145649
08/21/2024
Odin Health and Rehab Center
300 Green Street Odin, IL 62870
F 0550
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to answer resident call lights in a timely manner for 5 of 8 residents (R1, R2, R3, R4, R5) reviewed for call light response times in a sample of 8.
Findings included: 1. R1's EHR (electronic health records) documented R1 was admitted to this facility on 6/26/2024 on Hospice with diagnoses of Breast Cancer, Anemia and Right Renal Cell Carcinoma among others. R1's MDS (minimum data set) dated 7/2/2024 documented R1 has a BIMS (Brief Interview for Mental Status) score of 15 out of 15 which indicated R1 is cognitively intact. This same MDS documented R1 needs partial moderate assistance to transfer, for toileting and showering. On 8/20/2024 at 10:00am, R1 said she has waited up to two hours for staff to answer her call light. R1 said she couldn't remember what the date was but she spoke with V4 (Family) and a grievance form was completed concerning the event. The facility's grievance log for 6/1/2024-8/20/2024 documented R1 filed a grievance for excessive call bell response times on 6/30/2024, 7/13/2024 and 8/8/2024. The facility's written response to R1's call bell response time grievance for 6/30/2024 was documented as, Call lights are answered in an appropriate manner just being timely is a must and staff were verbally educated. The facility's written response to R1's call bell response time grievance for 7/13/2024 was documented as, Call light response time not appropriate according to family and discussions were had with staff. The facility's written response to R1's call bell response time grievance for 8/8/2024 was documented as, Call light was not answered and or care not provided in a timely manner and staff are to answer call bell in a timely manner. 2. On 8/21/2024 at 9:35am, R5 said he filed a grievance due to waiting 45 minutes for staff to come help him with pulling up his pants and underwear after toileting. R5 said he can do everything else but can't get his pants over his feet and pulled up. R5 said he sees call lights activated all the time while staff stand around the desk socializing and on their cell phones. R5's MDS dated [DATE] documented R5 has a BIMS of 15 out of 15, which indicates R5 is cognitively intact. The facility's grievance log for 6/1/2024-8/20/2024 documents R5 filed a grievance for excessive call bell response time on 6/27/2024. The facility's written response to R5's call bell grievance was documented as, Call bell had not been answered timely and spoke with staff about answering call lights in timely manner.
Page 1 of 2
145649
145649
08/21/2024
Odin Health and Rehab Center
300 Green Street Odin, IL 62870
F 0550
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
3. On 8/20/2025 at 11:25am, R4 said she has a very hard time getting the staff to answer her call light at times and she has to wait 30 or 40 minutes most of the time. R4 said it doesn't do any good to complain to the management because nothing gets done about it. R4's MDS dated [DATE] documented R4 has a BIMS of 15 out of 15 total indicating R5 is cognitively intact. 4. On 8/20/2024 at 1:59pm, R2 said he frequently has to wait 30-40 minutes for his call light to be answered. R2's MDS documented R2 has a BIMS of 15 out of 15 total indicating R2 is cognitively intact. On 8/20/2024 at 1:18pm, R2 activated his call light. R2's call light and doorway remained in continuous site of the surveyor while activated. At 1:40pm, staff went to answer R2's call light. R2's call light was activated 22 minutes before staff responded. 5. On 8/20/2024 at 1:19pm, R3 activated his call light. R3's call light and doorway remained in continuous site of the surveyor while activated. At 1:55pm, staff went to answer R3's call light. R3's call light was activated 36 minutes before staff responded. Multiple staff were observed standing in groups talking while R2 and R3's call lights were activated. At 2:00pm, R3 said he often waits long period of time for his call light to be answered, usually 30 to 60 minutes. R3's MDS documented R3 has a BIMS of 14 out of 15 total indicating R3 is cognitively intact. Facility's Resident Council Meeting minutes held August 7, 2024 document call light response times were a concern brought forward by the Resident Council at the meeting. On 8/21/2024 at 2:50am, V16 (Activity Director) said residents voiced concern at the August Resident Council Meeting about long call light wait times. V16 said staff are supposed to respond to resident call lights within 10 minutes or less. On 8/20/2024 at 11:15am, V6 (Certified Nursing Assistant) said staff are expected to answer resident call lights in less than 10 minutes. The facility policy titled Call Light Guidance (revision date of 8/20/22) documented the following, Resident call lights shall be responded to within a reasonable amount of time.
145649
Page 2 of 2
