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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Thursday, September 21, 2017 1:34 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 1/17/2016
Report Timely: Yes
Type of Occurrence: Diverted Drugs

DESCRIPTION OF OCCURRENCE:
On 01/17/16 the facility determined there was a drug diversion of 14 tablets of Zydis (antipsychotic) tablets from a patient, who was in his 60s.

FACILITY ACTION:
The facility conducted an internal investigation and notified the hospital police. Staff member (1) reported 14 tablets of Zydis were missing from this patient's medication drawer. A search was conducted of the medication drawers and medication room. The medications were not found. The medications had been stored in a locked medication cart in the locked medication room, accessible only by staff. No staff member reported an awareness of the missing medications. The facility would continue monitoring the weekly delivery of medications and was looking at alternative monitoring measures.

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: 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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