Failure to Protect Resident from Inappropriate Touching by Peer with Known Behavioral Issues
Penalty
Summary
The facility failed to protect a resident from inappropriate touching by another resident, despite being aware of the perpetrator's ongoing behavioral issues. One resident, diagnosed with paranoid schizophrenia and under conservatorship, had a documented history of poor personal boundaries, including repeated incidents of standing too close, touching others, and masturbating in public. Over the course of a year, staff documented hundreds of episodes of intrusive and inappropriate behaviors, including touching both residents and staff without consent. The care plan for this resident included interventions such as behavioral health consultations, participation in a special treatment program, and one-to-one counseling, but these measures did not prevent further incidents. The incident in question involved the resident with a history of boundary violations entering a shared bathroom while another resident was using it and attempting to touch the resident's private area without permission. The victim, also diagnosed with paranoid schizophrenia and under conservatorship, reported feeling scared, uncomfortable, and violated, and responded by physically defending himself. Staff interviews confirmed that the perpetrating resident was known for intrusive behaviors and that redirection and supervision were routinely used, but these interventions were insufficient to prevent the incident. Staff and other residents corroborated the pattern of inappropriate touching and lack of respect for personal boundaries. Documentation and interviews revealed that the psychologist responsible for the resident was not informed of the full extent of the inappropriate behaviors, including public masturbation and attempts to kiss staff. The facility's policy required identification of residents at risk for abusive behaviors and consideration of alternative placement if warranted, but these steps were not fully implemented. The failure to adequately monitor and intervene allowed the incident to occur, resulting in psychological and emotional distress for the victim and increased risk for peer conflict and safety concerns among other residents.