|Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 2/19/2015
Report Timely: Yes
Type of Occurrence: Diverted Drugs
DESCRIPTION OF OCCURRENCE:
On 02/19/15 the facility determined that a drug diversion of one tablet of Neurontin had occurred. Two patients on this unit received this medication; a female patient, in her 20s, and a male patient in his 40s.
The facility conducted an internal investigation. The facility police and administrative personnel were notified. Staff noted one tablet of 400 mg Neurontin was unaccounted for at shift change. The Neurontin was kept in the locked narcotic drawer in the locked medication cart which was kept in the locked medication room. A search was conducted of the medication room, medication cart and trash but the Neurontin was not found. The facility was unable to determine if one of the patients had been given an extra pill or if the medication had been lost. No perpetrator was identified. The psychiatric technician as well as other staff were re-educated on medication practice and policies.
The Department reviewed the facility's report and found the facility acted appropriately by reporting the occurrence, notifying the appropriate persons and agencies, conducting an internal investigation and search, and re-educating staff on medication practice and policies.
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: 4/3/2015
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 4/16/2015