The hang-up 911 call came into Alexandria's emergency communications center early Sunday morning from the Sunrise Senior Living facility on Duke Street.
Police responded at 2:55 a.m., but the after-hours call button, telephone calls and their cruiser sirens could not get the attention of caregivers inside. Eventually, the officers gained entry through an unlocked side door and swept the building.
A Dangerous Place: The Washington Post examines Virginia's assisted living facilities and the thousands of patients who have suffered in them.
Authorities said what they found was startling.
One resident, a hospice patient, was lying helplessly on the floor after falling out of bed, calling out for help. Another was having trouble with a catheter and had called 911 out of frustration.
No one had come to their aid, police discovered, because the three caregivers at the site were asleep. A fourth employee had not shown up for work.
Police located two of the employees sleeping on the third floor of the Alzheimer's wing and found a care manager asleep in a vacant room on the first floor, despite an audible burglar alarm sounding less than 10 feet away.
"Had a more severe emergency existed (fire, cardiac arrest, etc.), would the night staff be able to handle such an emergency locked away in vacant rooms sound asleep?" said Deputy Fire Marshal Andrea L. Buchanan, who described the scene to a supervisor in an e-mail obtained by The Washington Post. "How long has this practice been going on?" Reached yesterday, she declined to comment.
City and state officials, as well as long-term care advocates, all have begun investigations. Since Monday, each has sent staff to the facility, at 3520 Duke St., to interview employees and patients.
"The city is outraged," said Alexandria spokeswoman Barbara Gordon. "The good news is both the residents are okay."
Two Sunrise employees were fired Monday because of the incident, Gordon said. Sunrise officials would not comment on their employees. At a minimum, Virginia requires that homes need to have "sufficient" staff on hand to meet residents' needs and to conduct a fire drill.
The quality of care in Virginia's assisted-living facilities has become a political issue, with some members of the General Assembly vowing to introduce legislation to overhaul the system.
The Washington Post published a series of articles on the facilities earlier this year, finding thousands of incidents of harm since 1995, including avoidable deaths and injuries.
Sunrise Senior Living is the nation's largest chain of its kind, with more than 374 assisted-living operations. Alexandria's facility is privately owned and houses 109 residents. It is licensed to operate through Virginia's Department of Social Services, the sole agency that can mandate changes in procedures.
Yesterday, corporate officials with Sunrise would not comment on the incident at Sunrise of Alexandria except to say they are cooperating fully with city and state agencies investigating the matter and would take actions to prevent a similar incident.