14-Year-Old Resident Sexually Assaulted by His Roommate While Unsupervised

Old Vineyard Behavioral Health was cited by the Division of Health Service Regulation for failures to protect clients from abuse and harm by failing to monitor them during a disruptive incident. Video evidence showed one resident knocking out ceiling tiles and tearing metal support beams from the ceiling in the hallway. A separate camera captured two residents in their bedroom engaging in 15 sexual acts over the course of 1 hour and 15 minutes. One of the residents, who was 14 years old, reported the sexual contact to staff and said that his 17-year-old roommate forced him to do it.

While observation sheets for these residents documented periodic observations, video showed that staff never entered the room to monitor them. Further investigation revealed that because of the incident in the hallway, one staff member was responsible for observing eight residents at the time, instead of the usual four residents. When interviewed, the lead mental health counselor on the shift said, “eight patients is too much for effective monitoring … I should have called for additional staff for proper milieu management.”