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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Sunday, November 19, 2017 12:32 PM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 2/4/2016
Report Timely: Yes
Type of Occurrence: Neglect

DESCRIPTION OF OCCURRENCE:
On 02/04/16 the facility determined a nurse was potentially failing to follow standards of practice and facility policy with the potential for significant harm for male patient (A), in his 60's, male patient (B), in his 70's, and male patient (C), in his 50's.

FACILITY ACTION:
The facility conducted an internal investigation. Patient (A) returned after being hospitalized on 01/12/16 due to congestive heart failure. He was placed on a fluid restriction by his physician. On 02/04/16, nurse (1) witnessed patient (A) implore nurse (2) to obtain a soft drink for him as apparently promised by nurse (2). Nurse (1) reminded nurse (2) that patient (A) was on a fluid restriction and had already received half of the soft drink he was allowed for the shift. Nurse (2) disagreed with the restriction and called nurse (3), who confirmed the fluid restriction as set forth by physician order. Nurse (2) verbalized a decision to override the order with the intention to give patient (A) a soft drink and obtained money from the patient for a soft drink. Though no staff witnessed nurse (2) give patient (A) the soda, patient (A) stopped continually asking for a soft drink after nurse (2) collected the money, leading the facility to believe patient (A) had obtained a soft drink from nurse (2). During the same shift, a staff member observed patient (B) eating patient (C)'s special-order meal. The staff member learned that nurse (2) told staff to allow patient (B) to eat patient (C)'s special-order meal after patient (C) ate 10-20% of the meal and left. Meanwhile, nurse (2) reported ordering a regular meal for patient (C) with the intention of giving it to him after cutting up the meal instead of obtaining another special diet for him. Patient (C) was prescribed a special diet due to choking risks and was not safe to receive a regular texture meal. Patient (C) ultimately received only his special diet. However, based on the two events, nurse (2) was placed on administrative leave for potential neglect. Reviewers were ultimately unable to substantiate the allegations of neglect against nurse (2). Nurse (2), who classified patient (A)'s physician-ordered fluid restriction a "rights restriction violation," was allowed to return to duty on 04/07/16 after receiving education about concerns related to patient rights.

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: 4/14/2016

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


Released to Public: 4/25/2016

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