The Jan. 13 report is the latest and most damning in a series of sanctions and citations issued against the hospital since August.
A national accrediting group has revoked King/Drew's ability to train aspiring surgeons and radiologists and has threatened to do the same for trainees in neonatology.
This latest round of inspections was spurred by the deaths last summer of the two women in 4B. Both were supposed to be continuously watched by nurses but were not. State inspectors were so concerned by the events that they asked the federal government to authorize a more extensive review.
During that review, which began in December, inspectors pulled the files of 20 patients and found that eight of them had received inadequate care.
In three of those cases, the patients died.
Inspectors also found serious and unusual ethical breaches that deprived the most critically ill patients of adequate care.
"Confidential interviews revealed that nursing staff were prohibited from assigning patients a classification of IV," the most critical level of sickness, the report said.
As a result, inspectors said, nurses sometimes struggled to care for four times as many patients as the state allowed. Crucial medications and treatments were often delayed for hours. Nurses also did little to help patients who were in severe pain, according to the findings.
On one shift reviewed by inspectors, nine of the 16 patients should have been classified at the sickest level, which would have required one nurse for every two patients.
One patient was bleeding and required multiple transfusions, five required ventilators to aid their breathing and one of those patients had a temperature as high as 104 degrees, inspectors found. Four more patients were waiting to be admitted from the emergency room.
Yet there were only two registered nurses assigned to the unit -- one for every eight patients, according to the report. One less skilled licensed vocational nurse, though not qualified for the task, was left to watch the cardiac monitors. When nursing administrators were asked for help, they told the nurses on duty that no help was available, the report said.
The inspectors also found that the hospital hadn't followed through on pledges to correct problems.
For instance, in November, state health inspectors looking into the two women's deaths in 4B issued a report that cited errors, misconduct, and poor training of nurses. The county promised better training and oversight.
But the death of the man in December under similar conditions showed that those changes were not made, according to federal inspectors.
In fact, the man's family had to tell nurses that something was wrong with him. When nurses went to his room, they found a "flat line" on the cardiac monitor and no heart rate, the report said. He died within hours.
The employee assigned to watch the monitors "had not notified the nurse prior to being alerted by the patient's family" that the man's heart had stopped, according to the report. The Times reported this patient's death last month.
Even after this death, the hospital still did not ensure that employees in 4B were trained to use the monitors or were even paying attention, inspectors found.
When inspectors visited King/Drew on Dec. 23, the nurse assigned to watch the cardiac monitors told them she "did not feel comfortable" with use of the devices. Her employee file also lacked proof that she had been trained to operate them or spot abnormal heart rhythms, the report said.