|Facility: COLORADO MENTAL HEALTH INSTITUTE AT PUEBLO-PSYCH
Date of Occurrence: 6/2/2017
Report Timely: Yes
Type of Occurrence: Diverted Drugs
DESCRIPTION OF OCCURRENCE:
On 06/02/17 a possible drug diversion was identified by the pharmacy.
The facility conducted an internal investigation and notified the police. The pharmacy was auditing narcotics and narcotic sheets that had been dispensed to patient units. This was a new process the pharmacy had instituted to better track narcotics which are on patient units. On 06/02/2017 the pharmacy was unable to locate the 3 narcotic sheets and the associated narcotics on a unit. It was determined that staff member A had signed off the medication for one narcotic sheet from the 24 hour Report of Controlled Medication sheet and returned them to the pharmacy, however the pharmacy had not received them. Staff member (A) had also signed the Control sheet when she picked up the medication from the pharmacy for the other 2 sheets listed but had never entered them on the 24 hour Report of Controlled Medication sheet and the medications were never accounted for on the unit. Staff member (A) was placed on administrative leave and subsequently, her employment was terminated. The Board of Nursing was informed.
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: 7/21/2017
FACILITY COMMENT: Following receipt of the above summary, no additional comments were submitted by the facility.
Released to Public: 8/1/2017