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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Monday, September 25, 2017 3:49 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 1/28/2015
Report Timely: Yes
Type of Occurrence: Neglect

DESCRIPTION OF OCCURRENCE:
On 01/28/15, a staff member failed to ensure the doors were alarmed per protocol on this unit.

FACILITY ACTION:
The facility conducted an internal investigation. The physician and police were notified. Staff noted a red mark on a female patient (B)'s neck. She was in her teens. She reported a male patient (A) in his teens had entered her room briefly on two occasions. They engaged in kissing activities. Patient (B) was not distressed by these activities. Staff assessed patient (B) and no injuries noted. The doors were to be alarmed when patients were in their rooms, so that no other person could enter/exit without staff's awareness. The facility concluded this was not done per policy as patient (A) was able to gain access to patient (B)'s room, undetected. The patients were placed on peer restriction from each other. Patient (A) had one to one monitoring by staff. Patient (B) was being closely monitored by staff. The facility concluded the allegation was substantiated when a staff member failed to activate the door alarms. The staff member reported she got distracted when addressing another patient. The staff member on duty at the time of events received a corrective action for neglecting to initiate the door alarms. A supervisor performed wellness checks of the staff member at three different shifts to monitor performance. All staff on the unit received updated training related to the expectations for arming the door alarms when patients are in their rooms at night.

DEPARTMENT FINDINGS:
The Department reviewed the facility's report and found that the facility acted appropriately by reporting the occurrence, notifying the appropriate persons and agencies, conducting an internal investigation, assessing patient (B), implementing peer restriction and monitoring, disciplining a staff member, re-educating the staff on procedures and monitoring staff with supervisory visits.

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: 3/11/2015

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


Released to Public: 3/27/2015

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