The Incident at Commonwealth Senior Living

The incident description that follows is based on testimony given by Diane Franklin and her daughter, Jacqueline Carney, in sworn depositions and Diane Franklin’s description of the incident that she provided to family members. At the time of this incident, Diane was living at Commonwealth Senior Living (CSL) at Charlottesville.

Wednesday, December 9, 2015

Diane had gotten into bed for the night and was watching TV. When she reached to place the TV remote control on her nightstand, she felt a sharp pain in her left shoulder which was later confirmed to be the result of a broken clavicle. Combined with her limited mobility due to multiple sclerosis, the broken clavicle made it impossible for her to get out of bed or to reach her phone to call for help.

She spent a mostly sleepless night with her only comfort coming from the belief that the staff would rescue her when they performed the Daily Check-in process at approximately 10:30 a.m. on December 10.

Day 1: Thursday, December 10, 2015

Diane expected to be found by 10:30 a.m. The Daily Check-in procedure mandated a visual check of residents if they did not call the front desk. By this time, she had soiled herself and faced the embarrassment that would accompany the relief of being rescued.

When 11:00 a.m. passed and the staff had not checked on her, she tried to reassure herself that they must be busy and they would come to her apartment as soon as things slowed down. By now, 17 hours had passed since she had anything to drink and she was very thirsty. The tiniest movements send waves of pain through her broken clavicle.

Day 2: Friday, December 11, 2015

Again, her hopes rose as 10:30 a.m. approached. By this time, 40 hours had passed since she had eaten, had anything to drink or had taken her medications. Without her medications she suffered from uncontrollable muscle spasms. Each spasm shook her body and intensified the pain of her broken clavicle.

Again, no one came to check on her. The Daily Check-in procedure failed her for a second time.

Later in the day, the facility’s fire alarm sounded. She thought that if it was a real fire, someone would come to her apartment to evacuate her.* On the other hand, she feared burning to death in her own bed without anyone knowing the circumstances that she had endured. The alarm continued for 23 minutes, then shut off. No one was coming to check on her. At one point, she heard voices in the hall and tried to call out for help, but her throat was too dry for her to generate more than a whisper.

Throughout the day, her frustration grew. Her phone was ringing and she heard callers leave voice mails, but she could not answer. By Friday evening, her nightgown, sheets and mattress were saturated with her feces and urine. She had been two days without food, water and medication.

*The Commonwealth Senior Living Resident Handbook informed residents “if the fire is not in your apartment, the safest place to be in is in your apartment until help arrives to assist you in evacuation.”

Day 3: Saturday, December 12, 2015

Diane hoped the weekend staff would be more diligent about the Daily Check-in procedure than the weekday staff had been. As 10:30 a.m. passed and the day progressed, it became apparent that would not be the case.

The pain from her broken clavicle became unbearable and she passed in and out of consciousness. She heard her phone ring again and her daughter leave a voicemail asking if she needed anything. Diane was horrified by the thought that a family member would find her.

Motivated by this fear and despite the pain in her shoulder, she made a final effort to get herself out of bed. Diane hoped she would fall to the floor and be able to crawl to a phone to call for help. Although she was able to get her left leg over the side of the bed, she did not have the strength to get the rest of her body to the bed’s edge. After making this effort, she did not have the strength to get her left leg back on the bed and it was left dangling over the edge.

She had now gone over 3 days without food, water and medication.

Day 4: Sunday, December 13, 2015

Once again, 10:30 a.m. passed and the staff failed to perform the Daily Check-in procedure. In and out of consciousness from pain, lying in feces and urine from head to toe, dehydrated and unable to speak, she had given up all hope and wanted to die. She prayed first that someone would find her, then she prayed that it wouldn’t be her daughter finding her. Ultimately, she started praying that no one would find her.

Around 1:30 p.m., her daughter, Jackie, arrived at CSL. After Jackie passed the facility dining room, she began to smell urine. The smell intensified as she continued towards the entrance of her mother’s apartment. As she approached the apartment door, she saw several days’ worth of fliers that were partially slid under the apartment door. As she entered the apartment, she was overwhelmed by the smell of feces and urine. She called out to her mother and heard a faint “in here” response.

As Jackie entered her mother’s bedroom she was horrified by what she saw:

  • Her mother’s leg was hanging over the edge of the bed, mottled and swollen.
  • Her nightgown was soaked with urine and she lay in a pile of feces.

Her mother hoarsely whispered, “I need water” but was too weak to raise her head. Jackie ran to the cafeteria to get a straw while dialing 911. Jackie returned to her mother’s side and helped her drink. While waiting on the emergency medical team to arrive, Jackie began to clean her mother so that dry and warm bedclothes and linens could replace the soiled mess all around her mother.  

The ambulance crew arrived and with great difficulty and excruciating pain to Diane, she was transferred to a stretcher. The ambulance crew informed Jackie that they would be filing a report with the appropriate social services for this incident, as Diane was found in an unsafe environment.

The ambulance transported Diane to the Martha Jefferson Hospital Emergency Department (ED). Two ED nurses spent over an hour cleaning Diane so she could be taken for x-rays. Three trash cans were filled with dirty linens, bedclothes, wash cloths, towels and protective equipment used by the staff. After initial treatment in the ED, she was admitted for a wound that had developed on her coccyx and severe dehydration. She remained as an inpatient for six days, after which she was discharged to The Colonnades, a skilled nursing facility in Charlottesville, VA, where she received excellent care.

Diane’s attending ED physician informed Jackie that she would also be filing a social services report and stated that even if Diane had been stable enough to be released from the ED, the physician would not allow her to return to such an unsafe environment.

The Aftermath

During her stay at Martha Jefferson Hospital, Diane was diagnosed with breast cancer. When presented with treatment options, she declined them. The four days she was neglected had sapped her of the muscle tone and upper body strength that she had fought to maintain for 40 years. Without daily use, her muscles had atrophied. The complications of multiple sclerosis prevented her from ever regaining that strength. Even if she had chosen to pursue cancer treatment that was successful, those four days trapped in her bed cost her the ability to return to a productive and rewarding life.

Her children and other family members and friends were with her every day until she passed on April 26, 2016.

Next Chapter: