D.C. Village staff members did not follow clearly established rules when they failed to search immediately for an elderly patient who froze to death on the grounds of the nursing home early Wednesday, a Department of Human Services spokesman said yesterday.
"Basically, our conclusions are that the staff should have notified police and the facility's administrator a lot sooner," said DHS spokesman Charles Seigel, citing a preliminary investigation. He said the incident may prompt changes in procedures at the facility in far Southwest.
The body of 86-year-old Wilhelmina Franklin was found, after police were notified of her absence, at 4 a.m. Wednesday, 50 feet outside the building where she was a resident.
Franklin apparently had wandered outside the building where she lives at the city-run nursing home. "Many of the doors lock automatically," said Seigel. "Generally, all of them are locked at night, anyway."
Franklin, who was wearing only light clothing, was found lying next to her wheelchair on a night when temperatures plummeted to 25 degrees.
She was last seen by a staff member at 8:40 p.m. Tuesday. Although she was not in her room for the hourly bed checks beginning at 9 p.m., no one started looking for her until an 11 p.m. check. The staff was not worried about her absence because she usually did not go to bed until 11 p.m., according to Katherine B. Carroll, D.C. Village nursing director.
The DHS inspection and compliance office received an oral report from D.C. Village on the events surrounding Franklin's death. Once the investigation is completed, the DHS director and the D.C. public health commissioner will decide what action is warranted, Seigel said.
"The administrator of the Village distributed a year ago clear procedures on how to handle something like this," said Seigel. "But it seems the rules were not followed.
"The procedure describes steps to take when someone is missing," said Seigel. "The first step is to search immediately the area where the person lives and the immediate adjacent area outside."
Seigel said one explanation from the staff "of why it took so long to find her is that when they first told security she was missing, they also told them she wouldn't be outside because she hated the cold. They made a perfunctory search of the area, which was obviously a mistake."
"We're looking into what we could do to prevent this from happening again in the future," said Seigel. "It looks like we'll make major improvement in security procedures . . . "
D.C. Village, a 530-bed facility has about 450 residents, said Seigel. It is operated under the supervision of the D.C. Commission of Public Health, which is part of DHS.
Willie M. Franklin, the victim's son, said; "It didn't take too much investigating to come up with the conclusions they got. It only took the police 20 minutes to find her. Looks like they [at D.C. Village] should be more familiar with their own place than the police."