Updated

Federal investigators have found conditions at a Brooklyn hospital where a woman died on a waiting room floor "disturbing," "highly dangerous" and requiring "immediate attention."

A U.S. Department of Justice report, based on a yearlong investigation and made public on Thursday, documented a pattern of what investigators said was "inadequate care," violence among patients and sexual abuse at Kings County Hospital Center in Brooklyn.

"Substantial patient harm occurs regularly due to KCHC's failure to properly assess, diagnose, supervise, monitor, and treat its mental health patients," the report states.

Last August, staff discovered a male patient in an activity room having sex with a female patient, the report said. The man was arrested on a rape charge. A month later, a 14-year-old patient was forced to perform oral sex on another adolescent patient, according to the report.

The investigators also documented cases of patients attempting to kill themselves, including one who tied a torn hospital gown around her neck and later swallowed staples in front of staff. The incidents were reported as a "minor self-inflicted injury," not a suicide attempt.

The 58-page DOJ report was released as the city announced a new $153 million psychiatric center, increased mental health staffing and updated protocols for screening emergency-room admissions at Kings County.

City Health and Hospitals Corp. President Alan D. Aviles acknowledged the report as he announced the "radical changes" at the hospital on Thursday. He said that the unit "too often failed" its patients.

Aviles said efforts to update the hospital's psychiatric services took on greater urgency after the death last June of 49-year-old Esmin Green. She had been in a waiting room at Kings County for nearly 24 hours when she collapsed and died.

She lay on the floor for an hour before a nurse checked her pulse. The medical examiner said she suffered from blood clots.

Six employees lost their jobs over the incident even before it became public.

Aviles said improvements at Kings County would reduce overcrowding and shorten the average time patients must wait in the psychiatric emergency room to eight hours. The wait was 27 hours a year ago.