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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Thursday, November 23, 2017 4:02 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 1/18/2015
Report Timely: Yes
Type of Occurrence: Diverted Drugs

DESCRIPTION OF OCCURRENCE:
On 01/18/15 the facility was unable to account for 7 tablets of Aircept prescribed for a female patient in her 60s.

FACILITY ACTION:
The facility conducted an internal investigation. The facility notified police and the physician. The medication was missing from the patient's locked medication drawer. A search was conducted but the medication was not located. Pharmacy staff had been on the unit on 01/12/15 and filled the medication drawer with a 14 day supply (14 tablets). On 01/18/15 there should have been 9 tablets remaining but there were only 2 tablets left. Pharmacy staff provided information regarding the count process that is conducted prior to the medications going to the unit. The paperwork on this count verifies that a 2 week supply, 14 pills, were sent to the unit. The facility concluded that the medication was misplaced without any identified suspects. The facility implemented a process where the nursing staff will recount the medications that arrive from the pharmacy and sign off on the paperwork that accompanies the medications from the pharmacy.

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 a search and investigation and implementing a new process for counting and documenting medications delivered from the pharmacy.

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: 3/6/2015

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


Released to Public: 3/20/2015

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