The night George Spells was fatally scalded at the city-run D.C. Village nursing home, an official nurses' form indicated he had been checked hourly as required and found safe on his unit through 11 p.m. -- but Spells had been found burned and bleeding at 7:30 p.m. and had been rushed to a hospital.
The form, among the internal nursing home records released to Spells' family as part of a suit against the District, raises the question of when the confused and senile Spells had been checked during the evening of March 19, when the scalding occurred.
Other internal documents note that Spells had been found trying to bathe himself on two occasions earlier that month, and that the nursing home was aware that water temperatures were dangerously hot, exceeding limits in city regulations. But there is no indication in his medical records that any action was taken to prevent the 71-year-old Spells from harming himself.
Spells' death was the second unusual fatality this year at D.C. Village, at the farthest tip of Southwest Washington across the Anacostia River and serving about 430 residents, most of them poor, sick and elderly. In January, an 86-year-old woman, Wilhelmina Franklin, was found frozen to death next to her tipped-over wheelchair on the nursing home grounds.
City officials are in the process of taking personnel action in both cases, said Charles Seigel, spokesman for the D.C. Department of Human Services.
The District has not released the conclusions of an internal investigation about the Spells case because of the pending lawsuit and personnel actions, he said.
In February, a nurse reported on Spells' medical record that she planned to suggest that he be put in a protective vest at night to prevent him from wandering.
Seigel said city officials since have raised the issue with nursing home staff about why protective restraints were not used. The record showed that Spells, who had had three strokes since 1977, generally spoke only to answer yes or no to questions and had difficulty understanding and following simple directions.
The last notation in his medical records before the incident was dated the same day: "mentally confused and disoriented. Need s more attention."
The assisting nurse responsible for checking on Spells that night was Linda Bell, one of several nurses on duty that night, according to the nurse in charge of the ward. The initials "L.B." were on the patient's roster of March 19 in the boxes indicating hourly checks on Spells in his unit from 4 p.m. through 11 p.m. -- more than three hours after he had been taken to the Washington Hospital Center burn unit. Over the initials for the last four hourly checks, someone wrote the word "hospital" in heavy print.
Bell, reached at D.C. Village, said she would have no comment. Seigel, the department spokesman, said that after the incident Bell had explained that the initialing was "a mistake caused by the confusion of the night."
In a signed statement to homicide detectives, Sylvia Hackney, team leader on the ward that night, said that after the scalding Bell said she had checked on Spells in his room at 7 p.m., about a half-hour before he was found in the tub.
Asked if she believed Bell had made the check, Hackney originally replied, "I don't believe she did," according to the detective's report. Hackney said Bell had left the unit for lunch at 5:30 p.m. without signing out and returned without signing in.
Hackney later amended her statement, crossing out the sentence about not believing that Bell had checked and replacing it with "I have to take her word for it."
Spells, who used a wheelchair, had to go past the nurses station to get to the bathroom where he was scalded. He received second- and third-degree burns and died April 1 from his injuries.
Katherine Carroll, D.C. Village director of nursing, told the homicide detective that Spells had "an obsession with cleanness."
Spells, who was incontinent, was scheduled to be bathed twice a week.
There is a discrepancy in statements over what was done about the excessively hot water after it was discovered Feb. 20. Carroll said warning signs were put up in the bathrooms promptly. Nursing assistant Lillian Barnes said in her statement to police that the signs were put up in residents' bathrooms two days after the Spells scalding, though warning cards had earlier been placed in the utility area used by the staff.
By federal and city regulation, water temperature can be no higher than 110 degrees, but on the day of the scalding the water temperature was recorded at 127 degrees.
Since then the city has developed a policy by which water valves are to be turned off and the hot water drained from pipes if the temperature exceeds 115 degrees.