EL MONTE, CA - Federal inspectors found widespread call light system malfunctions at Mayflower Care Center during an August 1, 2024 investigation, documenting safety violations that left vulnerable residents unable to summon help during emergencies.
Call Light Accessibility Failures Put Residents at Risk
The inspection revealed multiple residents could not access their emergency call systems when needed. Investigators documented that call light cords were wrapped around bed frames and dangling inches from the floor, making them impossible for residents to reach. This problem was particularly concerning given that many of the affected residents had severe cognitive impairments and required assistance with daily activities.
When investigators interviewed Resident 1, they found her call light cord wrapped around the bed frame and completely out of reach. "She did not know where her call light was located," the report states. When informed about the location, the resident confirmed "she could not reach the call light button in that position." More alarming, Resident 1 reported she "had a fall on her right side in the bathroom" approximately a month prior and had no way to call for assistance during the incident.
A second resident faced similar difficulties. Resident 2's call light was also wrapped around the bed rail and inaccessible. When asked about bathroom emergencies, the resident explained she "did not use the call light for assistance in the bathroom" because "the cord is too short to reach when sitting on the toilet."
Bathroom Call Light Systems Compromised Throughout Facility
The investigation revealed systemic problems with bathroom emergency call systems affecting multiple residents. In one case, Resident 1's bathroom was completely missing the emergency pull cord, leaving no way to signal for help during bathroom emergencies. The resident told inspectors "the cord was missing for quite some time" and that she had "informed the nurses about it, but nothing was done."
During facility-wide testing, inspectors found bathroom call light cords measuring 15 inches or less in length throughout the facility, making them unreachable from toilet seats or the floor during falls. This creates dangerous situations for residents who may experience medical emergencies while using bathroom facilities independently.
Testing revealed additional malfunctions where call lights failed to properly alert nursing staff. In several rooms, pulling the bathroom emergency cords did not activate the warning lights above residents' doors, meaning staff would not be notified of emergencies even if residents could reach the call systems.
Medical Significance of Call Light Access
Call light systems serve as critical safety lifelines in nursing homes, particularly for residents with cognitive impairments, mobility limitations, and fall risks. The affected residents at Mayflower Care Center had complex medical conditions including dementia, encephalopathy, schizophrenia, and histories of falling - conditions that increase their vulnerability during emergencies.
When residents cannot summon help quickly, minor incidents can escalate into serious medical emergencies. Falls in bathrooms are particularly dangerous for elderly residents due to hard surfaces and confined spaces. Delayed response to cardiac events, strokes, or severe falls can result in permanent disability or death.
Federal nursing home standards require call lights to be within residents' reach at all times, including when using toilets, specifically to prevent these types of emergency situations. The regulation exists because cognitive impairment and physical limitations make it difficult for many residents to move independently to seek help.
Staff Recognition of Safety Hazards
Nursing staff interviewed during the inspection demonstrated awareness of the safety problems. When shown the wrapped call light cords, a Certified Nursing Assistant stated, "It should not be wrapped around the bed rail like that because Resident 1 will not be able to reach the call light." The staff member immediately repositioned the device and explained, "It is important to have the call light be visible and within reach for Resident 1 to use to call for help if we are not around."
Another staff member examining a too-short bathroom cord acknowledged that "Resident 2 would struggle to call for help if on the toilet and she wouldn't be able to reach a short cord." This recognition by staff indicated the problems were visible and known but had not been systematically addressed.
Additional Issues Identified
Beyond the call light system failures, the inspection documented residents with severe cognitive impairments and complex medical needs including dementia, schizophrenia, encephalopathy, and histories of falling. Multiple residents required assistance with basic activities like bathing, dressing, and toilet use, making access to emergency call systems even more critical for their safety.
The facility's own policy, revised in March 2023, specifically required "ensuring that the call light was within the resident's reach when in his/her room or when on the toilet," highlighting that staff were aware of proper procedures but failed to implement them consistently.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mayflower Care Center from 2024-08-01 including all violations, facility responses, and corrective action plans.
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