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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Thursday, November 23, 2017 4:12 AM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 3/3/2017
Report Timely: Yes
Type of Occurrence: Neglect

DESCRIPTION OF OCCURRENCE:
On 3/3/17 there was an allegation of staff neglect towards a female patient, who was in her 20s.

FACILITY/AGENCY ACTION:
The facility conducted an internal investigation and notified the police and pool agency. Per the patient's suicide prevention plan, she required one-to-one (1:1) staff monitoring. As a nurse was conducting wellness rounds on patients, she found the staff member who was assigned to conduct the 1:1 monitoring, asleep in the patient's room. The nurse reported she tapped on the staff member's arm three times before she woke up. Once the staff member awakened, she was removed from her assignment and another staff member took over the patient's 1:1 monitoring. It was reported the patient had been sleeping and did not appear to be in harm. The staff member was suspended pending the outcome of the investigation. The staff member admitted she had fallen asleep and acknowledged that it was her responsibility to monitor the patient. Another staff member reported observing this staff member awake during the previous 15-minute safety check on the patient. The facility determined the staff member failed to follow the policy for 1:1 monitoring that was in place for the patient's safety plan. The appointing authority was determining the next course of action to take with the staff member, but she remained on administrative leave.

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: 5/3/2017

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


Released to Public: 5/15/2017

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