|Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 3/28/2017
Report Timely: Yes
Type of Occurrence: Neglect
DESCRIPTION OF OCCURRENCE:
On 03/28/17 a staff member failed to assess the hand of a male patient in his 20s.
The facility conducted an internal investigation and notified the state licensing agency and the police department. The patient informed staff that his hand was swollen from punching a tree approximately a week to two weeks prior. The patient claimed he told a nurse that he needed to have an x-ray taken of his hand. The nurse did not assess the patient's hand or ask any further questions according to the patient. An ice pack was provided to the patient. The patient's hand was then assessed by the nurse and the medical provider was notified. The nurse was suspended during the investigation. An x-ray was ordered and negative. The staff member was interviewed and stated she said the patient thought he needed an x-ray of his hand. The nurse stated the patient never showed her his hand. The nurse did not enter any documentation in the patient's medical record about the patient's complaint or the interaction between her and the patient. Although the staff member stated she believed she had reported to the oncoming shift the patient's complaints, nothing was documented in the cross shift report. The staff member received corrective action regarding the incident.
In accordance with C.R.S. 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed.
The facility has fulfilled their reporting obligations and no deficiencies were cited.
Sent to Facility: 5/15/2017
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 5/25/2017