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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Monday, September 25, 2017 3:37 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 12/1/2015
Report Timely: Yes
Type of Occurrence: Diverted Drugs

DESCRIPTION OF OCCURRENCE:
On 12/01/15 a staff member reported 10 tablets of Atenolol were missing. The medication had been prescribed for a male patient in his 60s.

FACILITY ACTION:
The facility conducted an internal investigation. The facility notified facility personnel and police. The medication nurse noted there were only 6 Atenolol 25mg tablets in patient A’s medication drawer. The medication had been filled by the pharmacy the day before and there should have been 16 tablets present. The medication room, including the other patient’s medication drawers, the trash and the pharmacy return bag were searched but the missing Atenolol were not found. Staff were interviewed and denied knowing what happened to the medication. One staff member admitted sometimes leaving the medication cart unlocked in the medication room while administering medications to a patient in their room. A corrective/disciplinary action with the staff member was being reviewed at the time of the facility report.

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, conducting a search and investigation and considering corrective/disciplinary action with a staff member for failure to always lock the medication cart.

The Department will review this occurrence prior to the next survey.

Sent to Facility: 3/17/2016

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


Released to Public: 3/28/2016

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