NEW YORK — The people who worked at the brick building that housed 24 developmentally disabled residents called it the “Bronx Zoo.”

One worker regularly hit a resident while he ate, making him cower in fear at mealtimes. Another worker would repeatedly “smack, punch and push” a female resident, sometimes when she tried to watch staff members cook. A female worker sat in the lap of a male resident who used a wheelchair, placing his hands on her breasts and moving provocatively while other employees laughed and cheered, according to records and depositions.

Darlene Ruffin, an employee turned whistleblower, told state investigators that she saw bruising every day. “I couldn’t keep up,” she said.

The abuse first came to light five years ago, leading to a public outcry and an investigation by the state, which runs the facility, called the Union Avenue IRA, in the Bronx. But in a new review of the case, The New York Times found that when officials tried to fire 13 employees for abuse or neglect at the home, they failed each time.

The workers were shielded by the state arbitration process, whose shortcomings — a focus of earlier Times reporting — often return abusive employees to the job.

The Bronx case is emblematic of a larger problem across New York. Hundreds of pages of disciplinary records from 2015 to 2017, obtained by The Times under the state open-records law, show that more than one-third of the employees statewide found to have committed abuse-related offenses at group homes and other facilities were put back on the job, often after arbitration with the workers union.

The residents in the state’s far-flung network of more than 1,000 group homes are particularly dependent on their caregivers. In many cases, they are unable to communicate and live in group homes almost their entire lives. Some are also immobile, while others have been all but abandoned by their families.

Jennifer O’Sullivan, a spokeswoman for the Office for People With Developmental Disabilities, which oversees the state’s homes, said in a statement that abuse of people in the agency’s care “is completely unacceptable” and that the Bronx workers were disciplined and retrained.

Recycling abusive employees has long been an endemic problem. Eight years ago, The Times reviewed thousands of pages of disciplinary files for 233 workers. In a quarter of substantiated abuse cases, employees were transferred to other homes rather than fired, including in cases involving sexual assaults.

The newly obtained disciplinary records involved 120 employees. They show that while the transfers appear to have decreased, the state still keeps problematic workers at their jobs.

The findings are the latest sign that attempts to change the oversight of care for the developmentally disabled by Gov. Andrew M. Cuomo’s administration has stumbled.

“Eight years have passed, and there have been no significant reforms to stop or prevent physical abuse,” said Michael Carey, an advocate since his son Jonathan died in state care and the most outspoken critic of the governor’s reform efforts.

Carey has lamented that the developmentally disabled are largely cut off from the mainstream justice system, and has long backed a bill in Albany that would require group homes to call 911 to report assaults and serious injuries.

After any allegations of abuse or neglect, the state issues the accused employee a formal listing of accusations, setting in motion a disciplinary process that often ends in arbitration.

Questions of appropriate discipline extend across the state, the new case files show. One group home employee in the state’s Finger Lakes region was returned to work in 2016 even after being found to have pulled the hood of a garment over a resident’s head before smacking the resident repeatedly.

An employee in the Hudson Valley was transferred from one group home to another in 2017 after pinching a resident’s arm so many times that it caused bruising. An employee in Brooklyn who pushed a resident to the ground, causing a head injury, kept his job, even though in 2015 an arbitrator found his testimony “rambling at times and evasive at others.” A worker near Buffalo was also retained that year after sleeping on the job and throwing a shoe at a resident, striking the person in the back.

Some confrontations with staff members turn deadly. Heather Roselli, 35 but with the mind of a child, feared she was going to die at her group home near Rochester. In 2017, she pleaded to be moved out and said she was “concerned that she will be killed there,” according to a state record of an emergency call she placed.

Later that year, she was fatally injured when she was pinned to the floor; two workers pleaded guilty in connection with her death. One of them, Sarah DiLallo, was “very close to being fired” before Roselli’s death and had been demoted for “her failure to follow numerous agency rules,” the state said in court records.

“They’re not hiring the right people,” Keith Parks, Roselli’s stepfather, said n an interview. “You have to be a caring, compassionate individual to be in these settings. These are not machines; these are not shelves you are stocking. These are human lives.”

In 2013, in response to The Times’ articles, the Cuomo administration created the Justice Center for the Protection of People With Special Needs to investigate abuse. Critics have said it was poorly conceived, and judges have repeatedly challenged its power to prosecute cases. The center said it had an 85% conviction rate in the 174 cases it prosecuted over half a decade.

In its Bronx investigation, the center substantiated allegations of physical abuse or neglect against 13 employees but the state failed to persuade arbitrators to fire any of them. The center and the Bronx district attorney each said recently that they lacked sufficient evidence to bring criminal charges. Ten of the employees still work for the state.

“Cases involving individuals with special needs are particularly challenging,” the center said in a statement. “Victims may be nonverbal or unable to provide testimony, and witnesses may not be cooperative.”

In the Bronx and statewide, arbitration between the state and the Civil Service Employees Association can allow abusive employees to keep their jobs. One arbitrator returned an employee to work “over strong objection of state,” records showed, after he grabbed a resident by the pant leg and shirt and shoved the resident into a recliner with enough force that it hit a wall.

Mark Kotzin, a CSEA spokesman, declined to comment on specific cases. He said the employees have “some of the hardest work imaginable,” and when they hear of abuse or neglect, “they get upset and want the abusers gone.”

While many employees are compassionate, some boil over, case files reveal.

“I will pop you like a zit. I (expletive) hate you,” one worker said to a resident. “Why do you act like such a crazy person?” another worker asked a resident. A third proclaimed that she “did not give a (expletive) about the consumers” — a term the state uses to refer to developmentally disabled residents.

“Most families have no clue what they’re putting their kids into,” Carey, the advocate, said, adding, “It’s all hidden from the general public.”

In some places, the police appear to be more frequently intervening, particularly at Sunmount in northern New York, one of the last large housing facilities. One worker, for example, faced nine disciplinary charges after pouring Gatorade on a resident, slapping and jumping on a resident, and laughing while two colleagues were hitting a resident. He was arrested in 2015 and resigned.

But at the Bronx building, which includes three group homes, oversight appeared scant. In 2014, records documented multiple bruises for weeks at a time on a female resident’s breasts, arms, stomach, legs and buttocks, but she received no medical attention.

The state investigation — and a 2016 civil rights lawsuit filed on behalf of three residents of the Bronx facility against state officials and staff members — reinforced that well-meaning employees have long faced intimidation at an agency with a history of thwarting and even violating the confidentiality of whistleblowers.

“No one comes forward — nobody reports anybody,” said Ilann M. Maazel, the lead lawyer for the plaintiffs. “Individuals with developmental disabilities can’t speak for themselves. So, who is going to speak for them?”

In recent months, two former employees of the Bronx facility were so reluctant to be deposed in the lawsuit that a federal judge in Manhattan took the unusual step of having them arrested and brought into court, where they promised to testify.

The judge, Paul A. Engelmayer, told one witness, Ruffin, that he had made it clear there was to be no retaliation, adding, “I want you to know that I’ve got your back on that.”

Another former employee, Michael Robertson, told state investigators that his car window was broken after he reported on a colleague.

“Ain’t nothing confidential,” Robertson said, “so people develop a sense to keep their mouth shut, even if they’re angry about what they see.”

O’Sullivan, the Office for People With Developmental Disabilities spokeswoman, said the agency was aware of concerns about “potential peer retaliation” and took steps to “change the culture.”

The Bronx investigation began after Ruffin sent out letters anonymously — “because I was scared,” she later testified. Her identity was unmasked by investigators through handwriting analysis.

She regretted not acting sooner to protect the residents.

“I just waited too long,” she said. “I know that I failed them.”

New York Times

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