When neglect of the disabled starts at the top, so should prosecution| Ronnie Polaneczky

Clinton Cash was driving home from work when the surgeon called. Cash's son, Clinton Jr., needed to have the top of his finger amputated, fast.

"I had to pull over and get myself together," says Cash, emotional at the memory. "The doctor said the infection had gotten so bad, they didn't want it to spread."

The injury was the latest in a series of mysterious traumas that Clinton, 30, who has severe intellectual disabilities, had suffered while under the supervision of direct support professionals paid by the state to look out for him.

Each time, Cash says, his son's caregivers told him and Clinton's mom, Cynthia Thompson, that they weren't exactly sure what led to Clinton's injury.

Clinton is nonverbal, so he himself couldn't explain how he came to suffer burns on his leg and chest in his first group-home placement and scars and bruises in the second.

Nor could he confirm a caregiver's story in a third group home that Clinton's finger was cut to the bone because Clinton himself had been biting it.

"That made no sense," says Cash angrily. "My son has many issues, but self-mutilation has never been one of them."

But even if Clinton had been biting his finger, he had been assigned a one-to-one caregiver.  How did the finger get so bad so quickly?

Clinton was treated in the ER but he was hospitalized after infection set in – due to inept follow-up attention from his aides, Cash says  – and the finger had to be lopped off at the top.

The wound occurred last September while Clinton was under the care of BlossomPhiladelphia, a Chestnut Hill agency that operated 32 community homes for 89 intellectually disabled individuals before the state's Department of Human Services yanked its license for "gross incompetence."

As my colleague Harold Brubaker has been reporting since last summer, Blossom had undergone management changes that created danger and chaos for residents whose families rely on state-paid agencies to help them manage the lives of their disabled loved ones.

They told Brubaker about their kin's missed meals, medications, and doctor's appointments. Absentee staff. Inattention to clients' basic hygiene that was so rampant that one incontinent female resident named Dana Sessions developed severe bedsores from sitting too long in her soiled adult diapers. Her family is now suing Blossom.

But the atrocities hit their nadir on New Year's Eve, when a long-time male resident, 60, who had cerebral palsy and was able to swallow only pureed food, was allowed to eat a piece of pizza. He choked on it and died.

For 60 years, says a former agency staffer, this man managed to stay alive despite a life-threatening disease he had handled with grace and spirit. That he died in such a terrifying way is wrenching.

"Everyone knew he had dysphagia" – a swallowing disorder common in people with CP – the anguished former staffer told me. "How could anything like this happen?"

I don't know. But I know how to keep something like this from happening again: Punish the people at the top.

In cases of suspected agency abuse, neglect, or plain old incompetence, the front-line workers are usually fired and may even be criminally charged. But the pain rarely makes its way to the hotshots responsible for creating the conditions that allow hazards to exist in the first place.

I learned as much while reporting "Falling off the Cliff," a four-part series published in December.

It explored the lives of intellectually and developmentally disabled adults and the aging families who love them fiercely and will fret over them until the day of their own deaths.

Many families spoke of injuries their kin suffered behind the closed doors of their group homes or nursing homes.

In the most serious cases, lawsuits ensued, resulting in settlements paid by the offending agency's insurance carrier.

And then the agencies went on their way, until the next set of injuries got the litigious gears grinding again.

In too many cases, pricey insurance settlements have simply become the cost of doing business for incompetent agencies whose vulnerable clients are too impaired to tell the true stories of what happens to them.

How convenient. How appalling.

Change will come only when law-enforcement agencies start holding accountable the well-paid higher-ups whose positions protect them from consequences – like jail time or personal damages – usually suffered only by their low-paid, ill-trained, poorly managed direct-service professionals.

Only when their own liberty or financial worth is at serious risk will they take seriously the risks to their vulnerable clients.

At least in Blossom's case, serious scrutiny has begun. The Attorney General's office, through its Medicaid fraud control neglect team, is looking into Blossom's operations.

And locally, the Philly police are investigating that New Year's Eve choking death.

Because the investigation is ongoing, Ben Waxman, spokesman for District Attorney Larry Krasner, wouldn't comment on the case when I begged that it be put on the DA's radar. But he reiterated his boss' campaign promise to go broad when it comes to prosecuting injustice.

"In general, the DA is committed to holding people accountable not just on the front lines but higher up the food chain," said Waxman. "Systemically, that includes people in a decision-making capacity who create conditions at the ground level for low-income or otherwise compromised people" who can't afford a high-quality defense when the conditions hit the fan.

"The people on the front lines pay a much higher toll than people who are protected by position," Waxman says.

But not as high as those who pay with their lives — or mangled fingers.