Failure to Prevent Resident-on-Resident Abuse and Bullying
Penalty
Summary
The facility failed to protect two residents from abuse and the assertion of dominance by another resident, despite both individuals being identified offenders with a known history of prior incarceration together. One resident, who had diagnoses including cerebral infarction, cerebral palsy, epilepsy, schizophrenia, and major depressive disorder, reported being sexually assaulted in his room by another resident. The victim described being physically overpowered and sexually abused, recognizing the perpetrator by voice and sight. Multiple interviews with the victim, other residents, and staff confirmed ongoing bullying, threats, and physical intimidation by the alleged perpetrator, both in the facility and previously in prison. The care plans for the victim documented risks for abuse and prior allegations of sexual assault, but did not address the ongoing bullying or dominance by the other resident. There was no evidence of behavior tracking for the victim, and the care plan lacked interventions specific to the bullying and dominance issues. Staff and other residents reported witnessing the perpetrator's aggressive and intimidating behavior, including physical threats and harassment during smoke breaks and in common areas. Staff also reported that previous concerns about the perpetrator's behavior had been dismissed by prior administration. The facility's policies required the identification and care planning for residents at risk of abuse, as well as the incorporation of security measures for identified offenders. However, the care plans and progress notes for the perpetrator did not document the abuse allegations or the need for enhanced supervision. The facility failed to implement adequate measures to prevent further abuse, intimidation, and psychological harm, resulting in the victim becoming fearful, socially withdrawn, and refusing therapy and medical evaluation due to fear and embarrassment.