The June 8 fight erupted around 2 p.m. when Resident 1, who required supervision while smoking, asked Resident 2 for a cigarette lighter. Resident 2 took the cigarette from Resident 1 and threw it on the ground. Resident 1 then wheeled over to a housekeeping cart, grabbed a dust broom, and began striking Resident 2.
After wrestling the broom away, Resident 2 watched as Resident 1 returned to the cart and grabbed a dustpan. Resident 2 took that weapon away too, then hit Resident 1 on the forehead with it.
Licensed Vocational Nurse 1 discovered the scene while walking past the sliding glass door to the smoking patio. "I looked outside and saw [Resident 1] in the wheelchair from the back holding a broom in hand and Resident 2 in front holding a dustpan in the hand over the head as if to hit Resident 1," the nurse told inspectors.
When Resident 1 turned around in the wheelchair, the nurse saw blood on the left side of the forehead.
At Greater Los Angeles Community Hospital, doctors diagnosed Resident 1 with a head contusion and scalp laceration. The half-centimeter-deep wound required high-pressure saline wash and closure with Dermabond surgical glue. Doctors ordered close follow-up within 2-3 days.
Resident 1's care plan specifically noted episodes of touching staff and residents, with interventions to monitor whereabouts and maintain safe distances. The resident had diagnoses including stroke-related paralysis on the left side, bipolar disorder, depression, and epilepsy.
Both residents had intact cognitive abilities, according to their assessments.
The facility's smoking policy required designated staff to oversee smoking activities during seven daily 15-minute sessions, from 8:30 a.m. to 8 p.m. Residents needing supervision had their cigarettes and lighters locked in the activity office.
But no dedicated staff member was assigned to the smoking area that day.
"We did not have any dedicated staff to stay out here with residents that needed to be supervised so we would all watch from the dining room door," the Activity Director told inspectors. The director and assistant were the only ones with keys to the cigarette storage, though weekend managers also had access.
The Activity Director's assistant, who had been working that day, no longer worked at the facility by the time of the inspection.
Licensed Vocational Nurse 2, the charge nurse on June 8, said the Activities Department was supposed to notify nursing staff when Resident 1 went outside to smoke. "No one from the activity department told me that [Resident 1] was outside smoking that day," the nurse said.
The smoking policy stated the facility "shall assign a designated smoking staff to oversee smoking activity during specified hours." It required gathering smoking supplies at the end of each session and storing them in medication carts for safekeeping.
Resident 2's written statement described the escalation: Resident 1 "flipped off" Resident 2 after being told there was no lighter available. When Resident 1 returned asking again for a light, Resident 2 threw the cigarette on the ground, triggering the violence.
Two days after the fight, an interdisciplinary team informed Resident 1 of the facility's zero tolerance rule for violence. The team instructed the resident to notify staff of future conflicts and remove themselves from situations.
Resident 2 was discharged home four days after the incident.
"This incident could have been avoided if there was supervision during the time and if staff members would have been aware of the smoking times," Administrator told inspectors.
Licensed Vocational Nurse 1 agreed: "I do think we could have done a better job in terms of more frequent rounds when residents are outside smoking."
The nurse added, "I'm not sure what [Resident 1] needed when smoking but I would have guessed [Resident 1] needed to be supervised."
Federal inspectors cited the facility for failing to ensure residents were free from accident and injury, noting actual harm to a few residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Vista Post-acute Care Center from 2024-06-24 including all violations, facility responses, and corrective action plans.
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