atie n t’s
n u tritio n al s tatu s (10 NYCRR §§ 415.5, 415.11, 415.12, 415.14; 42
CFR §§ 483.10 , 483.25)
• Failu re to e n s u re th at p atie n t as s e s s m e n ts w e re co m p le te d
by an in d ivid u a l lice n s e d to do s o , i.e .,
n o t allo w in g an LPN to
p ractice o u ts id e th e s co p e o f N YS lice n s u re (10 NYCRR §§
483.35, 483.70 ; 42 CFR §§ 415.3, 415.11, 415.12, 415.13, 415.26, 415.27)
• Failu re to re ce ive ad e qu ate an d ap p ro p riate h e alth care ,
re s u ltin g in actu a l h a rm (10 NYCRR §§ 415.3, 415.5, 415.11, 415.12,
415.15, 415.26, 415.27; 42 CFR §§ 483.10 , 483.25, 483.34)
• Failu re to fo llo w acce p te d s tan d ard s and p ractice s re late d to
care an d tre atm e n t (10 NYCRR §§ 415.5, 415.11, 415.12, 415.26,
415.27; 42 CFR §§ 483.25. 483.34)
• Failu re to tim e ly e valu a te fo r th e p o te n tial o f an in fe ctio u s
p ro ce s s , i.e ., u rin a ry tract in fe ctio n (10 NYCRR §§ 415.3, 415.11,
415.15; 42 CFR §§ 483.10 , 483.25, 483.80 )
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" Failure to plan and implement necessary care and services to
attain or maintain the patient's highest practicable physical,
mental, and psychosocial well-being (10 NYCRR §§ 415·3, 415.5,
415.11, 415.12, 415.14, 415.15, 415.26, 415.27; 42 CFR §§ 483.10,
483.20, 483.25, 483.34)
" Failure to and appropriately implement a plan of
adequately
care, specific to the patient and within accepted standards of
practice, resulting in actual harm (10 NYCRR §§ 415.3, 415·4,
415·5, 415.11, 415.12, 415.26, 415.27; 42 CFR §§ 483.10, 483.12, 483.20,
483.25, 483·34)
" Failure to follow on the patient's change in
timely up
condition, resulting in actual harm (10 NYCRR §§ 415-3, 415-5,
415.11, 415.12; 42 CFR §§ 483.10, 483.25, 483-34)
" Failure to implement adequate interventions for the patient's
physical decline, resulting in actual harm (10 NYCRR §§ 415.3,
415.4, 415-5, 415.11, 415.12, 415-15; 42 CFR §§ 483.10, 483.12, 483.20,
483.25)
I HEREBY CERTIFY that the foregoing statements made by me are true and
accurate, to a reasonable degree of nursing certainty.
Dated:
J LLE C. G , DNP, SN, C ,
, CLNC
BEFORE ME, the undersigned authority, personally appeared JOELLE C. MARGREY,
DNP, MSN, CNL, RN, CLNC, who has produced identification and who after being fully
sworn deposes and says that she executed the foregoing AFFIDAVIT and that said FACTS IN
THE AFFIDAVIT are true and correct to the best ofher knowl and belief.
WITNESS my hand and seal this /
day of A , . 2022.
d Notary ub Stat f New York
a me: or\
&tÅ
B G My commission expires on: ( GT
NE
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EXH IBIT 1
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Dr.Joelle C Margrey, DNP, MSN, CNL, RN, CLNC
7637 Commander Circle Liverpool, NY 13090
315-591-7880
jmargrey@verizon.net
" Mentors staff at alllevels, sharing ideas, work and lessons-learned to improve processes, care and
efficiency and obtain success and higher levels of service to include oversight of complex care
programing.
" Builds and maintains relationships with the union workforce and builds a positive labor/management
relationship focusing specifically on clinical outcomes.
" Reviews, develops and assists in the implementation of consistent policies and procedures that will
address individual site needs, meet regulatory requirements, provision evidence-based practices and
support initiatives.
" Leads the change to ensure technology and data management play a key role in operational efficiency
at meeting clinicalexpectations; accountable for clinicaltrending factors in ensuring resident care is
maintained at the highest level.
" Ensures the certification program for CNAs meets the highest standards of excellence.
" Leads using a Person First Care Model in Nursing Services while optimizing family satisfaction.
" Serves as a member of the Senior Leadership Team.
" Advocates forthe Loretto Mission, Vision and Values as a basis for success as itrelates to allfacets of
the leadership aspect of the position.
3/2017 - 12/2021
Vice President of Skilled Nursing Operations
" Serves as key member of Loretto's Senior Leadership Team charged with setting the organization's
strategic direction and mission.
" Direct oversight and budget development/implementation of 719 skilled beds and 204 sub-
nursing
acute nursing beds located across two counties which employ over 1500 individuals and has annual
revenue in excess $115 million.
" Position entails leading the operational and clinicalteams which include licensed administrators,
physicians, nurse practitioners, nursing directors and support service department managers in
achieving operational excellence, exceptional quality of care outcomes while maintaining census,
balancing payer mix, reducing expenses and increasing employee retention rates.
" Proven track record of leading teams in achieving regulatory compliance and improving DOH survey,
CMI, and quality reporting results.
" Developed and successfully implemented the following projects in the past 12 months:
o Board National Speaker - presentation on implementation of telehealth
Advisory services,
reduction in hospitalizations and enhanced revenue.
o Secured a grant for an 8-bed palliative care unit.
o Implementation of a NYSDOH approved 144 bed, negative pressure COVID-19 building and
policies and procedures to meet regulatory guidelines and best practices for patient and
employee safety. Initiative included partnerships with local and surrounding hospitals for
decantation plan to reduce Covid positive patients.
2
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Dr. Joelle C Margrey, DNP, MSN, CNL, RN, CLNC
7637 Commander Circle Liverpool, NY 13090
315-591-7880
jmargrey@verizon.net
o Successful implementation of Covid vaccine clinics.
o In partnership with ImagineMIC, telehealth services were instituted within the facilitiesand
patients were set up with equipment and 24/7 telehealth services.
o Led initiative to reduce avoidable hospitalizations by seventy percent with the use of
ImagineMIC, care pathways and the use of the sub-acute care unit
o In partnership with Telistat and local hospitals, converted 25 skilled nursing beds to a sub-
acute care unit with state-of-the-art medical equipment. The focus of thisunit isdecreasing
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FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 EXH IBIT B FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 File No. 115311-0 1 SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF ROCKLAND ----------------------------------------------------------------X Index No. 0 330 87/ 20 19 MARION FAYO, Deceased, by an d through, Hon. Rolf M. Thorsen KATHLEEN FAYO, as Adm inistrator of the Estate of MARION FAYO AFFID AVIT IN Plaintiff, SU PPORT OF JOELLE C. MARGREY, -against- D N P, MSN , CN L, RN , CLN C NORTHERN RIVERVIEW HEALTH CARE CENTER, INC., Defendant. ----------------------------------------------------------------X STATE OF NEW YORK } } SS: COUNTY OF ONONDAGA } J OELLE C. MARGREY, D N P, MSN , CN L, RN , CLN C, a licen sed Registered Nurse in the State of New York, being duly sworn and deposed, states and affirm s the following under the penalty of perjury: 1. I am currently the Vice President of Skilled Nursing Operations at Loretto Health & Rehabilitation in Syracuse, New York, where I have direct oversight over 719 skilled nursing beds and 20 4 sub-acute nursing beds in m ultiple facilities located across two counties in Central New York. I was previously the Director of Nursing at Loretto, where I was directly responsible for the operation of the facility’s nursing departm ent com prised of 8 0 0 em ployees who cared for 583 residents daily. My experience an d educational background are set forth in m y Curriculum Vitae, which is attached as Exhibit 1. 1 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 2. I am very fam iliar with federal an d state regulations and associated guidelines for the operation, care, and services provided in various Nursing/ Medical settings, including Nursing Hom es and Skilled Nursing facilities. I also have extensive knowledge of the standards of care applicable to facilities such as Northern Riverview. 3. I have reviewed Marion Fayo’s records from her residence at Northern Riverview Health Care Center, including Care Plans, Clinical Assessm ents, Clinical Monitoring, CNA Accountability Records, Diagnostics an d Labs, Min im um Data Sets, Nutrition Evaluation and Docum entation, Physician Orders, Progress Notes, Risk Assessm ents, Therapy Records, Medication Adm inistration Records, and Treatm ent Adm inistration Records. I have also reviewed Ms. Fayo’s records of care at Orange Regional Medical Center. 4. Based upon m y records review an d the facts of this m atter, it is clear that the care, skill, and/ or knowledge exercised or exhibited in the treatm ent, practice, or work perform ed by Northern Riverview’s staff in its care and treatm ent of Ms. Fayo fell outside of acceptable professional standards or treatm ent practices. It is equally clear that Northern Riverview violated Ms. Fayo’s rights as a nursing hom e resident under state and federal regulations. 5. Ms. Fayo was 63 years old when she was adm itted to Northern Riverview on Decem ber 22, 20 16 following an inpatient hospitalization. H er adm itting diagn oses included cardiom yopathy, hyperten sion, Type 2 Diabetes, COPD, vitam in D deficien cy, hyperlipidem ia, dem entia without behavioral disturbance, acute ischem ic heart disease, m uscle weakn ess, unsteady on feet, and a history of falls. 6. Upon adm ission, Ms. Fayo was assessed as requirin g supervision assist 2 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 of one staff for transfers, assist of on e staff for am bulation, assist of one staff for bathing, som e assistance for hygiene and toilet transfers, independent for feedin g, and was in continent of bowel an d bladder. Ms. Fayo was approxim ately 65 in ches tall, weighed 151.2 pounds, and had a BMI of 25.95. She was also free of infection ; that is, she did n ot have either urin ary tract infection or sepsis. She was placed on a diet of regular, thin liquids, consistent carbohydrate, an d n o added salt. 7. Ms. Fayo was also assessed as having severe cogn itive im pairm ent. Non-com pliant behavior was not am ong Ms. Fayo’s diagnoses, however. In fact, the adm ission assessm en t reflected that she was alert and respon sive with periods of confusion, did n ot have an y m ood or behavior con cern s such as resistive/ refusal of care, and appeared happy to be at the facility. But on Decem ber 29, 20 16, it was docum ented that Ms. Fayo was hitting, had poor self-care, was un cooperative, displayed self-isolation, was sad and irritable, had a decreased appetite and weight loss, and lacked interest in activities. 8. On J anuary 5, 20 17, Ms. Fayo was transferred to Orange Regional Medical Center due to decreased intake and vom iting; she was returned to the nursing hom e that sam e day. By J anuary 12, 20 17, she was showing signs of dehydration and kidney failure as she still had decreased intake and vom iting, and she had lost m ore than 16 pounds since her adm ission. There is a physician order to obtain a urine culture and to catheterize if needed, but this was only attem pted one tim e. At her fam ily’s insistence, Ms. Fayo was transferred to Orange Regional Medical Center on J anuary 15, 20 17 where she was diagnosed with sepsis and dehydration, am ong other conditions. 9. It is m y professional opinion, within a reasonable degree of nursing certainty, that the care and treatm ent rendered by Northern Riverview fell below 3 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 m inim um acceptable standards of care, were in violation of the nursing hom e residents’ rights of care and treatm ent, and m ay also constitute abuse, neglect, and m istreatm ent. Below is a sum m ary of events that supports this conclusion. I have categorized this sum m ary with sub-headings. a. Docum entation: • On 12/ 29/ 16, an Interdisciplinary Behavior/ Psych Assessm ent indicated that the patient was hitting, had poor self-care, was uncooperative, displayed self-isolation, was sad and irritable, had a decreased appetite and weight loss, and lacked interest in activities. This assessm ent w as com pleted by an LPN , w hich is out of the scope of practice for licensure. • The plan of care im plem ented by the LPN indicated they would encourage, refer to unit activities, and offer alternate m eals, all of which the patient refused. There is no further docum entation to indicate the interventions that w ere put in place to assist w ith the behaviors and refusals, let alone an explanation as to w hy Ms. Fay o w as refusing care or m eals. • On 1/ 5/ 17, the patient was sent to the hospital at 1720 due to vom iting and decreased intake. Upon return on 1/ 5/ 17, there is no RN assessm ent of the patient or any docum entation of the course of treatm ent in the hospital. • On 1/ 13/ 17, an Interdisciplinary Behavior/ Psych Assessm ent indicates the sam e behaviors as the assessm ent on 12/ 19/ 16 and is com pleted by an LPN . • There are m any entries in the m edical record that the patient refused supplem ents and m edications, but there is no indication that the m edical providers were m ade aware. This is a N YSDOH regulation and best practice as a review of phy sician orders, w ith consistent refusals, is indicated for changes in the treatm ent regim en. There are also no interventions indicated for a change in the plan of care due to the refusals or alternate attem pts by the staff except an occasional re-approach. • There are m any notes throughout the m edical record that indicate the patient required skilled needs as she was presently being treated for an infection. There w as no indication that the patient had an infection, how ever, or that there w as a phy sician order for antibiotics. 4 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 b. Failure to Institute Tim ely Nursing Interventions: • There is very lim ited docum entation throughout the record by RNs or indications that an RN was notified in situations that would constitute an RN assessm ent per best practice standards. Som e exam ples include refusals of m edications 12/ 23/ 16, 12/ 26/ 16, 1/ 2/ 17, 1/ 3/ 17, 1/ 8/ 17 and 1/ 9/ 17. On 1/ 2/ 17, a note by an LPN indicates the patient had vom iting and was placed on a clear liquid diet; a 1/ 5/ 17 a note by an LPN indicates hydralazine was held due to a low blood pressure; and on 1/ 5/ 17 a note by an LPN indicates the patient was sent to the hospital due to vom iting and decreased intake. Any of these instances would have indicated the need for an assessm ent by an RN. It appears throughout the record that the LPN s w ere com pleting assessm ents and m aking decisions that w ere out of their scope of practice. • On 1/ 12/ 17 there is a physician order to obtain a urine culture and to straight catheterize if needed. The docum entation reflects this w as attem pted one tim e, and there is no further docum entation about attem pts or a discontinuation of the phy sician order. c. Physician Services • On 1/ 15/ 17 at 1323 a n ote indicates the fam ily is upset with the care. The NP is called to the room and the fam ily is told they were going to initiate intravenous fluids, the fam ily declined an d requested hospitalization. There is no docum entation in the record that there w as a discussion of initiating intravenous fluids or rationale for such prior to the fam ily reporting they w ere upset w ith the care. • The patient was adm itted with a diagnosis of diabetes, and laboratory values in the m edical record dated 10 / 24/ 16 (prior to adm ission) and signed 12/ 27 / 16 by the physician in the STR facility indicate that the patient’s glucose level was 10 1 (norm al range 65-99) and the HgAlC was 1.46 (normal range 0 .50 -1.30 ). There w ere no phy sician orders to m onitor the blood glucose levels. There is a notation in the LPN progress notes of a blood glucose level of 166 on 12/ 22/ 16 at 2155. There is no follow up indicated and no indication that the MD w as m ade aw are. Furtherm ore, this blood glucose reading of 166 taken on 12/ 22/ 16 at 2155 is carried through on m any of the progress notes. This indicates the sam e blood glucose reading w as used on an ongoing basis and there w as no regard to the signs and sy m ptom s that the patient w as having and the likelihood that 5 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 untreated diabetes w as contributing. The research indicates that signs and sy m ptom s of uncontrolled diabetes include w eight loss, infections, kidney problem s, and confusion. d. Care Plans • The inconsistencies listed below in the care plans were not docum ented as initiated and, if they had been initiated, the patient m ay have had an im proved transition to the facility and an im proved quality of life. Per NYSDOH regulations, any interventions noted on the care plan are to be im plem ented, but there is no docum entation of this. The care plans are not updated with treatm en t orders, m edication changes, changes in condition or hospitalization, and are not person centered per NYSDOH regulations. • The behavior care plan indicates that an attem pt will be m ade to identify patterns of behaviors to target interventions. There is no indication in the record that this w as com pleted, and this care plan w as initiated on 1/ 28/ 17 after the patient had been discharged to the hospital. • The noncom pliance care plan in dicates that the patient refuses m edications, food, labs, and diagnostics, and the plan of care is to recognize the right to refuse treatm ent and accept choices without judgem ent. There is no indication of other interventions trialed for the patient’s refusals or assessm ents as to the reason w hy the patient refused. Essentially , the plan of care is to allow her to refuse, even though it w as detrim ental to her health outcom e and quality of life. e. Activities of Daily Living (ADL) Docum entation • There are om issions in the following docum entation, concluding that the care was not provided: Am bulation; Bathing; Bed m obility; Bladder/ Bowel Incontinence; Bowel Movem ents; Dressing; Pain Checks every shift; Hygiene; Skin Observation; Transfers; Dining/ Intake by m outh – food; Dining/ Intake by m outh – fluids. f. Nutrition • On 12/ 27/ 16, a progress note by an RD indicates that the patient had an 8 .3-pound weight loss in 5 days an d is on furosem ide, intake was 50 -75% and Hi-Cal 60 cc four tim es a day will be added. There is no indication in the nursing assessm ent that the patient had edem a present on adm ission to indicate such a 6 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 w eight loss in 5 day s. • On 1/ 2/ 17, there is a progress note in dicating that a care plan m eeting was held with the patient’s sister, at which tim e they discussed decreased in take and weight loss. They discussed high interest foods and added ½ sandwich, offering snacks and would discuss with the MD to liberalize diet. The Hi-Cal and HCS supplem ent was discontinued due to refusal. There is no indication in the docum entation that it w as discussed w ith the MD to liberalize diet and there is no MD order for such. There is no further docum entation of snacks that w ere trialed and offered to the patient to increase intake. Since adm ission, the patient had decreased intake and had continual w eight loss, totaling 16.6 pounds in approxim ately 5 w eeks, and the docum entation reflects the only attem pts to increase intake included Hi-Cal and HCS supplem ents and offering a ½ sandw ich. g. Medication Adm inistration Records (MARs) and Treatm ent Adm inistration Records (TARs) • There are m any om issions on the MARs/ TARs, and there is no docum entation as to the reason why or that the resident refused. The patient was sent to the hospital on 1/ 5/ 17 at 1720 and was returned to the facility on 1/ 5/ 17. The records do not indicate that on 1/ 5/ 17 the patient's m edications and treatm ents were not given as she was in the hospital, nor does it reflect that the MD was notified upon hospital return as to adm inistering the m issed m edications or withholding them . Exam ples include: • 12/ 20 16 - Donepezil 5m g at HS on 12/ 22/ 16, Lipitor 20 m g at HS on 12/ 22/ 16, Check ID qs for DNR (11-7 shift) on 12/ 22/ 16, Pain scale qs (11-7 shift) on 12/ 22/ 16, HCal 120 cc QID on 12/ 27/ 16 at 170 0 and 210 0 , and on 12/ 28/ 16 at 0 90 0 and 130 0 , antifungal to perineal on 12/ 25/ 16 at 0 90 0 , an d siderails for bed m obility (11-7 shift) on 12/ 22/ 16 and 12/ 27/ 16. • 1/ 20 17- Carvedilol 25m g at 170 0 on 1/ 5/ 17, Colace 10 0 m g at 170 0 on 1/ 10 / 17, Check ID bracelet for DNR on 1/ 5/ 17 (3-11 shift), Vital signs on 1/ 2/ 17 (11-7 shift), Vital signs on 1/ 3/ 17 (7-3 shift), Vital signs on 1/ 5/ 17 (3-11 shift), Antifungal to sacrum / peri-area on 1/ 5/ 17 at 170 0 blank. h. Minim um Data Sets (MDS) • On 12/ 29/ 16, the adm ission MDS was com pleted and indicated 7 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 that the BIMS was 99; therefore, unable to com plete an assessm ent of cognition. Throughout the record, the patient is noted to be alert and oriented w ith periods of confusion. W as the patient re-approached to com plete this assessm ent, w hich w ould have assisted in form ulating the plan of care for the patient and triggered pertinent care area assessm ents (CAAs) on the MDS. 10 . Ms. Fayo was showing signs of dehydration and kidney failure due to septicem ia from an untreated infection on J anuary 15, 20 17. As discussed above, she had decreased intake, vom iting, and weight loss without appropriate interventions/ care plan m odifications for com pliance per NYSDOH regulations. She was adm itted to Orange Regional Medical Center on J anuary 15, 20 17 as septic, with a rectal tem perature of 10 0 .6, and a urine sam ple that was thick, yellow and brown. The urine culture showed a turbid appearance and revealed m oderate bacteria, which are indications of a positive result, and she was given an antibiotic. She was also dehydrated, as eviden ced by the Basic Metabolic Panel findings of Sodium level of 133 (related to kidney failure), BUN level of 56 (indicates kidney failure due to dehydration), and Creatinin e level of 2.97 (indicates im paired kidney function due to dehydration, vom iting). Had the nursing hom e obtained the urine culture as ordered on 1/ 12/ 17 and/ or follow ed up w ith the MD if they w ere unable to obtain it, Ms. Fay o’s outcom e w ould not have been a negative one. 11. Furtherm ore, even though Ms. Fayo had a history of noncom pliance with eating, taking m edications, and not allowing laboratory and diagnostics to be com pleted, the noncom pliance m ay have im proved if the nursing hom e had evaluated the reasons for such and attem pted alternative interventions. The care plans were not person-centered as NYSDOH requires and reflect only generic interventions such as accept choices without judgem ent, encourage the fam ily to support, and re-offer, which 8 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 clearly did not work. Im plem enting a non-com pliance care plan does not relieve the facility from the requirem ents to continually trial and care plan alternate interventions to prevent weight loss and dehydration. I would also question whether Ms. Fayo was truly being non-com pliant or whether she was having a worsening of her dem entia which would lead to a reduction in intake. Either way, the facility should have continually trialed and docum ented alternative m easures. 12. Alternative interventions that could have been attem pted include but are not lim ited to: super potatoes, super pudding, high calorie ice cream , sm all frequent m eals, an d finger foods; trial of an appetite stim ulant; evaluation of past history of eating routines and favorite foods; discussion of insertion of a gastronom y tube; evaluation of m edications to determ ine whether any were contributing to a reduction in intake (som e m edications contribute to a reduction in appetite, and som e contribute to a reduction in appetite because they leave a m etallic taste in the m outh); and assess for dehydration, which can suppress appetite. 13. The nursing hom e should also have evaluated Ms. Fayo to determ ine whether she had an untreated depression, given the change in physical status and environm ent in which she was residing. As n oted in Paragraph 7 above, Ms. Fayo did not have an y m ood or behavior con cerns upon her adm ission but, within one week, she was hitting, had poor self-care, was uncooperative, displayed self-isolation, was sad and irritable, had a decreased appetite and weight loss, and lacked interest in activities. These changes can correlate to depression. 14. There is also no m erit to the claim that Ms. Fayo’s fam ily was hin dering the nursing hom e’s efforts by bringing in food that she was not supposed to have. Ms. Fayo was not eating, and her fam ily was sim ply trying to provide her with nourishm ent. 9 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 The fact that Ms. Fayo’s diet consisted of no added salt did not change the fact that she was not taking in enough to sustain her needs. It also did not lead to the hospital adm ission and diagnosis of urinary tract, infection, dehydration, acute kidney failure, and sepsis. 15. In m y opinion, within a reason able degree of nursing certainty, Ms. Fayo did not receive adequate and appropriate healthcare services, preventative care, or care within best practice standards at Northern Riverview. It is also m y opinion, within a reasonable degree of n ursing certainty, that Northern Riverview violated Ms. Fayo’s right to adequate an d appropriate m edical an d nursing care as m andated by state an d federal law. These failures include: • Failu re to tre at an d care fo r th e p atie n t w ith e vid e n ce -bas e d p ractice an d w ith in be s t p ractice gu id e lin e s (10 NYCRR §§ 415.3, 415.5, 415.11, 415.12, 415.26, 415.27; 42 CFR §§ 483.10 , 483.25, 483.34, 483.70 ) • Failu re to accu rate ly d o cu m e n t an d m o n ito r th e p atie n t’s n u tritio n al s tatu s (10 NYCRR §§ 415.5, 415.11, 415.12, 415.14; 42 CFR §§ 483.10 , 483.25) • Failu re to e n s u re th at p atie n t as s e s s m e n ts w e re co m p le te d by an in d ivid u a l lice n s e d to do s o , i.e ., n o t allo w in g an LPN to p ractice o u ts id e th e s co p e o f N YS lice n s u re (10 NYCRR §§ 483.35, 483.70 ; 42 CFR §§ 415.3, 415.11, 415.12, 415.13, 415.26, 415.27) • Failu re to re ce ive ad e qu ate an d ap p ro p riate h e alth care , re s u ltin g in actu a l h a rm (10 NYCRR §§ 415.3, 415.5, 415.11, 415.12, 415.15, 415.26, 415.27; 42 CFR §§ 483.10 , 483.25, 483.34) • Failu re to fo llo w acce p te d s tan d ard s and p ractice s re late d to care an d tre atm e n t (10 NYCRR §§ 415.5, 415.11, 415.12, 415.26, 415.27; 42 CFR §§ 483.25. 483.34) • Failu re to tim e ly e valu a te fo r th e p o te n tial o f an in fe ctio u s p ro ce s s , i.e ., u rin a ry tract in fe ctio n (10 NYCRR §§ 415.3, 415.11, 415.15; 42 CFR §§ 483.10 , 483.25, 483.80 ) 10 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 " Failure to plan and implement necessary care and services to attain or maintain the patient's highest practicable physical, mental, and psychosocial well-being (10 NYCRR §§ 415·3, 415.5, 415.11, 415.12, 415.14, 415.15, 415.26, 415.27; 42 CFR §§ 483.10, 483.20, 483.25, 483.34) " Failure to and appropriately implement a plan of adequately care, specific to the patient and within accepted standards of practice, resulting in actual harm (10 NYCRR §§ 415.3, 415·4, 415·5, 415.11, 415.12, 415.26, 415.27; 42 CFR §§ 483.10, 483.12, 483.20, 483.25, 483·34) " Failure to follow on the patient's change in timely up condition, resulting in actual harm (10 NYCRR §§ 415-3, 415-5, 415.11, 415.12; 42 CFR §§ 483.10, 483.25, 483-34) " Failure to implement adequate interventions for the patient's physical decline, resulting in actual harm (10 NYCRR §§ 415.3, 415.4, 415-5, 415.11, 415.12, 415-15; 42 CFR §§ 483.10, 483.12, 483.20, 483.25) I HEREBY CERTIFY that the foregoing statements made by me are true and accurate, to a reasonable degree of nursing certainty. Dated: J LLE C. G , DNP, SN, C , , CLNC BEFORE ME, the undersigned authority, personally appeared JOELLE C. MARGREY, DNP, MSN, CNL, RN, CLNC, who has produced identification and who after being fully sworn deposes and says that she executed the foregoing AFFIDAVIT and that said FACTS IN THE AFFIDAVIT are true and correct to the best ofher knowl and belief. WITNESS my hand and seal this / day of A , . 2022. d Notary ub Stat f New York a me: or\ &tÅ B G My commission expires on: ( GT NE 11 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 EXH IBIT 1 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 Dr.Joelle C Margrey, DNP, MSN, CNL, RN, CLNC 7637 Commander Circle Liverpool, NY 13090 315-591-7880 jmargrey@verizon.net " Mentors staff at alllevels, sharing ideas, work and lessons-learned to improve processes, care and efficiency and obtain success and higher levels of service to include oversight of complex care programing. " Builds and maintains relationships with the union workforce and builds a positive labor/management relationship focusing specifically on clinical outcomes. " Reviews, develops and assists in the implementation of consistent policies and procedures that will address individual site needs, meet regulatory requirements, provision evidence-based practices and support initiatives. " Leads the change to ensure technology and data management play a key role in operational efficiency at meeting clinicalexpectations; accountable for clinicaltrending factors in ensuring resident care is maintained at the highest level. " Ensures the certification program for CNAs meets the highest standards of excellence. " Leads using a Person First Care Model in Nursing Services while optimizing family satisfaction. " Serves as a member of the Senior Leadership Team. " Advocates forthe Loretto Mission, Vision and Values as a basis for success as itrelates to allfacets of the leadership aspect of the position. 3/2017 - 12/2021 Vice President of Skilled Nursing Operations " Serves as key member of Loretto's Senior Leadership Team charged with setting the organization's strategic direction and mission. " Direct oversight and budget development/implementation of 719 skilled beds and 204 sub- nursing acute nursing beds located across two counties which employ over 1500 individuals and has annual revenue in excess $115 million. " Position entails leading the operational and clinicalteams which include licensed administrators, physicians, nurse practitioners, nursing directors and support service department managers in achieving operational excellence, exceptional quality of care outcomes while maintaining census, balancing payer mix, reducing expenses and increasing employee retention rates. " Proven track record of leading teams in achieving regulatory compliance and improving DOH survey, CMI, and quality reporting results. " Developed and successfully implemented the following projects in the past 12 months: o Board National Speaker - presentation on implementation of telehealth Advisory services, reduction in hospitalizations and enhanced revenue. o Secured a grant for an 8-bed palliative care unit. o Implementation of a NYSDOH approved 144 bed, negative pressure COVID-19 building and policies and procedures to meet regulatory guidelines and best practices for patient and employee safety. Initiative included partnerships with local and surrounding hospitals for decantation plan to reduce Covid positive patients. 2 FILED: ROCKLAND COUNTY CLERK 08/17/2022 06:05 PM INDEX NO. 033087/2019 NYSCEF DOC. NO. 68 RECEIVED NYSCEF: 08/17/2022 Dr. Joelle C Margrey, DNP, MSN, CNL, RN, CLNC 7637 Commander Circle Liverpool, NY 13090 315-591-7880 jmargrey@verizon.net o Successful implementation of Covid vaccine clinics. o In partnership with ImagineMIC, telehealth services were instituted within the facilitiesand patients were set up with equipment and 24/7 telehealth services. o Led initiative to reduce avoidable hospitalizations by seventy percent with the use of ImagineMIC, care pathways and the use of the sub-acute care unit o In partnership with Telistat and local hospitals, converted 25 skilled nursing beds to a sub- acute care unit with state-of-the-art medical equipment. The focus of thisunit isdecreasing