According to a state report, a mental health worker did not conduct the 15-minute checks and falsified the patient's record to suggest otherwise. Although the worker wrote that Clyburn was sleeping at 7:15 a.m., a nurse reported at 7:20 a.m. that Clyburn was "unarousable, cold & stiff to touch with a blue face," suggesting that he had been dead for some time.
In a plan submitted to the state on the April deaths, Las Encinas said it fired the mental health worker involved.
The hospital also issued new rules to enhance monitoring of patients and visitors. For example, it mandated frequent checks of routine vital signs and searches of visitors' bags. Las Encinas has had similar problems in the past, state records show. In October 2004, an 18-year-old patient died after being placed in leg restraints for two days, instead of 3 1/2 hours as ordered. Two weeks later, a patient was found dead after drowning himself in a bathtub. The incidents caused the federal government to threaten to pull funding, but the issues were deemed resolved.
The most recent events have already affected the hospital's relationship with an insurer. The mental health subsidiary of UnitedHealth Group, the nation's second largest health insurer, has suspended referrals there until it completes its own probe, said spokesman Brad Lotterman.
Some family members remain distraught and outraged.
Taras Otus said the hospital has not followed up with his family since they were informed of his brother's death. He described Otus as a gregarious struggling actor who worked as an extra and on the set of the television show "Ripley's Believe It or Not." Among his possessions was a note from host Dean Cain, thanking him for ensuring Cain was well-lighted during filming.
Otus, a UCLA graduate, had his first manic episode about seven or eight years ago, his brother said. He was stable for a while, but last summer he started to use Ecstasy and crack, then became suicidal.
At the hospital he had been in a unit where he was on suicide watch, then was transferred into a unit that treats substance abuse, the brother said.
On July 31, the hospital called the family, saying Otus was missing, the brother said. The next morning, hospital employees found his body hanging from the beam of a dilapidated shed on the hospital campus, the brother said.
Otus hanged himself using a white plastic bag, a coroner's report said.
The shed "really should've been torn down 50 years ago," Taras Otus said.
"You'd think there is some kind of moral responsibility to call the family, reach out and say, 'I'm sorry.' But apparently they don't do that at this hospital," the brother said. "They gave us two garbage bags of his stuff, which I guess is what happens."
The parents of Alex Clyburn say they are pursuing legal action.
As a teenager, Clyburn was an Eagle Scout and two-time pitcher of the year at Thousand Oaks High School.
He was recruited to play baseball at Chapman University in Orange County and later transferred to Cal State Northridge, where he studied communications.
In 2006, after Clyburn suffered painful injuries in an auto accident, he became addicted to the painkiller OxyContin, said Burke, the Clyburns' lawyer.
"He was already in rigor mortis when he was found," Burke said. "He had gone for several hours without being checked . . . so it looks like they certainly weren't doing what they said they were going to do."
Contacted last week, Greg Hearn, the father of Jeffrey Hearn, said he had seen no reason to fault the hospital's care. He knew Dr. Pinsky, and had given the hospital a donation "because they took care of my son."
Then he learned from a reporter about the inspection report stating that another patient apparently gave his son the drugs on which he overdosed.
"Wow. I didn't know. It's stuff I didn't know. . . .
"It's so sad . . . I lost my only son."
Times researcher Vicki Gallay contributed to this report.