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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Sunday, November 19, 2017 5:00 PM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 12/8/2015
Report Timely: Yes
Type of Occurrence: Diverted Drugs

DESCRIPTION OF OCCURRENCE:
On 12/08/15 a staff member reported 1 tablet of Ativan was missing.

FACILITY ACTION:
The facility conducted an internal investigation. The facility notified police. A staff member completed a noon medication pass. She then recounted the narcotics and noted she was short 1 tablet of Ativan. A search was conducted but the missing pill was not found. Staff spoke with 2 patients who receive Ativan. One patient stated he had received 1 tablet and the other patient could not say what he received as he takes numerous medications. The staff member was interviewed and denied leaving the medication cart unlocked or having the keys out of her possession. The facility concluded the medication was accidentally lost or an extra dose inadvertently administered. The staff member was given an Opportunity for Improvement which included a review of the policy for Medication Practice. Monitoring of the staff member was initiated.

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, giving the staff member an Opportunity for Improvement and increasing monitoring of the staff member.

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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