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Occurrence Summary Reports for:
COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Sunday, November 19, 2017 12:50 PM

Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 5/2/2017
Report Timely: Yes
Type of Occurrence: Diverted Drugs

DESCRIPTION OF OCCURRENCE:
On 05/02/17 two staff members noted ten benzodiazepine tablets were missing during cross shift narcotic count for a female patient, who was in her 50s. The staff members failed to notify the appropriate staff of the finding until the next day, creating the suspicion for drug diversion.

FACILITY ACTION:
The facility conducted an internal investigation and notified the police and Board of Nursing. On 05/02/17, registered nurse (RN) (1) requested an Ativan refill and retrieved forty Ativan 1 milligram (mg) tablets from the pharmacy. RN (1) identified four blister packs with ten tablets per card, but failed to remove the cards from the plastic bag to verify the count. RN (1) dispensed one tablet to a patient from the new supply, but failed to verify the count at that time. At 7:00 p.m. that evening, RN (2) counted narcotics with RN (1) for cross shift count. Both RN's noted the four blister packs of Ativan with ten tablets on each card, but failed to remove the medication from the plastic bag to verify the number of tablets present. Both RN's signed the count indicating it was correct. RN (2) then performed cross shift count of narcotics with agency RN (3) at 11:00 p.m. that evening and noted ten Ativan 1 mg tablets were missing. RN's (2) and (3) failed to notify the appropriate staff of the missing medication until 7:00 a.m. on 05/03/17. RN (2) noted he/she thought the card had been misplaced and conducted a search of the medication cart during the night but did not find the missing Ativan. The medication room was searched again after the 7:00 a.m. count on 05/03/17, but the Ativan was not located. A drug screen was performed on RN (2), which was negative. However, the possibility of diversion remained. RN (3) was separated from employment as of 05/05/17 for failure to cooperate with an investigation. RN (2) was separated from employment on 05/23/17.

DEPARTMENT FINDINGS:
In accordance with Colorado Revised Statute 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 agency/facility has fulfilled their reporting obligations and no deficiencies were cited.

Sent to Facility: 6/8/2017

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


Released to Public: 6/19/2017

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