Herbert R. McMaster Sr.'s fatal fall at Cathedral Village on April 12 was his fifth fall during a four-day stay at Cathedral Village's nursing home, according to the Pennsylvania Department of Health's investigative report on events leading to the 84-year-old's death April 13.

The 141-page report, posted on the state's website Saturday morning, said staff at Cathedral Village, a nonprofit in the Upper Roxborough section of Philadelphia, did not properly investigate the four earlier falls, did not complete all the required neurological checks, and failed to develop plans to prevent additional falls.

State investigators found that Cathedral Village's administrator and its director of nursing "failed to fulfill the essential duties and responsibilities" of their positions.

The state Attorney General's Office on May 10 charged Christann S. Gainey, 30, a temporary licensed practical nurse, with neglect of a care-dependent person and involuntary manslaughter in McMaster's death. Records show that Gainey did not perform any of the required neurological checks on McMaster, the father of former national security adviser H.R. McMaster Jr.

An attorney for the McMaster family said the state Health Department report points to broader responsibility.

"It's very clear from this report that this is not just a rogue employee in the middle of the night grossly neglecting her job," said Martin S. Kardon, a Center City attorney who is representing McMaster's estate.

Gainey, whose preliminary hearing is scheduled for Tuesday morning, did neglect her job, Kardon said, but the Health Department report highlights major administrative problems, such as the failure of the quality-assurance committee to review McMaster's earlier falls.

"At the end of the day, the facility itself is responsible for the care that happens there," Kardon said. "That's why you see the [director of nursing] and the administrator cited for not doing their jobs."

In a statement Saturday, Cathedral Village deflected responsibility for what happened to McMaster: "While we have been asked not to discuss specific details due to the ongoing prosecution of an outside agency nurse, what we can tell you is that there is no higher priority at Cathedral Village than the safety and health of every resident for whom we care."

Problems with McMaster's care started soon after his arrival. Documentation of his first fall at Cathedral Village, on April 9, said he fell when he was trying to get to the bathroom, but there was no sign that staff had implemented a schedule for getting McMaster to the bathroom in an effort to prevent additional falls.

Video showed that on the evening of April 12 the nurse aide assigned to McMaster, who was known to be at high risk of falling when he checked into Cathedral Village on April 9, did not help the patient get to the bathroom at all or even check if he needed anything.

On the morning of April 13, after McMaster had died, staff moved him from a lounge near the nurses' station, where he spent the night in a reclining chair, back to his bed. A nurse noticed that McMaster's "brief was heavily saturated with urine and feces," she told investigators.

The report also said Gainey and two unidentified registered nurses did not call 911 and made no attempts to resuscitate McMaster after he was found unresponsive on the morning of April 13. That violated Health Department regulations.

The day McMaster had his fifth and final fall, state Health Department surveyors had completed their annual licensing inspection at Cathedral Village. Among the findings was that Cathedral Village was using seven different temporary nurses during a portion of McMaster's stay.

The acting administrator could not prove that management had evaluated the skills of four of the seven outside nurses.