Despite severe disabilities and difficulties with eating, Steven Zlotnick should not have choked to death on bread two years ago at Crystal Run Village, an Orange County home for disabled people, according to a lawsuit.
He died, Zlotnick”™s brother, Michael, claims, because Crystal Run Village Inc. mishandled Steven”™s care.
Crystal Run”™s “reckless, willful and wanton indifference,” according to a Feb. 4 lawsuit filed in U.S. District Court, White Plains, “led directly to Steven”™s terrifying and painful death.”
The organization”™s acting CEO, Bethany Latulipe, declined to comment on the allegations.
Crystal Run spends about $39 million a year on programs that help people with intellectual and developmental disabilities enjoy opportunities, dignity and independence. The Middletown nonprofit organization employs about 700 people and serves more than 700 people in the mid-Hudson and Catskill regions.
The organization operates homes that are staffed 24 hours a day and provide meals, daily programs, transportation and medical assistance. Steven Zlotnick lived in a two-story house in Hamptonburgh with five other individuals.
He lived with autism, epilepsy, severe mental retardation, impulse control disorder, schizophrenia, thyroid disease and difficulty swallowing, according to the lawsuit.
He could not communicate with words, the complaint states, but he enjoyed life and connected with people. He loved music, watching “Sesame Street” and participating in outings such as bowling and miniature golf.
He also frequently tried to grab food from other people and swallow it unchewed.
He had stolen or choked on food at least five times from 2013 to 2017.
Crystal Run was well aware of Zlotnick”™s tendencies and risks, according to the complaint.
“Steven is very quick once an item is left unattended,” a behavior support plan stated. “He will shovel as much of the item he can in his mouth without chewing.”
He required 24-hour supervision. Food had to be locked up to prevent stealing. His food had to be cut into half-inch squares.
No one should grab food from him, a plan stated, because he might try to shove it in his mouth and swallow without chewing. Instead, staff should approach him slowly and offer food alternatives.
The Hamptonburgh home was supposed to have one staff member on duty for every two residents, according to the lawsuit.
On Feb. 6, 2019, only Robin Cohen was there for a while.
She did not ordinarily provide direct care for residents, but Christopher Fortune, the chief program officer, had assigned her to oversee the home for a week while another employee was on leave.
Around 2:35 p.m. Cohen found herself responsible for five residents, and a sixth was due to arrive at 3 p.m. Bus driver Patrick Cello, who had just brought in four residents, offered to stay and assist, according to the complaint. Cohen allegedly declined the offer and did not call a supervisor for backup.
She left Zlotnick unattended to help another resident remove his coat. When she returned to Zlotnick, he was holding a bag of bread.
Cohen tried to take the bread away, according to the version of the incident detailed in the complaint, and Zlotnick ran and tried to swallow the bread.
As Cohen chased Zlotnick upstairs, he began to choke and fell down. Cohen tried to sweep the food from his mouth and tried to perform the Heimlich maneuver, but Zlotnick ran and stumbled into a bedroom.
At 2:50 p.m., Cohen called Orange County 911. As she was speaking to paramedics, employee Jasmine Arthur arrived and heard Cohen screaming for help.
Cohen and Arthur began CPR on Zlotnick as he gasped for breath, according to the complaint. Two paramedics arrived around 3 p.m. and assisted with CPR. One paramedic swept out “copious amounts” of bread from Zlotnick”™s mouth.
“Eventually, Steven stopped breathing,” the complaint states. “His lips were blue.”
A paramedic tried to intubate Zlotnick in the ambulance on the way to Orange Regional Medical Center. At 4:02 p.m., he died at the hospital. He was 57 years old.
The medical examiner ruled the cause of death as asphyxia, according to the complaint, “due to obstruction of the airway by aspirated food bolus (bread).”
Michael Zlotnick of Budd Lake, New Jersey, sued Crystal Run, Cohen and Fortune, as administrator of his brother”™s estate.
He is demanding unspecified monetary damages for violation of the Rehabilitation Act of 1973, negligence and wrongful death. He is represented by Manhattan attorneys Ilann M. Maazel and Emma L. Freeman.
