BRENDA NELSON hurried through the doors of Martin Luther King Jr./Drew Medical Center in October, toting a container of gumbo for her son, Mario. She expected him home soon.
To her surprise, she was told that Mario, 28, was in intensive care. There, a security guard repeatedly refused to let her in. When she finally was allowed through an hour later, nobody told her what she would find.
Mario was dead, his eyes and mouth open.
"I screamed and hollered," she said recently, her hands trembling. "I tried to pull my baby out of the bed."
Then she closed his eyes.
A nurse told Nelson that Mario -- the family's chief party planner and cook, and a onetime church choir director -- had suffered from AIDS, something she hadn't known. The immediate cause of death was respiratory failure brought on by pneumonia.
What Nelson was not told, until The Times reported it five days later, was that the nurse assigned to keep constant watch over Mario had not done so. She had silenced the alarm on his vital-signs monitor, then failed to notice his heartbeat fading, according to Los Angeles County health officials and the nurse's suspension letter.
Nor was Nelson told that the nurse had allegedly falsified her son's medical chart. According to county health officials, the nurse indicated that she had found Mario stable at 6 p.m. -- more than an hour after he had died.
"She took it in her hands to play God," said Nelson, who has sued the county, which owns the hospital in Willowbroook, south of Watts.
Mario's death was no isolated incident. Three King/Drew patients, all hooked up to monitors, died last year after nurses failed to notice their declining vital signs, state and federal inspectors found.
The nursing department is often considered the heart of a hospital; its failings alone can incapacitate the entire institution.
The frequency of lapses in King/Drew's nursing department suggests a systemic problem, one that exceeds mere individual shortcomings.
In fact, a Times investigation found that such failings extend well beyond nursing, to at least three other areas.
Mistakes and lax supervision at times have debilitated King/Drew's pharmacy and doctor-training programs, which affect nearly every patient. And the newspaper found the small but essential department of orthopedic surgery to be crippled by employee misbehavior -- absenteeism, profiteering, even the commission of felonies in off hours.
The fault, hospital experts say, lies with the institution's overall leadership.
Unless leaders can identify and fix what is broken, a hospital cannot operate safely, said Dr. Donald Berwick, president of the Boston-based Institute for Healthcare Improvement. Otherwise, he said, it's like insisting, "My car is fine except for the brakes."
Until recently, the county Board of Supervisors, King/Drew's governing body, had balked at wholesale repairs. Over the years, as the evidence piled up in audits, malpractice cases, internal memos and reports from regulators, the board largely stood by, seemingly paralyzed. The health department it oversees did little more.
"Fundamentally, someone has to step up to the plate and lead the people out of the morass that they're in," said Dr. Kenneth W. Kizer, president of the National Quality Forum, a nonprofit group seeking to improve healthcare.
Orthopedic surgeons are the carpenters of medicine, called in to repair limbs shattered by bullets or snapped in car wrecks. They tend to the aching joints of the elderly and the torn ligaments of the weekend warriors.
At King/Drew, they also quite often get into trouble.
It starts at the top.
Dr. Clarence Woods, who was removed as department chief this fall, was twice faulted by county auditors for having little or no control over his staff -- including surgeons and physician assistants who often worked only when they wanted to.
Dr. William T. Long, the only other full-time orthopedic surgeon, recently resigned after being threatened with dismissal for allegedly falsifying his time cards and referring insured King/Drew patients to his private practice at Centinela Hospital Medical Center in Inglewood. Auditors found him performing surgeries and seeing private patients at Centinela on at least five Fridays this year when his time card indicated he was at King/Drew.
Long said the county dropped its allegations against him before he resigned. "I was not found to be at fault for anything when I left there," he said.
Department of Health Services officials said they could not comment on personnel matters.
Dr. James K. Brannon, a surgeon and medical entrepreneur, is under investigation by county auditors for alleged conflicts of interest.
Although he works just part time at King/Drew, the doctor over five years ordered nearly $1 million in medical equipment for his surgeries from a company he co-owns. The disposable items, used for bone grafts, are far more expensive than the reusable devices employed by most hospitals, orthopedic surgery experts told The Times.