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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Monday, September 25, 2017 3:31 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 12/15/2015
Report Timely: Yes
Type of Occurrence: Neglect

DESCRIPTION OF OCCURRENCE:
On 12/15/15 ECT (Electroconvulsive Therapy) was started prematurely on a male patient, in his 50s.

FACILITY ACTION:
The facility conducted an internal investigation and notified the patient and administrative personnel. Staff was setting up the patient for an Electroconvulsive Therapy (ECT). The treatment started before staff administered the general anesthesia. Upon realization, staff immediately administered the IV push of Brevital to sedate the patient and the treatment continued. At the cessation of the seizure, the patient was assessed and found to have superficial puncture marks to his lower lip. The patient's vital signs were within normal limits and the medical providers felt there were no adverse reactions to the incident. Through the investigation, it was determined that a miscommunication coupled with a non-routine procedure contributed to the start of treatment without the administration of anesthesia and staff did not intentionally attempt to harm the patient. Staff was counseled to minimize distractions during the administration of ECT therapy treatments.

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 and conducting an investigation.

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


Sent to Facility: 2/19/2016

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


Released to Public: 3/1/2016

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