UNC Hospitals’ accreditation is at risk after problems found at facilities

UNC Hospitals have been placed on a “preliminary denial of accreditation status” after a national accrediting agency found several problems during a recent review.

UNC Health Care confirmed the accreditation decision in a written statement Friday but did not detail the problems cited by the surveyors.

UNC Health Care spokesman Phil Bridges said there is “no finding of any immediate threats to patient health and safety.” The areas that require attention are “with respect to some new standards implemented as of July 1.”

An internal UNC System document, obtained by The News & Observer and verified by a source closely affiliated with both the UNC System and UNC Hospitals, cites problems that include suicide prevention and medication management.

That document details deficiencies in “documentation of suicide screening and assessment;” along with a lack of “ligature resistant hardware and furniture in behavioral health areas of the emergency department and inpatient units (e.g., door handles, hinges, phone cords, chairs, beds, bathroom doors in private rooms, etc.).”

The document also cites medication problems, saying that “some physician orders were found to be incomplete and documentation did not adequately reflect the care provided.”

The hospital’s official statement Friday afternoon said the Joint Commission, a national organization that accredits and certifies health care organizations and programs, had accepted UNC Hospitals’ plans for improvement on Thursday.

According to the statement: “UNC Hospitals has developed plans to address each area cited for improvement. Those plans (or mitigation) have already been implemented.”

The survey is regularly completed every three years.

Another survey could come as soon as next week, the statement said, and UNC Hospitals expects to be removed from probation.

The accreditation issues come a few months after a New York Times investigation found high death rates in children undergoing heart surgery at UNC’s Children’s Hospital.

UNC eventually released data that showed higher death rates for most categories of pediatric heart surgery. The hospital has temporarily stopped doing some complicated heart surgeries on children, The News & Observer has reported.

A joint state and federal investigation triggered by The New York Times article found “no current deficiencies” in the hospital’s operation, the N.C. Department of Health and Human Services reported Aug. 1. The review was coordinated with its federal oversight agency, the U.S. Centers for Medicare & Medicaid Services.

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