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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Thursday, September 21, 2017 1:29 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 7/5/2016
Report Timely: Yes
Type of Occurrence: Abuse/Physical

DESCRIPTION OF OCCURRENCE:
On 07/08/16 a female patient, in her 60's, reported an allegation of physical abuse occurring on 07/05/16.

FACILITY ACTION:
The facility conducted an internal investigation and notified the police. The patient was admitted to the facility on 06/20/16. She had a history of psychiatric diagnoses and was declared incompetent to proceed related to charges of theft/defrauding Social Security and Medicaid. She was described as verbally aggressive with staff when she perceived her needs were unmet. On 07/08/16, the patient showed staff member (1) two bruises on her left, upper thigh. The bruises were approximately two centimeters in diameter and purple in color. The patient stated she was in the shower on 07/05/16 at 11:00 a.m. when staff member (2) allegedly entered the shower, grabbed the patient's leg, and made threatening statements to her. The patient asked staff member (1) not to report the alleged incident to anyone. The patient complained of intense thigh pain, for which pain medication was administered. The patient later reported the pain was resolved. The patient denied fearing staff member (2). Staff member (2) was placed on administrative leave pending the outcome of an investigation. The facility's investigation revealed staff member (2) was involved in an alleged neglect occurrence from September 2015, during which a staff member allegedly witnessed staff member (2) being verbally threatening and neglecting a patient's toileting needs. As a result of the occurrence, staff member (2) was required to attend re-training of "Verbal Judo Skills" and review an abuse and neglect policy. The facility interviewed fellow staff members regarding the current allegation. Staff reported observing interactions between the patient and staff member (2) during which the patient was allegedly verbally aggressive with staff member (2). Staff reported the patient appeared to be "targeting" staff member (2). Staff member (3), who was assigned to perform shower checks on 07/05/16, identified staff member (2) was not observed entering the shower room during the time given by the patient. Also, documentation reflected the patient was in the shower on 07/05/16 from 8:05 a.m. to 8:20 a.m. and not around 11:00 a.m. as reported by the patient. Staff member (2) was noted to be facilitating a community meeting during that time. The patient reported she and staff member (2) never "hit it off," stating they "butt heads all the time." During the course of the investigation, the patient made inconsistent statements regarding the event in question, specifically the statement allegedly made by staff member (2) during the patient's shower. The delegated appointing authority reviewed the event and was unable to substantiate the patient's abuse allegation. Staff member (2) was directed to attend a "Verbal Defense and Influence" class and an "Effective/Therapeutic Communication" class to assist with communication skills. Staff member (2) returned to work on 07/25/16.

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: 10/13/2016

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


Released to Public: 10/26/2016

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