|Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 10/20/2015
Report Timely: Yes
Type of Occurrence: Diverted Drugs
DESCRIPTION OF OCCURRENCE:
On 10/20/15 during the change of shift narcotic count, a patient's Hydrocodone medication was off by 1 tablet. The medication was prescribed for a male patient, in his 40s.
The facility conducted an internal investigation. The facility notified police and appropriate facility personnel. Staff members A and B performed a count of controlled medications at the change of shift, between shift III and shift I on 10/20/15. The count was correct for all medications. Staff member A administered 2 Hydrocodone tablets to the patient at 9:00 a.m. for a complaint of pain. Later when staff member A was checking the medication book and medication count he noticed there were 18 Hydrocodone tablets but there should have been 19. A search was conducted but the missing Hydrocodone was not found. During interview, a staff member reported obtaining 2 tablets of Hydrocodone from the locked medication drawer. He stated he remembered 1 pill that was in a blister pack, but not attached to the other blister packs, fell out of the bag. He believed he had put it back in the bag when he was done. The facility concluded this staff member was responsible for the missing tablet but did not believe he intentionally diverted it. The staff member was given an Opportunity for Education Plan which included a review of the policy Medication Practices and Procedures for Controlled Medication Count and Wasting Controlled Medication with his 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 and giving the staff member an Opportunity for Education Plan.
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: 3/11/2016
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 3/22/2016