|Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 3/9/2015
Report Timely: Yes
Type of Occurrence: Diverted Drugs
DESCRIPTION OF OCCURRENCE:
On 03/09/15 a potential drug diversion occurred when a tablet of Neurontin, prescribed for for a male patient were noted missing. The patient was in his teens.
The facility conducted an internal investigation. The facility notified the police department and appropriate facility administration and personnel. During the narcotic count between shifts, the Neurontin count was one tablet short of the expected amount on the control record. Staff members were unaware of the discrepancy until the next narcotic count when a staff member drew a line through the control record to indicate a neurontin tablet had been wasted. Investigation revealed the staff member had dropped the missing tablet and incorrectly documented the event. Policies and procedures were not followed. The facility provided the involved staff member with counseling on policies and procedures for proper waste documentation followed by supervision for compliance.
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, and implementing corrective action to staff member in question through counseling and supervision.
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: 4/10/2015
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 4/20/2015