|Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 9/21/2015
Report Timely: Yes
Type of Occurrence: Diverted Drugs
DESCRIPTION OF OCCURRENCE:
On 09/21/15 during the change of shift narcotic count at 7:00 p.m, one Neurontin capsule was missing. The medication had been prescribed for a male patient in his 50s.
The facility conducted an internal investigation. The facility notified police and appropriate facility personnel. Staff member (1) and staff member (2) counted narcotics at 7:00 a.m. and the count was correct. Staff member (1) said she administered 1 Neurontin capsule to the patient at 9:00 a.m. and did not verify the count at that time. At 7:00 p.m. staff member (1) and staff member (3) counted the narcotics and the count for the Neurontin was off by 1 capsule. A search was conducted but the missing capsule was not found. Staff member (1) said she maintained possession of the keys to the locked medication cart throughout the shift. The patient was interviewed and said he had received 2 capsules of Neurontin. The patient was not considered to be a reliable historian. The facility was unable to determine if the missing Neurontin was the result of a deliberate diversion or if the staff member somehow lost the Neurontin or inadvertently administered an extra dose. Staff member (1) received retraining and the lead nurse reviewed procedures for cross shift narcotic counts in nursing rounds.
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, retraining staff member (1) and reviewing change of shift count procedures with nursing staff.
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: 11/16/2015
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 11/27/2015