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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Sunday, November 19, 2017 5:04 PM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 12/2/2014
Report Timely: Yes
Type of Occurrence: Diverted Drugs

DESCRIPTION OF OCCURRENCE:
On 12/02/14 the facility determined that a drug diversion of 7 tablets of Omeprazole had occurred. The medication had been prescribed for a male patient in his 60s.

FACILITY ACTION:
The facility conducted an internal investigation. The facility notified the police department. The pharmacy dispensed 8 tablets of Omeprazole for the patient on 12/01/14. One tablet was administered on the same date. The next day, a staff member went to administer the medication and found the pharmacy bag empty. A search was conducted, but the missing medication was not found. Staff were interviewed and no suspect was identified. One staff member stated she had left the keys to the medication room and medication cart in a drawer at the nurse's station. Leaving the keys unattended was a violation of facility policy. Staff were required to review the facility medication policy and practices.

DEPARTMENT FINDINGS:
The Department reviewed the facility's report and supplemental documentation and found that the facility acted appropriately by reporting the occurrence, notifying the appropriate persons and agencies, conducting an internal investigation, completing a search for the missing medication, interviewing staff, and ensuring staff reviewed the facility medication policy.

No deficient practice was cited. The Department will review this occurrence prior to any survey or upon receipt of any complaint that may be filed against this facility.

Sent to Facility: 1/29/2015

FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.


Released to Public: 2/11/2015

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