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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Monday, September 25, 2017 3:47 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 12/16/2014
Report Timely: Yes
Type of Occurrence: Neglect

DESCRIPTION OF OCCURRENCE:
On 12/16/14 a female patient, in her 50s, sustained an injury when a staff member neglected to maintain proper supervision.

FACILITY ACTION:
The facility conducted an internal investigation. The facility notified the physician. The patient was asleep in her bed while she was being monitored one-to-one by a staff member. The staff member looked away for a moment and when she looked back, the patient was observed on the floor. The patient was assessed and noted to be bleeding from her nose. The patient denied any pain and her vital signs where within normal limits. The patient refused to participate in an interview. She had been diagnosed with mental health issues. The staff member met with her supervisor to review and discuss policies and procedures related to one-to-one monitoring. She received disciplinary action and further education regarding patient safety and fall precautions.

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, assessing and treating the patient, interviewing staff, issuing disciplinary action to the staff member, educating the staff member regarding patient safety and fall precautions and reviewing policy and procedure related to one-to-one monitoring.

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: 2/11/2015

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


Released to Public: 2/26/2015

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