Government inspectors have now identified five patients who died at King/Drew last year after what were determined to have been grave errors by staff members, and the findings could trigger criminal investigations into possible misconduct by the nurses and their supervisors.
The Jan. 13 report also said hospital officials had failed to fix dangerous lapses in care after promising to do so.
Details in the report suggest that problems at the Los Angeles County-owned hospital in Willowbrook, just south of Watts, are far worse than previously disclosed and that the county faces a daunting task in turning it around.
For instance, inspectors found that nurses had all but ignored 20-year-old Oluchi McDonald, who was suffering from gangrene of the intestines, when he arrived by ambulance March 12. Eighteen hours later, he was found on the floor -- where he had fallen unnoticed -- in a pool of his own vomit, according to the federal report and an autopsy summary. He could not be revived.
"It's extremely distressing to know that he was rendered invisible," said his mother, Akilah Oliver, a college lecturer in Boulder, Colo., "that his life seemed not to be important to his caretakers."
Four days after McDonald died, another patient suffering from gangrene and other problems died. He was neglected for almost a day, the report said.
Then, in July, two women died when nurses did not notice their conditions were deteriorating, even though they were connected to cardiac monitors, government inspectors found. In December, a fifth patient died under similar circumstances in the same unit, known as 4B, the report said.
Taken together, the deaths and other shortfalls in patient care illustrate the "failure of the hospital to ensure quality health care in a safe environment," said the report by the U.S. Centers for Medicare and Medicaid Services, which oversees federal healthcare funding. The document has not yet been released publicly but was obtained by The Times.
A federal health official familiar with King/Drew, who declined to be identified, said the problems found and the number of questionable deaths were highly unusual.
Nurses told inspectors, for instance, that their supervisors had ordered them to downplay the conditions of critically ill patients to subvert rules requiring that the sickest patients get more nursing care.
In response, officials suspended assistant nursing director Margaret Latham without pay last Friday and had her escorted from the hospital. She could not be reached for comment Thursday.
The county had already suspended the hospital's nursing director without pay and hired an outside firm to run the nursing operation.
"It's criminal," said Supervisor Zev Yaroslavsky, one of five county supervisors responsible for overseeing the hospital, referring to nurses' alleged misconduct. "It's just unbelievable. It's unethical. It's immoral and it's probably illegal."
Officials in the county Department of Health Services said they were preparing cases to be presented to the district attorney's office for possible criminal prosecution. These include "intentional misrepresentation of patient conditions," said Fred Leaf, the agency's chief operating officer.
Leaf said that the department was investigating 20 to 25 cases of misconduct at the hospital and that he expected to discipline employees in coming weeks.
In recent weeks he has spent much of his time at King /Drew, which was founded to provide desperately needed services to South Los Angeles after the 1965 Watts riots and remains one of the few healthcare providers in the area.
If the problems are not corrected, the hospital could lose all federal funding, which accounts for about half its $430-million annual budget. Such a move would be rare, however, and county officials say they are making reforms to avoid that.
"I think you will find that, once they see what we've done, they will be amazed at the extent to which we have taken immediate and decisive action," said Dr. Thomas Garthwaite, director of the county health department.