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A scathing federal audit released Thursday faults Massachusetts officials for frequently failing to alert authorities when developmentally disabled residents of the state’s group homes suffer broken bones, burns, and other injuries potentially caused by abuse and neglect.

The audit, by the inspector general of the US Department of Health and Human Services, found that 58 percent of emergency room visits that involved reasonable suspicion of abuse and neglect were not reported to investigators between January 2012 and June 2014.

In one case, a developmentally disabled man had second-degree burns on his shoulder that neither he nor an aide at his group home could explain.

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In another case, a woman prone to seizures and defiant behavior was brought to the emergency room on two separate oaccsions with cuts on her head after she was restrained by group home staff.

And in a third, an autistic man had a bed sore that was so infected it was possibly gangrenous and in need of extensive surgery and reconstruction.

Curtis M. Roy, the audit manager who oversaw the report, said he was flabbergasted and disturbed by the findings.

“I shake my head every time I read these reports because I don’t quite see how people can see somebody laying there with an infected gangrenous bed sore and not pick up the telephone,” he said. “I just don’t understand that. I really don’t.”

State officials said they disagreed with many of the findings of the report, which they said were overstated. Nevertheless, they said they had issued several new advisories to group home contractors on how to identify suspected abuse and neglect and are developing additional training for group home workers and state officials.

The state “is committed to protecting the health and welfare of individuals with intellectual and developmental disabilities who are receiving services, has carefully reviewed the findings in the OIG’s report and is in the process of implementing recommendations,” said Michelle Hillman, spokeswoman for the state health and human services agency.

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Private contractors operate about 1,800 group homes in Massachusetts, while the state directly runs about 200, according to the Arc of Massachusetts, an advocacy group for people with developmental disabilities. They serve a total of 10,000 residents with disabilities.

The federal audit found the lack of action by state officials and group home workers placed developmentally disabled adults – some of whom cannot speak, hear, or see, and many of whom have serious physical and intellectual disabilities – at risk of harm.

The state’s failure to report the injuries to investigators also violated state and federal rules.

“Personally, I would be at least moderately concerned, if not very concerned, if I had a relative in a group home,” Roy said. “I just don’t think there should be any tolerance of abuse or neglect of anybody, but in particular of developmentally disabled people.”

US Senator Christopher Murphy, a Connecticut Democrat, requested audits of several states’ group homes after the Hartford Courant reported in 2013 that abuse and neglect had been cited in the deaths of 76 developmentally disabled people in Connecticut between 2004 and 2010.

As a result, the inspector general’s office reviewed the safeguards designed to prevent abuse and neglect in group homes in Massachusetts, Connecticut, New York, and Maine.

Connecticut’s audit, released in May, found that state, like Massachusetts, often failed to report possible abuse or neglect to investigators, including cases involving a man who suffered a broken spine and a woman who repeatedly swallowed razor blades.

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Massachusetts’ audit f0und that state officials and group home workers, by not acting on possible cases of abuse and neglect, “failed to adequately protect” 146 of the 334 developmentally disabled residents whose emergency room visits were reviewed.

The audit also found that the Department of Developmental Services, the state agency that oversees group homes, did not ensure that group homes detail the “action steps” they would take to prevent injuries from occurring again in 29 percent of cases.

The report was based on a review of 587 emergency room visits made by 334 group home residents on Medicaid between January 2012 and June 2014 – cases that involved broken bones, burns, open wounds, drug overdoses, and swallowed objects.

Christine Griffin, executive director of Disability Law Center of Massachusetts, said she hopes the report prompts officials to overhaul how the state handles potential abuse and neglect – including what she called the chronic underfunding and understaffing of the Disabled Persons Protection Commission, which investigates possible cases in group homes.

She said the state should also implement, as others have, a registry of group home workers who have abused or neglected residents, to ensure they can’t be hired again at another group home.

“It’s startling to me that we’re this behind,” Griffin said. “Especially someone who is nonverbal, we just discount what happens to them in some way. If they can’t say, ‘Somebody did this to me and this is who that person is,’ then things that happen to them get ignored by everybody.”

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Nancy A. Alterio, executive director of the Disabled Persons Protection Commission, said the agency fields 10,000 reports of potential abuse and neglect a year, has a $3 million budget and five investigators. Each investigator typically has 50 open cases.

“In Massachusetts, we work very diligently and vigilantly to ensure the protection of persons with disabilities,” she said. “We’re far from a perfect system, but we’re often seen as a model across the country because of our collaborative efforts and focus.”

Roy said it is essential that group home workers and officials understand that they must act if they are concerned that the injuries suffered by a developmentally disabled person might have been caused by abuse or neglect.

“If you have to even think about it,” Roy said, “you should tell someone.”


Michael Levenson can be reached at mlevenson@globe.com. Follow him on Twitter @mlevenson.