|Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 5/18/2015
Report Timely: Yes
Type of Occurrence: Diverted Drugs
DESCRIPTION OF OCCURRENCE:
On 05/18/15 the facility discovered a possible diversion of Neurontin, prescribed for a male patient in his 80s.
The facility conducted an internal investigation. The facility notified police and hospital personnel. Nurse (1), who was administering medication on shift II, told the Charge nurse that she was going to hold the HS (bedtime) dose of Neurontin 200 mg for the patient as he was asleep. The medication is ordered for aggressive behavior at HS (Sundowners) and he receives two 100 mg capsules. As the Charge Nurse was leaving the unit, she noticed a Neurontin 100 mg. capsule on the floor at the front entrance door to the unit. The Neurontin count was correct at cross shift with four 100 mg. doses signed off as having been administered to the patient. Nurse (1), who administered medications, was the last person to exit the unit prior to the Charge nurse leaving. When contacted, she indicated that the patient was asleep on the couch at 5:00 p.m. Upon being awakened, he took two of his other medications and only one Neurontin capsule, refusing the second. Thinking she might convince him to take it in awhile, she stuck it in her pocket but then forgot about it. At bedtime he was again asleep on the couch so she initially planned to hold the medication. He did awaken, however and took the medication without issue. She contends that when she went to leave the unit, the 100 mg dose she'd put into her pocket must have come out when she pulled out her keys to open the door. She denied deliberately diverting this dose of medication. She did admit that this was extremely poor practice. However, she indicated that the medication in her pocket was not in the blister-pac and the medication that was found on the floor was in an intact blister-pac, never having been opened. The staff member will not be allowed to administer medication again until she has passed the medication administration competency. A Performance Improvement Plan will be initiated addressing her poor practice and failure to follow hospital policy for medication administration. Nurse (1) was not drug screened as the facility was informed that according to State of Colorado Personnel rules, drug screening cannot be initiated unless a staff member is obviously impaired at work.
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 investigation, removing nurse (1) from medication administration and implementing a Performance Improvement Plan for nurse (1).
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: 6/4/2015
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 6/15/2015