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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Sunday, November 19, 2017 12:42 PM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 8/15/2016
Report Timely: Yes
Type of Occurrence: Equip Malfunction/Misuse

DESCRIPTION OF OCCURRENCE:
On 08/15/16 a male patient, in his 50's, was being assisted to the bathroom with the use of a mechanical lift. During the transfer, the patient slipped through the belt of the lift, landed on his right side, and complained of right rib pain.

FACILITY ACTION:
The facility conducted an internal investigation and notified the police. The patient was diagnosed with traumatic brain injury and dementia. He was gravely disabled and required total care with activities of daily living. He was assisted to the toilet by a staff member with the use of a mechanical lift. He was reportedly bouncing himself in the lift. He ultimately slipped through the belt of the lift and landed on his right side. He was assessed as uninjured and initially reported no pain. When assessed by the medical provider, the patient complained of right rib pain. An x-ray was immediately obtained which revealed an old, healing rib fracture. He required no treatment and remained at his baseline status. The lift was inspected by a manufacturer's representative and found to be in working order. The facility determined the staff member who applied the straps of the lift to secure the patient failed to place them tight enough, allowing the patient to slip out of the straps. The staff member identified using the same lift at a previous place of employment. The staff member noted current training on the lift was received by facility peers. The facility identified formal training for proper use of the lift was not in place. The facility began formal training on proper use of the lift on 08/19/16. All staff was required to attend a training session and demonstrate competency through return demonstration. The facility was developing competencies and policies related to use of the lift. The training was slated for inclusion in the facility's annual competency fair. Staff was not allowed to use the lift until training was received.

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: 11/23/2016

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


Released to Public: 12/13/2016

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