Failure to Protect Residents from Mental Abuse by Peer
Penalty
Summary
The facility failed to protect residents from mental abuse by another resident, as evidenced by multiple incidents involving inappropriate sexual behavior and harassment. One cognitively intact resident with a history of non-traumatic brain dysfunction, cerebral palsy, anxiety disorder, depression, and bipolar disorder reported that another resident exposed their genitalia and made inappropriate requests in a common area. The affected resident expressed feeling unsafe and fearful due to repeated unwanted advances, including gestures that were perceived as threatening, though no physical contact occurred. Another cognitively intact resident with medically complex conditions reported a similar incident where the same resident entered their room, grasped their own genitals through their pants, and made sexually suggestive comments. This resident also reported previous inappropriate propositions from the same individual in the dining room and noted that other residents had experienced similar behavior but were unwilling to speak up. Staff were reportedly nearby during at least one incident but did not intervene at the time. The facility's policy required assessment and care plan revision in response to resident aggression, but these measures were not implemented for the resident involved in the incidents.