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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Friday, August 18, 2017 3:16 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 9/25/2016
Report Timely: No
Type of Occurrence: Neglect

DESCRIPTION OF OCCURRENCE:
On 09/25/16 staff neglected to follow the dietary restrictions of a male patient in his 60s.

FACILITY/AGENCY ACTION:
The facility conducted an internal investigation and notified the police department and the state licensing agency. The patient was provided a hamburger by staff as part of an incentive program to shape appropriate, non-aggressive behavior. The patient began eating the food rapidly, despite direction by a staff member to slow down. The patient subsequently choked on the hamburger and despite attempts to dislodge the obstruction using the Heimlich maneuver and then CPR, the patient required transport to the hospital. The patient was placed on life support and later expired. The facility determined three staff members lacked knowledge of the patient's dietary restriction. The hamburger was given to the patient whole and should have been cut into bite size pieces prior to giving it to the patient per his care plan. All three staff members were suspended during the investigation. At the conclusion of the investigation, one staff member resigned her employment, another staff member had her employment terminated, and the other staff member returned to work after receiving corrective action which included requirements for training and policy review. She was assigned supervision including meeting with her supervisor to monitor her progress and address any new issues.

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. The Department conducted an on-site investigation and substantiated the allegation of neglect, however, no deficient practice was cited because the facility had identified the issue and implemented corrective measures prior to the investigation. The Department will review this occurrence prior to the next survey.


Sent to Facility: 4/27/2017

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


Released to Public: 5/8/2017

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