She immediately called an ambulance.

"All I know is that she had to be suffering," Martin said. "I mean, when you have sores where you can see someone's skeleton, it has to be painful. This was a human being. She didn't deserve to die this way."

By the time HRS investigators were called to document Smith's injuries, she was already dying. They found her covered in bed sores. They were on her back, her legs, her feet, her ankles and her groin.

Bryant told investigators she noticed only a sore the size of a teacup on Smith that "eventually caved in." She cleaned the sore with an antiseptic, she said, and telephoned Smith's doctors. She said they never called her back. Before that, she sent Smith to a local clinic, where they treated her at least twice, Bryant said.

"I'm not an abusive woman," Bryant says today. "She came to me with all this stuff. Those are just lies about me."

She said she never wanted to accept Smith in the first place, but Smith's family pleaded with her because they couldn't take care of her any longer. Bryant says the family was well- aware of Smith's declining health.

HRS later discovered that Bryant's foster care license had expired, but the state Office of Aging and Adult Services, charged with monitoring foster homes, had never noticed.

An autopsy showed Smith died of overwhelming infection. Maria Conte, Dade associate medical examiner, said Smith should have received skilled nursing care and didn't belong in a foster home. Conte's investigation also found that Smith did not have the bedsores before she was admitted to the foster home.

HRS ruled it a clear case of medical neglect that led to death.

The Dade state attorney's office called it one of the most disturbing cases of medical neglect ever investigated in the past five years.

But there wasn't enough evidence to prosecute anyone. Instead, Smith became a casualty of the state's seldom-used, poorly defined neglect and abuse laws.

"We got into it, and we thought, 'This is a good one,' " said Katherine Fernandez Rundle, a chief assistant prosecutor in Dade. "We were outraged. I'll never forget it. But there was no way to hold Edith Bryant fully responsible criminally. She clearly didn't do a good enough job, but she at least was doing something."

The Florida Long-Term Care Ombudsman Council this year chastised the state for its lax regulation of foster homes, saying in its 1991 annual report: "There is the potential for exploitation of the system by opportunistic facility owners and desperate case managers" who don't do enough, or care enough, to protect the sick and vulnerable.

Even in skilled nursing homes, where the elderly are supposed to get advanced care, The Herald found life-threatening medical problems going unreported or unattended.

Tony Rosco says no one at the Meridian Nursing Home in Plantation ever told him that his mother had injured herself, and he had no idea what was wrong with her the last day he saw her at the home. Sue Rosco was dying. Normally alert, she didn't speak. She didn't recognize her son.

"I just thought she was peaceful for once," he said.

The Meridian Nursing Home has since been sold to Global Health Management, another corporation. Gary Sudhalter, a Global Health spokesman, said he knows nothing about Rosco's death and couldn't comment on it.