|Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 4/1/2015
Report Timely: Yes
Type of Occurrence: Diverted Drugs
DESCRIPTION OF OCCURRENCE:
On 04/01/15 a tablet of Tramadol was determined to be missing.
The facility conducted an internal investigation and notified police and appropriate facility personnel. The missing medication was discovered during a change of shift medication count. A search was conducted but it was not found. An empty blister pack for a 50 mg Tramadol was found in a trash can in the medication room. No patients were prescribed Tramadol at the time of the incident. Nurse A reported she had handed off the medication keys twice during her shift narcotic counts were not done either time. The facility was not able to determine what happened to the medication. The 3 staff members were given Performance Improvement Plans for their failure to follow facility policy regarding counting of narcotics anytime keys are handed off.
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 investigation and implementing Performance Improvement Plans for staff who failed to follow facility policy.
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: 5/28/2015
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 6/11/2015