Hospital is accredited, but ordered to improve County General found deficient in monitoring drugs, keeping records

September 29, 1995|By Jackie Powder | Jackie Powder,SUN STAFF

Carroll County General Hospital has received renewed accreditation from a national agency that monitors health care facilities -- along with orders to correct deficiencies uncovered during the review.

A report issued by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) says the hospital must improve on keeping medical records, monitoring unused drugs and documenting physicians' credentials.

The commission also found that the hospital did not meet its guidelines for restraint and seclusion of patients.

But Carroll County General is appealing this finding to the JCAHO.

The Joint Commission on Accreditation, based in Chicago, is a private, nonprofit group that certifies most U.S. hospitals.

Aside from the issue that is under appeal, hospital officials said they're satisfied with the commission's findings.

"We're happy with the survey and we feel we're paying full attention to what's been recommended," said Pam Shafer, Carroll County General's assistant vice president for quality assurance and risk management.

Hospital spokeswoman Gill Chamblin said the hospital is developing policies and procedures to correct the deficiencies and will submit written progress reports to the commission.

JCAHO's findings are based on a three-day evaluation of Carroll County General in May.

The commission's accreditation is good for three years.

Carroll County received its last JCAHO accreditation in 1992.

Alice Brown, a JCAHO spokeswoman, said that commission accreditations of hospitals are generally accompanied by orders for improvements.

"About 90 percent of the hospitals that we accredit receive recommendations for improvement," Ms. Brown said.

The JCAHO made four "Type 1" recommendations at Carroll County General. If not addressed, "Type 1" deficiencies could cause adverse outcomes for patients, said Carole Patterson, JCAHO's associate director for standards development.

Ms. Patterson said the problems identified at Carroll County General aren't "real serious issues."

"Hospitals tend to screw up in having the appropriate documents pulled together," she said.

Carroll County General has appealed the commission's finding that raised questions about the hospital's policy on restraint and seclusion of patients.

JCAHO requires that all orders for restraint or seclusion of a patient must address a certain incident and include time limitations. The order cannot direct that a patient be restrained or secluded for an unspecified reason or period of time.

Of the six restraint and seclusion cases reviewed by JCAHO investigators at Carroll County General, five had specific orders while one indicated that the patient was to be restrained as needed.

Ms. Chamblin said Carroll County General appealed the JCAHO finding because its procedures meet commission standards and state law. A decision is expected next month.

"We believe the order was geared toward a specific event; it was not a general seclusion," Ms. Shafer said.

The JCAHO's other recommendations address the hospital's disposal of medication, medical recordkeeping and documentation.

Commission investigators identified potential problems in documenting and discarding drugs remaining after medical procedures.

In another finding that addresses medical recordkeeping, the commission determined that in some instances doctors signed medical orders, but failed to date them. JCAHO investigators also identified deficiencies in the hospital's method of documenting physicians' credentials.

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