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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Friday, September 22, 2017 11:47 PM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 2/14/2015
Report Timely: Yes
Type of Occurrence: Diverted Drugs

DESCRIPTION OF OCCURRENCE:
On 2/14/15, the facility determined ten pills of Naproxen were missing from a female patient's medication supply. The patient was in her 60s.

FACILITY ACTION:
The facility conducted an internal investigation. The facility police and appropriate personnel were notified. Staff discovered ten pills of Naproxen 500 mg were missing from this resident's supply in the locked medication cart. There should have been 16 pills and six were found. Facility staff administered the medications to the patient. A search was conducted of the medication cart. The pills could not be located. Through the investigation, it was discovered the lock on the medication cart could be opened without a key and that drawers were too small to hold two weeks of medications delivered from the pharmacy. Staff were interviewed. No perpetrator was identified. The patient had no increased pain complaints. The medication cart is locked and kept in the locked medication room, accessible to staff. The facility concluded the allegation of drug diversion was substantiated. The lock on the medication cart was repaired. A new cart was ordered. Staff were re-educated on reporting issues timely.

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 a search, conducting an internal investigation, repairing the lock, and re-educating staff on reporting issues.


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: 3/27/2015

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


Released to Public: 4/10/2015

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