A member of the nursing staff at St. Elizabeths Hospital began coughing on March 20. He thought it was his chronic bronchitis flaring up, so he took his medication and took off work to recover. Over the next two days, his health deteriorated.

On March 25, he checked into MedStar Washington Hospital Center with a fever of 103 degrees, then was placed in intensive care and put on a ventilator. The next day, he tested positive for the novel coronavirus.

After more than three weeks in the hospital, he is hoping to be released later this week and is angry over the District’s early efforts to contain the spread of the coronavirus. Since about the time he was diagnosed, the disease has sickened dozens within St. Elizabeths and killed four.

“If we’re in a government building, and there’s a rumor that somebody’s got a gun, what are they going to do? They’re going to clear the building,” he said, speaking on the condition of anonymity for fear of losing his job. “If there’s a rumor that there’s someone with corona in the building a week or two weeks ago, why didn’t they take precautions?”

As coronavirus cases increase among patients and staff at St. Elizabeths, advocates say the hospital hasn’t done enough to protect those who live and work at the 165-year-old city-owned facility in Southeast Washington. Four patients at the facility — which houses civilly and criminally committed mental patients — have died of the coronavirus, while about 12 percent have tested positive and more than half are in quarantine.

D.C. health officials said this week that an 81-year-old woman is the latest fatality. A voluntary patient at the hospital since the early 1970s, she was transferred after showing symptoms to Howard University Hospital, where she died. Her name hasn’t been released. The other victims were identified as Kenneth Ellison, 69; Eugene Carter, 77; and Salvador Rivero, 86.

Mayor Muriel E. Bowser (D) said Wednesday that nine of 12 units at St. Elizabeths — home to about 60 percent of its 240 patients — are under quarantine. Forty-seven staff members have tested positive, as have 28 patients. The facility is also working to “accelerate the discharge of patients where clinically appropriate,” Bowser said.

On a call Tuesday with members of the D.C. Council, City Administrator Rashad M. Young defended the hospital’s response, saying staff members have temperature screenings at the beginning of their shifts. Those who show symptoms are not permitted to work and are referred for testing. He said additional personal protective equipment was provided to the hospital on March 13 and April 10.

“They are one of the highest priorities for making sure they have the PPE they need, given the population they serve and the work they do,” he said.

Patients’ temperatures are also taken, Young said, and they are monitored for symptoms. He said those suspected of being sick are housed in a unit where staff wear personal protective gear.

“We are managing both the staff population and the patient population as safely as we can,” he said.

LaQuandra Nesbitt, director of the D.C. Department of Health, said most residents would be recovering at home if not for their psychiatric diagnoses.

“We have provided St. Elizabeths with all of the personal protective equipment that they need and a full spectrum of personal protective equipment as quickly as they have requested,” she said.

Some staff members say those precautions aren’t enough.

A member of the nursing staff who tested positive for the virus described inconsistent usage of masks after the hospital failed to quarantine a patient with covid-19 symptoms in March. Some employees — including those working at an entrance used by employees — were not issued N95 respirator masks, she said, while administrators who don’t work with coronavirus patients were able to get them.

“This is why we were so angry,” said the member of the nursing staff, who spoke on the condition of anonymity for fear of losing her job. “It was stressful.”

When this employee was quarantined for 14 days, beginning April 1, after working on a unit with coronavirus patients, she was unable to get a coronavirus test from St. Elizabeths because she had no symptoms. After turning to her doctor, she learned she was positive, two days before she was scheduled to return to work.

Susan Nelson-Pierre, a nurse at the hospital, said quarantines and a lack of tests have put pressure on staffing levels. Without widespread access to rapid tests, anyone possibly exposed to the virus must wait on the sidelines until they are cleared.

“Our issue mostly is that we need to be tested because we are straining,” she said. “Fourteen days with 30 people out is a lot of people.”

Edward Smith, executive director of the D.C. Nurses Association, said in a statement that “we simply need more N95 masks at St. Elizabeths and other health care facilities in D.C. It almost appears D.C. government is playing Russian roulette with the nurses and other health care workers at St. Elizabeths.”

Patient advocates are seeking the release of several people living in the hospital.

The D.C. Public Defender Service filed an emergency motion last week in D.C. Superior Court seeking the release of residents charged with misdemeanors who are undergoing competency evaluations at D.C. institutions, including St. Elizabeths. On Wednesday, a judge ordered five patients named in the case to be released within 48 hours.

Kimberly Clark, chief of the mental-health division of the Public Defender Service, said the agency was “devastated to learn about the death of a fourth patient” and is concerned that St. Elizabeths continues to accept additional patients.

“PDS has serious doubts about St. E’s capacity to follow CDC guidelines about social distancing for our clients and to care for those who might be symptomatic with Covid-19,” Clark said in an email. “The hospital’s lack of transparency both with the public and us leaves us terrified for our clients, many of whom are elderly, are medically vulnerable, or both.”

Ellison, the first coronavirus-related death reported at St. Elizabeths, died at the facility earlier this month after testing positive at George Washington University Hospital.

Ellison, who was committed to St. Elizabeths in 1975 after being found not guilty by reason of insanity on rape and burglary charges, spent decades in and out of the hospital. He was diagnosed with schizophrenia and suffered from dementia, according to court documents.

Carmen Ball, Ellison’s sister and legal guardian, said her brother’s condition deteriorated after he was robbed and beaten about five years ago while living in a group home. She said she didn’t have “anything negative to say” about his treatment at St. Elizabeths.

“This is a horrible disease that’s going on, but this is the first disease I’ve experienced in my lifetime where love is being poured out by the gallon,” she said. “This is bringing out something better than what we’ve seen before.”

Rivero, who died of covid-19 last week, was a Cuban immigrant who worked odd jobs and at a restaurant before he developed dementia and became homeless, according to Jilma Lasso, his court-appointed guardian. Though he lived with a group of nuns for a time, he was committed to St. Elizabeths in 2015 after his dementia progressed too far for them to care for him.

“He was loved,” Lasso said. “He was a great spirit. He loved music. He loved to dance. He was just overall a joyful person. He loved to sing even though he had a terrible voice.”

The coronavirus is the latest in a string of incidents over the years to befall St. Elizabeths.

In October, the facility brought in temporary showers and bottled water for more than a month after legionella bacteria, which can cause Legionnaires’ disease, was found in its water system. Although no one became ill, the hospital faces a class-action lawsuit over the matter.

Disability Rights DC, a nonprofit that monitors conditions at the facility, criticized St. Elizabeths last year in a report, saying it improperly uses restraints. Andrea Procaccino, an attorney at the organization, said it is “begging” the District to send more resources to the hospital.

“We continue to have very serious concerns that stem not only from years of in-depth reports regarding inadequate nursing and medical care, but also from what we have been hearing from individuals at the hospital,” she said in an email. “We are very concerned that we are running out of time to protect patients and staff at St. Elizabeths from unnecessary illness and unnecessary deaths.”

Lasso, Rivero’s guardian, said she expects more deaths among older people housed at institutions in the Washington region and elsewhere. As a legal guardian for several institutionalized patients, she said at least two already had contracted the coronavirus.

“They are among the most vulnerable,” she said. “It is devastating for them to go like this.”

Keith L. Alexander and Spencer S. Hsu contributed to this report.