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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Friday, September 22, 2017 11:47 PM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 12/6/2015
Report Timely: No
Type of Occurrence: Neglect

DESCRIPTION OF OCCURRENCE:
On 12/06/15 a male patient, in his 20s, alleged he had been neglected by staff.

FACILITY ACTION:
The facility conducted an internal investigation and notified the police. This patient reported several concerns regarding his care and treatment. The patient stated staff member (1) got upset with him and called him derogatory names. The patient also stated he was left on the floor mat following a seizure and staff did not assist him into bed. The patient stated he heard staff member (2) tell other staff members to leave him on the floor, "if he doesn't want to get up, just leave him there." The patient reported he had been given Ativan which made him extremely sedate and he was unable to move or help staff. The patient reported he believed he was on the floor approximately three hours before he woke up again and then he was able to get himself up. The patient denied he was injured and stated he was not fearful. The two staff members were placed on administrative leave pending the outcome of the investigation. Staff reported the patient did have a seizure and they were caring for him. The staff reported the patient was combative when they tried to move him, so they provided him with a pillow and sheet to sleep. Staff member (2) did acknowledge she made this comment in frustration. A staff member failed to complete an incident report on these allegations. Staff received disciplinary action for late reporting. Staff member (2) was placed on a performance improvement plan including a review of the Code of Conduct and attended a class for communicating non-defensively. Staff member (1) also received a personnel performance action plan. A new safety plan was implemented to address the patient's post seizure needs. The facility reported the patient worked out the issues with staff and had no further concerns.

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/agencies and conducting an investigation. However, the facility is subject to a deficiency for late reporting.

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


Sent to Facility: 3/3/2016

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


Released to Public: 3/17/2016

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