By Joaquin Sapien, ProPublica

The woman was sent to a Connecticut emergency room 19 times in 15 months. Her injuries were ghastly. She swallowed pieces of razor blades. She burned herself. She inserted pins, nails, metal can lids and other objects inside her vagina and rectum.

She was developmentally disabled; living in a group home overseen by Connecticut state authorities. Each of her injuries should have been investigated by the state. None of them were.

The woman’s experience is part of a federal report formally released Wednesday by the Department of Health and Human Services Office of the Inspector General. Hers were among more than 300 emergency room visits examined by federal investigators between January 2012 and June 2014.

The report found that on dozens of occasions, Connecticut group home workers failed to uphold their legal obligations to report incidents of abuse, injury, and neglect to authorities. Even when such reports were made, the state rarely took appropriate steps to find out what happened.

“The results of this investigation are worse than I could have imagined, and clearly the oversight agencies have failed in their responsibility to prevent and investigate incidents of abuse,” said Sen. Chris Murphy, D-Conn., who ordered the report following a 2013 investigation of Connecticut homes for the disabled by the Hartford Courant. “The state needs to take action as quickly as possible to address the issues raised in this disturbing report."

Group home workers are required by law to report all injuries and signs of abuse or neglect to a state social services agency. In Connecticut, the Department of Developmental Services is then supposed to pass on particularly alarming reports— those of severe injury or that might suggest abuse at the hands of staff— to an independent state agency called the Office of Protection and Advocacy, which employs specially trained investigators.

But the federal investigation found that Connecticut’s oversight system failed at almost every level.

The Inspector General reviewed 152 “critical incidents” where residents came to harm. It found that group home workers understated their severity in more than half the cases; that the state failed to appropriately follow up on 99 percent of incidents that should have raised “reasonable suspicions of abuse or neglect,” and that hospital workers, who are also required to report such incidents, failed to do so in all but one of 310 emergency room visits.

As in many other states, Connecticut’s developmentally disabled were once held in large institutions with hundreds, even thousands, of beds. Some of those facilities became notorious for abusive conditions, with patients suffering severe injuries and even death. Many of them were shut down and Connecticut has moved people into smaller group homes meant to resemble a family atmosphere and provide better supervision. 

The report looked specifically at people whose care is paid for with federal Medicaid dollars. Currently there are more than 2,000 such beneficiaries living in scores of group homes throughout the state.

“The goal of these programs is to improve the quality of the lives of people with developmental disabilities by moving them out of large institutions and into homes in their own communities,” said Mary Kahn, a spokeswoman for the Inspector General. “The findings in this report suggest there is more work to be done to assure that dream is realized.”

The Inspector General is conducting similar investigations in other states. Curt Roy, the auditor who authored the Connecticut report, told ProPublica that those probes have thus far unearthed similar problems.

The results of these investigations are particularly disturbing for Jim Conroy. In 1995, he appeared on a “60 Minutes” episode that focused on an array of abuse allegations at a large Connecticut institution called the Southbury Training School.

In a recent interview with ProPublica, he recalled crying over the level of care being offered thousands of disabled residents. “I told my parents I saw 3,000 American citizens living in a place where we wouldn’t put our dog for the weekend,” Conroy said.

Conroy, who today is a Pennsylvania-based consultant, has spent the intervening decades helping U.S. states and foreign countries improve quality of care for the disabled. He has long supported the transition to smaller, community-based group homes, pointing at reams of data he has collected showing better outcomes for residents.

That neglect is now happening to residents in those alternative settings disturbs him greatly.

“What we did in institutions was overcrowd, understaff and underpay,” he said. “And I am fearful that we are repeating the exact same pattern in our community support systems now.”

For its part, the Connecticut Department of Developmental Services agreed with many of the findings in the report and an official with the agency told ProPublica it will continue to “make changes to this system.”

As for the woman who was hospitalized 19 times in 15 months, the Office of Protection and Advocacy issued a protective order for her after being confronted by federal investigators. It also initiated a review of her care at the group home.

Peter Hughes, the director of the OPA’s abuse division, said he could not comment on the status of that review due to privacy restrictions.

Of the report as a whole, Hughes called it an “eye opener” and said his agency “worked for many, many hours on the report” with the Inspector General and “ultimately everyone wound up agreeing that we really need to do a better job of making reports and evaluating them.”

To Learn More:

For Many of Connecticut’s Disabled, Home Is Where the Harm Is (by Joaquin Sapien, ProPublica)

Connecticut Did Not Comply with Federal and State Requirements for Critical Incidents Involving Developmentally Disabled Medicaid Beneficiaries (Department of Health and Human Services, Office of the Inspector General) (pdf)

FDA to Ban Electric Shock Devices Used for Decades on Disabled Boston Residents (by Heather Vogell, ProPublica)

Court-Freed Documents Show 13 Deaths at Developmentally Disabled Facilities (by Ken Broder, AllGov California)

3 State Facilities for Developmental Disabled Face Funding Loss after Patients Found in “Immediate Jeopardy” (by Ken Broder, AllGov California)

12 Years Later, Whistleblower MD Wins Suit over Abuse at State Developmental Disabilities Center (by Ken Broder, AllGov California)

State Decertifies Its Largest Center for Developmentally Disabled (by Ken Broder, AllGov California)