But it hurts Smith more that his tormentors went largely unpunished, even though a state investigation substantiated that he was assaulted by staff at Cherry Hospital in Goldsboro.

"When I'm manic, I'm not exactly the easiest guy to be around," said Smith, who lives in Roanoke Rapids. "But this happened to me in a mental hospital. They're there to help you, not beat you up."

In the seven years since North Carolina decided to reform its mental-health system, regulators have sanctioned at least 192 state employees for abuse, neglect or stealing from patients. Another 38 employees of state mental hospitals and homes for people with developmental disabilities are under investigation, records show.

They are listed on a state registry available to prospective employers. Though most lost their state jobs, employees blacklisted for abusing and neglecting patients were charged with a crime 13 percent of the time.

Convictions are rarer still, with employees often denying the accusations and the only other available eyewitnesses being victims whose mental illness can be used to undermine their credibility.

At least 19 employees on the blacklist were allowed to keep their positions or were subsequently rehired, according to a review of state personnel records. At least nine others were allowed to transfer to new government jobs as prison guards or law enforcement officers.

The mental-health reforms of 2001 aimed to de-emphasize the use of hospitals and to promote community treatment. But treatment hasn't developed as expected, and the hospitals have become busier while being considered less important.

Each of the 192 employees on the blacklist worked in institutions under increasing strain; the number of patient beds was cut by nearly a third as demand for treatment rose.

Admissions have gone up while the average length of stay has shrunk. Patients are admitted more frequently and often discharged before they are ready.

It's unclear whether abuse in state psychiatric institutions is getting worse, because more than three dozen complaints from the past two years are still being reviewed. But federal investigators have been penalizing the state more severely in recent months for cases of abuse, neglect and wrongful deaths, cutting off federal funds to Broughton Hospital in Morganton and threatening to do the same at John Umstead Hospital in Butner and at Cherry.

While legislators and administrators at the state Department of Health and Human Services have focused on replacing aging hospitals with new buildings, low salaries have driven experienced workers to better-paying jobs at private facilities.

"The inevitable consequence of understaffing, overwork and low wages is poor employee morale," said Vicki Smith, the executive director of Disability Rights North Carolina, a group that investigates abuse in state facilities. "Poor morale results in staff turnover, making it harder to ensure that workers are appropriately trained. Poorly trained workers provide poor services. This translates to poor patient care, meaning increased abuse and neglect."

In an interview this month, the head of the state hospital system said he was unaware so few were charged with a crime.

"I cannot tell you why these were not [prosecuted] in the past," said James Osberg, chief of the state-operated services section of the state Division of Mental Health, Developmental Disabilities and Substance Abuse Services. "But I'm saying at this point that when there is a case of substantiated abuse ... and it is determined that charges are appropriate, we will direct that they take the charges on those individuals."

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