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Based on medical record review, policy review, and staff interview, it was determined the facility failed to follow their policy to ensure complaints were properly logged and investigated. This affected two (Patient #1 and #3) of three medical records reviewed for complaint investigation process. The census was 54.

Findings include:

Review of the complaint log on 01/07/25 revealed no complaint from Patient #1 or Patient #3.

1. Review of Patient #1's medical record revealed an involuntary admission date of 12/06/24 for severe depression, inability to contract for safety, and to benefit from stabilization at an inpatient hospital. The patient was admitted to the Sage Unit at 4:00 PM from the hospital after being assessed and or medically cleared for transient left sided facial droop, altered mental status, confusion, and a saccular aneurysm.

Review of the transferring hospital discharge information stated the patient had opioid dependence and was being seen in the community by a methadone clinic. Further review of the transferring hospital discharge revealed a list of all at home and inpatient medications, which included methadone (drug used for addiction to block the high from opioids drugs) 60 milligrams (mg) by mouth once a day. The discharge information also stated Patient #1's methadone was decreased at the previous hospital to 60 mg because she had taken all the methadone was provided to last her through 12/10/24. The last dose of methadone 60 mg was administered on 12/05/24 at 11:12 AM at the hospital prior to admission at River Vista.

Review of provider note dated 12/07/24 at 11:02 AM revealed the patient was requesting methadone and reported she could not eat without taking it. The provider noted the patient had been seen at a hospital on 11/27/24 for concerns of encephalopathy due to opioid withdrawal. Review of nursing note dated 12/07/24 at 10:33 PM revealed the patient complained of abdominal pain and shortness of breath. The nurse notified the on-call provider and was ordered to continue monitoring the patient. Vital signs were obtained and within normal limits.

Review of a nursing note dated 12/08/24 at 7:44 PM revealed the patient told the nurse her stomach hurt and she was having a hard time breathing. The nurse practitioner was notified at 12:39 PM and ordered an electrocardiogram (EKG), Bentyl for abdominal pain, and Imodium for diarrhea. Review of nursing note dated 12/08/24 at 6:25 PM revealed the patient was having issues regarding withdrawal symptoms, complaining of stomach pain and nausea. The nurse noted the patient was previously on methadone and the psychiatric nurse practitioner was awaiting confirmation from the methadone clinic to confirm her dosage and "As this was not done the previous day." The nurse noted the methadone clinic was Googled and was listed as closed on Sundays and did not open again until Monday 12/09/24. The psychiatric nurse practitioner was notified of this on 12/08/24 and ordered Suboxone (medication used to treat narcotic dependence) 8 mg/2 mg by mouth. The Suboxone was given at 9:15 AM on 12/08/24 and the nurse noted there were no issues immediately after taking the medication. The nurse noted later the patient came out of her room, lowered herself to the floor, and laid down. The nurse practitioner was notified. The nurse noted later that same day the patient lowered herself to the floor again complaining of stomach pain. Vital signs were obtained and the health nurse practitioner was notified. It was not advised to send the patient out at that time. At 3:05 PM the nurse noted she contacted the psychiatric nurse practitioner who stated he had spoken with the health nurse practitioner and they decided Bentyl and Flexiril could be given to help the patient. At 3:58 PM a Code Blue was called for the patient. Cardiopulmonary resuscitation (CPR) was initiated and emergency medical services (EMS) arrived at 4:10 PM. EMS continued CPR and gave the patient epinephrine with a pulse regained. EMS then transported the patient to the hospital.

The nurse noted while the code was going on the patient's family, to include a daughter, was at the hospital for a visitation. The daughter stated she had called this hospital on Friday, 12/06/24, and whoever she spoke to already knew her mom was on methadone. The nurse noted the daughter stated her mom had been at the facility on 12/06/24 at approximately 3:00 PM and she did not understand why the medication had not been verified by 12/08/24. The nurse noted she explained to the family that even though it was on her medication list it had to be verified by the methadone clinic.

Interview on 01/07/25 at 3:30 PM, Nurse Manager Staff F stated she was not sure why the concerns the daughter had voiced were not on the complaint log.


2. Review on 01/07/25 at 2:08 PM of Patient #3's medical record revealed the patient was admitted on 09/25/24 from another hospital with a diagnosis of schizophrenia. She was sent to the hospital from her group home for a psychiatric evaluation and possible medication adjustments. The presenting problems were listed as homicidal ideation, agitation, and audio and visual hallucinations.

Review of the Initial Medical Screen dated 09/25/24 revealed the patient was independent with physical care including toileting and hygiene. There was no more mention of Patient #3's skin. Review of the Patient Valuables and Belongings Inventory dated 09/25/24 at 10:27 PM revealed the patient did not require a bin for her belongings as there were pink shoes, a tan bra, black pants and a gray shirt. Glasses were not listed on the form.

Review of the Initial Nursing Assessment, including the skin assessment, dated 09/26/24 at 12:40 AM revealed the patient had redness under right breast and to left groin area.

Review of the General Progress Note dated 09/26/24 at 3:00 PM noted by Staff G, a licensed social worker (LSW), revealed he spoke with the patient's caretaker regarding the patient's needs while in the facility. The needs they spoke of were not documented in the note.

Review of the discharge summary dated 10/03/24 revealed the patient was admitted for psychosis, unspecified mood disorder, depression and anxiety. The provider noted the patient was able to perform activities of daily living to include grooming and hygiene.

Interview on 01/08/25 at 11:50 AM with Staff F stated Patient #3's group home had called and said the patient had not showered and did not have her glasses. She stated she pulled the shower logs and the patient had showered on 09/26/24 at 7:00 PM and 09/30/24 at 6:20 PM. She stated the hospital pulled the camera recordings to verify the patient was showered. Staff F verified the patient did not have on glasses on admission as per her admission picture, nor was it noted in the inventory paperwork. She stated the hospital pulled the camera recordings to see the patient being admitted and there were no glasses present. Staff F verified that the concerns raised about Patient #3 were not on the complaint log. Staff F verified that some sort of investigation had been completed already and stated she did not know why this was not on the complaint log.

Review of the hospital policy titled "Patient Complaints and Grievances," dated 01/23, revealed any complaint received by a staff member will be appropriately documented and an attempt to resolve the concern must be made if possible. If the concerns cannot be resolved at that time, the complaint will be referred to the patient advocate or designee. Any complaint or grievance received after the patient is no longer in the facility should be documented by the staff member receiving it and forwarded to the patient advocate or designee. The patient advocate or designee will review and attempt to resolve the grievance within seven business days. All other grievances will be followed up with a letter within 30 days of the facilities decision. The complaint/grievance and resolution should be documented on the complaint log.

Based on medical record review and staff interview, it was determined the facility failed to ensure medication was administered as ordered. This affected one (Patient #1) of three medical records reviewed for medication. The census was 54.

Findings include:

Review of Patient #1's medical record revealed an involuntary admission date of 12/06/24 for severe depression, inability to contract for safety, and to benefit from stabilization at an inpatient hospital. The patient was admitted to the Sage Unit at 4:00 PM from the hospital after being assessed and or medically cleared for transient left sided facial droop, altered mental status, confusion, and a saccular aneurysm.

Review of the transferring hospital discharge information stated the patient had opioid dependence and was being seen in the community by a methadone clinic. Further review of the transferring hospital discharge revealed a list of all at home and inpatient medications, which included methadone (drug used for addiction to block the high from opioids drugs) 60 milligrams (mg) by mouth once a day. The discharge information also stated Patient #1's methadone was decreased at the previous hospital to 60 mg because she had taken all the methadone was provided to last her through 12/10/24. The last dose of methadone 60 mg was administered on 12/05/24 at 11:12 AM at the hospital prior to admission at River Vista.

Review of the medical record revealed the methadone had not been administered during the patient's stay.

Review of a nursing note dated 12/08/24 at 7:44 PM revealed the patient told the nurse her stomach hurt and she was having a hard time breathing. Review of nursing note dated 12/08/24 at 6:25 PM revealed the patient was having issues regarding withdrawal symptoms, complaining of stomach pain and nausea. The nurse noted the patient was previously on methadone and the psychiatric nurse practitioner was awaiting confirmation from the methadone clinic to confirm her dosage and "As this was not done the previous day." The nurse noted the methadone clinic was Googled and was listed as closed on Sundays and did not open again until Monday 12/09/24. The psychiatric nurse practitioner was notified of this on 12/08/24 and ordered Suboxone (medication used to treat narcotic dependence) 8 mg/2 mg by mouth. The Suboxone was given at 9:15 AM on 12/08/24 and the nurse noted there were no issues immediately after taking the medication. On 12/08/24 at 3:05 PM the nurse noted she contacted the psychiatric nurse practitioner who stated he had spoken with the health nurse practitioner and they decided Bentyl and Flexiril could be given to help the patient.

On 12/08/24 the patient was transferred to the hospital following a Code Blue with resuscitation. The nurse noted while the code was going on the patient's family, to include a daughter, was at the hospital for a visitation. The daughter stated she had called this hospital on Friday, 12/06/24, and whoever she spoke to already knew her mom was on methadone. The nurse noted the daughter stated her mom had been at the facility on 12/06/24 at approximately 3:00 PM and she did not understand why the medication had not been verified by 12/08/24. The nurse noted she explained to the family that even though it was on her medication list it had to be verified by the methadone clinic.

Interview on 01/07/25 at 3:30 PM with Nurse Manager Staff F revealed when patients come to the hospital on methadone the hospital staff must verify the dose from the methadone clinic who is following the patient. Staff F stated the providers are not allowed to order the methadone. Staff F stated the methadone clinics hours are short, Monday through Friday from 6:00 AM through 1:00 PM and from 6:00 AM through 9:00 AM Saturdays, and closed Sundays. Staff F stated medications should be reconciled in 24 hours and verified the patient arrived between 3:00 PM and 4:00 PM on Friday, 12/06/24. Staff F stated the nurse practitioner did not come in on 12/07/24 until after the methadone clinic closed, around 11:00 AM.

Interview on 01/08/25 at 4:00 PM with Staff H (Pharmacist) revealed when a patient is admitted on methadone nursing staff or the provider will need to call the methadone clinic to verify the dose the next time the clinic is open. Staff H stated since the methadone clinics do not report to Ohio Automated Record Reporting System (OARS) you can't verify the dose there. Staff H stated the medications should be reconciled within 24 hours. Staff H stated methadone is available in the hospital pyxis.