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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Friday, September 22, 2017 11:48 PM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 9/4/2015
Report Timely: Yes
Type of Occurrence: Abuse/Physical

DESCRIPTION OF OCCURRENCE:
On 09/04/15 a male resident, in his 50s. was allegedly physically assaulted by a staff member.

FACILITY ACTION:
The facility conducted an internal investigation. The facility notified the police department and appropriate facility administration and personnel. Staff member (2) witnessed the patient attempting to attack staff member (1). Staff member (1) allegedly pushed the patient. Staff member (1) reported the patient did not fall or sustain any injury. Staff member (1) was suspended. The patient was assessed and there were no injuries noted. Staff member (2) reported the resident fell backward into the wall but did not fall down. Investigation revealed there was another staff member (3) who also witnessed the incident. Staff member (3) reported the resident was observed leaning against the wall and staff member (1) was standing with their arms held out. Staff member (3) did not see staff member (1) push the resident. Staff member (2) and (3) were suspended for not reporting the incident timely. Another patient reported they saw staff member (1) with their arm held out and did not see staff member (1) touch the patient. Staff member (1) reported the resident attempted to hit him so he put his hand out in a stop gesture. The patient began to walk away, but then turned and attempted to attack staff member (1) again. Staff member (1) put his hand up in a stop gesture. The patient hit staff member (1)'s hand and then lost his balance. The patient was able to stabilize himself and went to his room. The patient did not exhibit any signs of withdrawal or andy change in behavior. All staff members were reinstated. Staff member (2) and (3) were educated on timely reporting. Staff member (1) received a performance improvement plan which included education on abuse and reporting incidents. The facility will monitor staff member (1) for six months to ensure compliance with policies and procedures.

DEPARTMENT FINDINGS:
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, assessing the patient, suspending staff member (1), conducting an investigation, suspending staff member (2) and (3), reinstating the 3 staff members, educating staff members (2) and (3) on timely reporting, issuing a performance improvement plan for staff member (1), educating staff member (1) on abuse and incident reporting and monitoring staff member (1) to ensure compliance.

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: 11/5/2015

FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.


Released to Public: 11/16/2015

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