Internal District government reports on the freezing death of an elderly resident of the city's D.C. Village nursing home indicate she had a well-known habit of going outside in the cold, contrary to city officials' public explanation of why the staff concentrated their search for her inside.
The director of nursing at D.C. Village said after the death of 86-year-old Wilhelmina Franklin in January that staff members "had no idea" that Franklin would go outside because she "hated the cold weather."
But a security officer told city investigators that he had brought Franklin in from the cold on several occasions. Officer Clayton Gore said Franklin "had a history of going outside and it was well known by the staff," according to one investigation report.
Only two weeks before her death, several staff members saw Franklin outside near the water fountain where her frozen body eventually was discovered, according to interviews described in the report.
That area was not part of an initial search after she was missing from her room during a 10 p.m. bed check last Jan. 15, and her body was not discovered for more than six hours afterward, the reports show. Security officers said they were not officially told she was missing until midnight.
One man at the facility, who was not identified, told investigators that he had informed a staff member the night Franklin died that she had gone outside but that the staff member took no action. A member of the housekeeping staff denied he was told Franklin had gone outside, and an investigation report said no evidence was found to corroborate the charge.
The findings are contained in a series of incident reports by staff persons and investigation reports by both the D.C. Office of Investigation and Compliance and D.C. Public Health Commission employes responsible for the operation of D.C. Village.
The documents were obtained by The Washington Post through the D.C. Freedom of information Act. City officials deleted several names and sections in the reports, including many of the reports' conclusions.
City officials are in the process of suspending some employes in connection with the death, a Department of Human Services spokesman said. He would not say who or how many were involved or whether they are still at their jobs.
On the night of Franklin's death, the nursing assistant assigned to Franklin had 17 patients to care for, because of the absence of one of three assistants normally on the unit, the reports said.
Franklin was last reported to be seen alive at 8:40 p.m. Jan. 15. Her body was found at 4:15 a.m. the next day. A chronology of events put together by city officials shows that when she was missing from her room at bed checks, staff members were not alarmed, because Franklin was believed to be visiting with other residents.
Security officers did not use available searchlights in an initial search outside, reports found. The area where the body was discovered was not searched until D.C. police officers arrived at 3:35 a.m.
Paul Lavigne, D.C. long-term care administrator who had responsibility for D.C. Village, requested that a lawyer from the corporation counsel's office be assigned to the case because he was concerned about a potential lawsuit, it said.
Reports on another unusual fatality at D.C. Village this year, the scalding death of George Spells, 71, showed that staff members knew at least a month before the incident that the water temperatures were dangerously hot in the bathtub where he received his injuries. Spells received second- and third-degree burns on March 19 and died as a result of his injuries on April 1.
The water temperature was 127 degrees on March 19, though city regulations specify that water temperatures in nursing homes cannot exceed 110 degrees. Nursing staff had been informed on Feb. 20 of a mechanical malfunction that resulted in water temperatures of 140 degrees on two units, one report said.
A floor plan of the unit showed that to get to the bathtub Spells had to negotiate his wheelchair past the nurses' station and down a corridor in view of the station before turning into the bathroom. The ratio of staff to patients that night was 1:9, which the report described as "adequate."
Spells' sister, Katheryn Spells Jackson, has questioned whether her brother was strong enough to put himself in the tub, but she said that if he was trying to do so she questioned whether he was being bathed regularly.
A D.C. Village policy and procedure manual states that "all patients are to be bathed twice a week" and as needed.
Incident reports filed by city officials at D.C. Village in 1984 and 1985 show a number of reported thefts of money and belongings at the nursing home, which currently has 432 resident.
They also detail a mix-up of bodies in the nursing home's morgue in late February, when a funeral parlor came in and picked up the wrong body. After embalming the remains, the funeral parlor operators noticed a bracelet that identified the deceased as someone else. They returned the body the next day.
Elderly and sick indigents in the care of the city generally are taken to D.C. Village.