|Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 9/30/2016
Report Timely: Yes
Type of Occurrence: Diverted Drugs
DESCRIPTION OF OCCURRENCE:
On 09/30/16 a medication count conducted by two staff members revealed a tablet of Ativan, a benzodiazepine, was missing. The Ativan was prescribed for a male patient, who was in his 60's.
The facility conducted an internal investigation and notified the police. The patient's Ativan was stored in a locked narcotic drawer inside a medication cart. The medication cart was locked when not in use and stored in a locked medication room. On 09/30/16 at 6:30 a.m. during cross shift count, a tablet of the patient's Ativan was noted to be missing. Investigation revealed staff member (1) administered various narcotics on 09/29/16, but failed to follow the correct process to sign them out during shift two. Staff member (1) used a pictorial census form to document narcotics pulled, then later tried to reconcile the notes with the count sheets. During cross shift count on 09/29/16 between shifts two and three, staff members (1) and (2) failed to verify medication counts with individual narcotic control records. The medication counts were only checked against a 24-hour report, which included controlled medication information. Additionally, staff member (2) gave the medication room keys to staff member (3). Staff member (3) was not responsible for passing or counting medications and entered the room unaccompanied to hang a dietary form. After staff member (3) left the medication room, staff member (2) failed to re-count the medications. The facility noted staff's failure to follow policy and procedure during medication administration and reconciliation created the potential for an incorrect count, inadvertent administration of an incorrect medication, and/or drug diversion. The facility noted that an explanation for the missing Ativan was not identified. It was recommended that staff member (1) undergo three observed medication passes on three separate days by qualified staff. It was also recommended that staff members (1) and (2) receive education on proper cross shift count, narcotic reconciliation, and the medication administration policy.
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 summary findings were based on facility information provided to the Department at the time of review.
The Department will review this occurrence prior to the next survey.
Sent to Facility: 1/23/2017
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 2/6/2017