|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 one tablet of Ativan was discovered to be missing. It had been prescribed for a male patient in his 70s.
The facility conducted an internal investigation. The facility notified police and management. The missing medication was discovered during the change of shift medication count. A search was conducted but it was not located. Only one patient was taking this specific medication and the nurse on duty reported she remembered administering it to him. She denied handing off the keys to the medication cart to anyone and did not take a break during the shift. The nurse received a corrective action and increased monitoring from her supervisor.
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 a search and investigation, giving a corrective action to the nurse and increasing monitoring of the nurse.
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: 4/27/2015
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 5/8/2015