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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Monday, September 25, 2017 3:45 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 2/9/2017
Report Timely: Yes
Type of Occurrence: Abuse/Physical

DESCRIPTION OF OCCURRENCE:
On 02/09/17 male patient (A), in his 50s, put his arms around male patient (B)'s neck while holding a piece of silverware in his hand. Patient (B) was in his 20s.

FACILITY ACTION:
The facility conducted an internal investigation and notified the police and physician. The patients were in the dining room. A staff member observed patient (A) put his arms around patient (B)'s neck while holding a piece of silverware in his hands. Initially, staff thought it was horseplay, but quickly realized it was not and directed patient (A) to stop and separate from patient (B). Patient (A) immediately let go and threw the piece of silverware on the floor and then lunged towards patient (B) in an angry manner. Additional staff arrived at the scene and was able to redirect patient (A) and escort him out of the dining room. Several staff were instructing the dietary staff to push the duress alarm that is located behind the service counter in the kitchen. Staff reported that dietary staff never sounded the alarm. Hospital police were called and arrived to conduct an investigation. Patient (B) did not want to press charges. Patient (B) was assessed and had a slight red mark on the side of his neck, but no signs of bleeding or bruising. Patient (A) was immediately regressed to a unit with a higher level of supervision. Patient (B) was fearful until patient (A) was moved to another unit. The dietary team initially thought that the patients were involved in horseplay, therefore did not sound the alarm immediately. The Dietary Manager was made aware of what transpired and will follow with the staff.

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. The summary findings were based on the information provided by the facility at the time of the Department review.

Sent to Facility: 4/26/2017

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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