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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Thursday, November 23, 2017 3:51 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 11/23/2016
Report Timely: Yes
Type of Occurrence: Abuse/Sexual

DESCRIPTION OF OCCURRENCE:
On 11/23/16 there was an allegation of sexually inappropriate behavior from male patient (A), in his 70s, towards another female patient (B), who was in her 60s.

FACILITY/AGENCY ACTION:
The facility conducted an internal investigation and notified the police. The facility reported patient (A) was a recent admission to the facility on charges of sexual assault and a diagnosis of mental illness. He had been deemed mentally incompetent. Staff were providing frequent redirection due to sexually inappropriate comments he was making towards staff. A care plan had been in place to address his preoccupation with sexual behaviors. On this unit, staff performed 15-minute safety checks and patient (B) had a door alarm. During a wellness check, staff found patient (B) in her bed with patient (A) leaning over her. Staff noted patient (A) had his hand in patient (B)'s groin area and her pants and underwear were partially down. Staff intervened and separated the patients. When staff asked patient (A) what he was doing, he stated, "she is allowed to have one of us in here." Staff informed patient (A) his actions were inappropriate. Patient (B) has a diagnosis of mental illness and had been deemed mentally incompetent as well. When staff asked about the event, she stated he walked into her room and started talking with her. She claimed she did not know who he was and then declined to say anything else. Nursing attempted to assess patient (B), but she declined an assessment. Later, staff reported patient (B) stated she "liked it" and did not want to press charges. Both patients denied any penetration occurred. It was determined patient (B)'s alarm had been activated, but staff had not heard the alarm sound. The facility concluded the allegation of sexual abuse was unsubstantiated due to patient (B)'s comment. Staff implemented assault II precautions on patient (A) and moved him to a different unit. Patient (B) did have an alarm on her door to alert staff of any visitors to the room and she was counseled to keep the alarm on at all times. The unit adjusted staffing assignments and designated one staff member to monitor the hallway for any unit housed with male and female patients.

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 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: 1/11/2017

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


Released to Public: 1/23/2017

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