New Vista Post-Acute: Smoking Fight Injury - CA

The June 8 incident at New Vista Post-Acute Care Center involved two residents and cleaning tools from an unattended housekeeping cart. Federal inspectors found the facility failed to provide required supervision, allowing a violent confrontation that sent one resident to the hospital.

Resident 1, who had suffered a stroke affecting the left side of his body and lived with bipolar disorder and depression, was supposed to be supervised while smoking. His care plan specifically noted episodes of touching staff and residents, with interventions requiring staff to monitor his whereabouts and maintain safe distances.

The facility's smoking policy designated seven specific 15-minute smoking periods throughout the day, from 8:30 a.m. to 8:15 p.m. Resident 1's cigarettes and lighter were kept locked in the activities office, distributed one at a time when he wanted to smoke.

But on the afternoon of June 8, nobody was watching.

According to Resident 2's handwritten statement, Resident 1 was trying to get a cigarette lit but no one would help, so people moved away. Resident 2 called Resident 1 back, offering to light the cigarette, but Resident 1 responded by giving him the middle finger.

When Resident 1 returned asking for a light, Resident 2 took the cigarette and threw it on the ground.

That's when the fight escalated to weapons.

Resident 1 wheeled his chair to a housekeeping cart left in the smoking area, grabbed a dust broom, and struck Resident 2 four to five times on the head, shoulder, and hands. Resident 2 wrestled the broom away. Resident 1 went back to the cart, grabbed a dustpan, and hit Resident 2 again.

Resident 2 then took the dustpan and struck Resident 1 in the forehead.

Licensed Vocational Nurse 1 discovered the fight by accident around 2 p.m. while looking for another resident. Walking past the sliding glass door to the smoking patio, she saw Resident 1 holding a broom from behind and Resident 2 in front holding a dustpan over his head "as if to hit Resident 1."

She rushed outside immediately.

When Resident 1 turned around in his wheelchair, blood was streaming from the left side of his forehead. No other staff members were present.

The nurse wheeled Resident 1 to the nursing station, where the charge nurse applied an ice pack and called 911. Emergency medical technicians transported him to the hospital that evening.

At the emergency department, doctors diagnosed a head contusion and scalp laceration. The wound measured half a centimeter deep through the top layer of skin. Medical staff performed laceration repair with high-pressure saline wash and closed the area with surgical skin glue.

He returned to the facility the same evening.

The Activities Director explained the smoking supervision system to inspectors. Only she and her assistant held keys to the office where cigarettes were stored. On weekends, any department head on duty as manager would have access.

"Nursing staff do not have access to the activity office or any of the residents' cigarettes," she said.

But the supervision itself was haphazard. The facility had no dedicated staff assigned to the smoking area. Instead, supervision was "provided by all staff through frequent visual checks" and watching "from the dining room door because there is a direct line of sight to the smoking area."

The Activities Director wasn't present during the fight. Her assistant, who might have been supervising, no longer worked at the facility by the time inspectors arrived.

The charge nurse on duty June 8 told inspectors that Resident 1 required supervision when smoking and was at risk for injury if left alone. She said the Activities Department was supposed to notify nursing staff when Resident 1 was outside smoking.

"No one from the Activities Department told me that [Resident 1] was outside smoking that day," she said.

Licensed Vocational Nurse 1, who broke up the fight, acknowledged the system's failure. "I do think we could have done a better job in terms of more frequent rounds when residents are outside smoking," she told inspectors. "We don't have anyone designated to sit out there so it's up to all of us to collectively watch the residents."

She wasn't sure what supervision Resident 1 needed while smoking, "but I would have guessed [Resident 1] needed to be supervised."

The facility's own policy promised to "protect the rights, safety, and wellbeing of each resident" against "any treatment that would result in physical harm, pain, mental suffering." The policy specifically defined physical abuse as including "assault" and "hitting."

Two days after the incident, the facility held an interdisciplinary team meeting with Resident 1. Staff informed him of the facility's "zero tolerance rule for violence" and instructed him to notify staff immediately about any future conflicts with residents and remove himself from situations.

They also told him to participate in activities.

When inspectors interviewed the Administrator about the incident, she was direct about what went wrong. "Yes, 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."

Resident 2, who had diabetes and was missing his right leg above the knee, was discharged home four days after the fight.

The housekeeping cart that provided the weapons remained accessible in the smoking area, where residents requiring supervision continued to gather during designated smoking periods throughout the day.

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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