The cries began shortly before 5 a.m., echoing down the almost empty corridors of United Medical Center's nursing home. From his bed in Room 704, Warren Webb's moans cohered into words: "Help! I can't breathe!"
A registered nurse appeared and adjusted the height of his bed. But the nurse quickly began arguing with Webb's wheelchair-bound roommate, who was pleading for her to do more to help. Webb rolled out of bed and landed on the floor, his diaper coming loose.
Webb, a 47-year-old AIDS patient, would lie on the floor in his own waste for approximately 20 minutes while his nurse quarreled with his roommate and then conversed with a security guard. When he was finally lifted back into bed, his caregivers could not find a pulse. Just after 6 a.m., he was pronounced dead.
Webb's death on Aug. 25, reconstructed through a time-stamped audio recording of the incident obtained by The Washington Post and interviews with three eyewitnesses, is the latest in a string of troubling incidents at the District's only public hospital.
UMC staff members do not appear to have followed what medical experts described as basic and potentially lifesaving protocols in their treatment of Webb immediately before his death.
In the aftermath, hospital officials fired one of the nurses involved but failed to report details of Webb's case to regulators that would have triggered an outside investigation. Webb's relatives say hospital staff members misled them about the events that preceded his death.
A spokeswoman for the D.C. Health Department said that the nursing home had filed an incident report concerning Webb — who, according to his death certificate, died after a heart attack — but that the report "did not contain any information that pointed towards injury, neglect or abuse."
After learning new details about Webb's death from The Post, the Health Department is launching an investigation, spokeswoman Jasmine Gossett said.
The Joint Commission, an accreditation body that visited UMC in September, was not aware of any patient-safety concerns related to Webb's death, a spokeswoman said. She said the commission would now review the incident.
Hospital officials declined to answer detailed questions about Webb's case but issued a statement asserting that the incident was handled properly.
"The matter was investigated and based on the findings, appropriate actions were taken," the statement reads. "Timely notification to the appropriate regulatory and licensing bodies was provided and they are conducting their respective investigations. Due to resident/patient and employee privacy regulations, as well as the other ongoing investigations, we are not at liberty to discuss the matter further. However, we continue to cooperate fully."
Questions about Webb's death come as D.C. elected officials are intensifying their oversight of UMC, which is struggling with deteriorating finances and growing concerns about patient safety. Since last year, the city has been paying a politically connected consulting firm, Veritas of Washington, $300,000 a month to run the hospital.
Vincent Gray, a Ward 7 Democrat and chairman of the D.C. Council's health committee, plans to hold a hearing Monday on whether UMC needs new management.
The city's largest medical facility east of the Anacostia River, UMC has for decades drifted in and out of financial turmoil while serving its poor and predominantly African American patients in Southeast Washington and Prince George's County, Md.
On Aug. 7, regulators closed the hospital's nursery and delivery rooms after discovering dangerous medical errors in the treatment of pregnant women and newborns.
The Post reported last month that the consultants managing UMC had delivered about a tenth of the $9 million in extra revenue they had promised to generate even while collecting $5 million in taxpayer dollars.
Webb's treatment and the handling of his death could revive allegations that have dogged hospital officials in recent months: that UMC staff is sometimes dismissive of or disrespectful toward patients and that hospital supervisors are slow to acknowledge and correct mistakes.
Webb's father, Baye' Webb, a 71-year-old resident of Lanham, Md., said nurses did not disclose key details when they explained his son's death, such as his repeated cries for help or the extended period when he was left on the floor of his room.
"We totally felt like they were misleading us and the facts weren't forthcoming," he said. Of the new information about his son's death, he said simply: "It's agonizing."
Warren Webb was born in the District and — although he spent some of his teenage years in South Carolina and as an adult lived in Georgia — always considered Washington his home.
A cinephile who organized movie nights at his apartment complex in Southeast Washington, he jokingly called his mother "Mommie Dearest," a reference to the 1981 film that depicts actress Joan Crawford's tortured relationship with her daughter.
That sense of humor helped him weather difficult stretches in his life, including his HIV infection, his diagnosis with a form of bipolar disorder and a period when he used crack cocaine, said his mother, Tujuana Bigelow, a resident of Glenarden, Md. In late July, he was admitted to UMC's skilled nursing facility for rehabilitation after being diagnosed with a brain mass that caused strokelike symptoms.
Bigelow, a 66-year-old Prince George's County school bus driver, said she visited her son almost every day. She quickly became alarmed by what she saw as his nurses' inattentiveness.
When her son was admitted, she said, he could still walk to the bathroom. At UMC, they immediately put him in diapers. She said his nurses were slow to respond to the call button in his room and would sometimes leave him in a soiled diaper for hours on end.
"Nobody helped. Nobody cared. It was so sad," Bigelow said.
After being notified of their son's death on the morning of Aug. 25, Webb's parents met with his caregivers at the UMC nursing home. Bigelow said they gave a halting explanation of what had happened: A nurse recounted that she "slid him to the floor to clean him up" after he had a bowel movement and then sent him to the emergency room when she noticed that he wasn't breathing.
"What they were saying didn't make any sense to me," Bigelow said. "Why would you take a patient out of the bed and put him on the floor to change him?"
Bigelow said she suspected hospital officials were withholding information. "You could see it the way they were stumbling every time I asked a question," she said.
A plea and an argument
Several hours earlier, Webb's 58-year-old roommate, Gregory Gary, rolled up in his wheelchair to the nursing station on the hospital's seventh floor.
At the nursing station, Gary asked Peter Offor, a licensed practical nurse, if he could send someone to change Webb's diaper.
In an Aug. 31 written statement describing the incident to hospital officials, Offor said he sent Webb's charge nurse to the patient's room. In an interview, Offor identified the charge nurse as Christiana Ekwue.
Gary said in an interview that when he returned to the room the charge nurse was there, and Webb, who had become contorted on his bed, was complaining that he couldn't breathe and calling for help to sit up.
Gary said the nurse pushed a button that dropped Webb's mechanical hospital bed to its lowest setting. Webb then "rolled off the bed onto the floor with all the mess and stuff all over," Gary said. "She didn't give him any assistance to try to better the situation. She didn't make no attempt to help him sit up to where it would allow him to breathe better."
Ekwue repeatedly declined to discuss Webb's death when reached by telephone but confirmed that she is still employed at UMC.
In the recording obtained by The Post, Webb can be heard crying out at least 25 times during a three-minute period that begins just before the nurse enters his room. Many of his cries are inchoate, but he clearly gasps out his complaint:
"I can't breathe!" Webb says. "Help me up! Please!"
In the recording, Gary also urges the nurse to help Webb. "He can't hardly breathe," Gary says. His pleading grows more urgent as Webb rolls out of his bed. "You ain't helping him!" Gary says. "You ain't doing s---!"
"Mind your business," Ekwue says on the tape.
Mary Uwemedimo, a certified nursing assistant, entered Webb's room shortly after Ekwue. She said in an interview that when she arrived Webb was lying on the floor and that she placed some linens around him to soak up the urine and feces from his loosened diaper.
"I was shocked to see him lying on the floor," said Uwemedimo, who later resigned for reasons she said were unrelated to Webb's case. She said the charge nurse told her she had lowered the bed so Webb wouldn't hurt himself if he fell off.
A security guard arrived — it is unclear whether he was making routine rounds or responding to a call about the argument — and spoke to Gary about his alleged hostility toward the nurse. He then spent several minutes at the nursing station talking with Ekwue and Offor.
About 5:10 a.m., Ekwue can be heard asking for help at the nursing station to lift Webb off the floor. Offor said in an interview that when he entered the room Webb did not appear to be in distress, but that after they lifted him back into bed, they could not find his pulse.
About 5:23 a.m., Offor can be heard in the recording calling for a "crash cart," a mobile stand that carries emergency lifesaving equipment.
Offor and Uwemedimo said a night supervisor was called. In the recording, the supervisor — who is not identified — can be heard entering the room about 5:26 a.m., asking what happened and demanding a stretcher so Webb could be moved to the hospital's emergency room.
A delay ensues, however, as Uwemedimo returns almost two minutes later and says she cannot find a stretcher. "Get one downstairs!" the supervisor orders in the recording.
Uwemedimo told The Post that the stretcher usually kept on the seventh floor of the hospital was not in its normal place and that she believed nurses from another floor had taken it. She said she went downstairs, got a stretcher and returned with it to Webb's room.
Webb was pronounced dead in the emergency room at 6:01 a.m. His cause of death: a heart attack.
Death certificates for low-income nursing home residents are notoriously imprecise, said Jonathan Evans, a Charlottesville specialist in geriatric medicine and past president of the American Medical Directors Association.
But if the principal listed cause of death for Webb — myocardial infarction, commonly called a heart attack — is correct, leaving him on the floor for an extended period could have affected his chances of survival, Evans said.
"If he had a heart attack, that time delay could have had a significant impact on whether he lived or not," he said.
Tammy Slater, an acute-care nurse practitioner and instructor at the Johns Hopkins School of Nursing, said a complaint of shortness of breath from a nursing-home patient should trigger an immediate physical assessment, including measurements of heart rate, respiration rate, blood pressure and blood-oxygen saturation.
"A quick, fast assessment — I'm talking minutes — should occur, because this patient could be having a life-altering scenario," Slater said. Trouble breathing could be a sign of two potentially deadly conditions that require immediate treatment, Slater said: a heart attack or pulmonary embolism.
In both situations, she said, "minutes count."
Slater said a patient rolling out of bed onto the floor — even if only a short distance — should also have been treated as a fall and triggered a prompt assessment for injuries.
It remains unclear what steps hospital officials took to investigate after Webb's death. Uwemedimo said her supervisor asked her to provide a written statement about what happened on the morning Webb died but that nobody has interviewed her.
Offor was fired after Webb's death. In a September letter explaining Offor's termination that was obtained by The Post, nursing home administrator Stephen Gbenle wrote that "Warren Webb was yelling for help, saying 'I can't breathe' " and that Offor "did not get up from his seat to assist the resident."
UMC Chief Nursing Officer Maribel Torres also filed a complaint against Offor with the District's nursing board. It is unclear why Offor — who was the first person to realize the seriousness of his condition and attempt to save his life — was targeted for punishment.
Offor said that hospital officials "refused to carry out the corporate investigation" of Webb's death that should have been performed and that nobody interviewed him about what happened before he was approached by The Post.
Gary left UMC in October to move into an apartment in Southeast Washington. He said that Gbenle approached him about a week after Webb's death to discuss the incident but that he wasn't feeling well and asked him to come back later. No one ever followed up, he said.
"You have some people who come here that's compassionate about their job," Gary said of the UMC nursing home. "And you have a lot of them come here that's not."
Julie Tate and Daniel Mich contributed to this report.