As rivals like HCA, HealthSouth, and Tenet Healthcare have been hit with government investigations for fraudulent billing and accounting, U.H.S. has burnished its reputation as the humble hospital chain. "We don't do any funny stuff with our numbers," C.E.O. Alan Miller said in a 2003 BusinessWeek article. "We grow the old-fashioned way, through hard work and modest acquisitions." For years, U.H.S. has been the only for-profit hospital chain with an investment-grade rating from Standard & Poor's.

But U.H.S. has not entirely escaped scrutiny. In several states, regulators have uncovered severe understaffing and excessive use of restraints and seclusion for elderly and mentally ill patients at U.H.S. hospitals, and ongoing lawsuits allege that the company has overcharged patients with no insurance. The company, in filings with the Securities and Exchange Commission, has disclosed that an investigation into billing practices at its Texas facilities is also ongoing. And in 2002, an investigation by the U.S. Attorney's office found that 91 patients at a Pennsylvania hospital acquired by U.H.S. had been improperly restrained over a six-month period, leading to the death of an Alzheimer's patient who was suffocated by her restraint vest after she fell out of bed. The government alleged that even though U.H.S. had promised to limit its use of restraints six months prior to the incident, it had not. After a protracted dispute, U.H.S. agreed to pay $200,000 for the violations and review its policies. The Philadelphia Inquirer quoted a U.H.S. lawyer who stated that the death had occurred during a "transitional period of ownership" seven months after the company had purchased the hospital. Through a spokesperson, U.H.S. declined Condé Nast Portfolio's repeated requests for interviews. The company also declined to respond to questions submitted in writing.

But the Pennsylvania incident—and the company's claim that it stemmed from turnover—struck a theme that would resurface four years later in response to the Alyssa Shinn case and to questions about how effectively U.H.S. supervised a revolving door of pharmacy managers at Summerlin.

U.H.S. is hardly alone in outsourcing vital patient-care services. With the increasing corporatization of medical care, hospitals have outsourced everything from emergency-room treatment and radiology to infection control. But every transition of vendors, every change in hands, multiplies risk, says James Unland, president of the Chicago consulting company Health Capital Group. "When something as crucial as a pharmacy company changes, it's not just some people in the basement of the hospital," Unland says. "It has an effect of permeating the entire organization."

III. The Pharmacist: Pam Goff
When Pam Goff left Walgreens to work at the Summerlin Hospital pharmacy in February 2006, she had never encountered anything like it. The pace was frenetic, the procedures sloppy, and the turnover staggering, she says.

Goff, 31, does not seem like a typical pharmacist. She sports colorful tattoos, and her cell-phone ringtone is her favorite Pink tune. But she has a pharmacist's DNA. She's hardworking, high-strung, and meticulous, with a deep sense of personal responsibility, having clawed her way out of poverty with an ethic that has kept her working since age 14.