Hospital Now Fully Accredited : Health: A Los Robles official says the center’s conditional status was due to filing and record-keeping practices.

Los Robles Regional Medical Center has received full accreditation after more than half a year on a conditional status with the nation’s major hospital accreditation organization, hospital officials said Thursday.

The Joint Commission on Accreditation of Healthcare Organizations slapped the hospital with conditional accreditation last January for failing to meet filing and record-keeping standards.

The restoration of accreditation came after the Thousand Oaks hospital’s fourth commission inspection in less than two years.

Commission officials would not say why Los Robles received the only below-standard review in Ventura County, but hospital administrator Robert Quist said the citations resulted from improperly recording families’ autopsy decisions and inadequately documenting patient restraints.

Record-keeping problems are the usual cause of conditional accreditation and should throw no blight on the institution’s medical reputation, said David Langness, a spokesman for the Hospital Council of Southern California. Los Robles faced losing its accreditation this summer, however, if it did not meet commission standards on this fourth inspection.

The new accreditation is retroactive to October, 1991, when the problems first were documented. That means the hospital will have to undergo a new round of accreditation in October, 1994, Quist said, but at this point he’s not worried.

“We feel like we’ve had a continual focus on accreditation for the last two years,” he said, adding that the hospital’s staff will not have to make too much effort to gear up for next year’s inspection.

Because the federal government also uses accreditation as a qualifier for a hospital’s participation in Medicare and Medicaid programs, the commission looks for strict compliance with often highly detailed federal regulations. The commission is not a federal regulatory organization, but a nonprofit corporation supported by hospital education and inspection fees.

Los Robles does not participate in the Medicaid program, but had it lost its accreditation, it could have faced higher liability insurance rates and a lower bond rating than it now has, commission officials said.

One of the commission’s citations was for not properly recording autopsy decisions. Physicians must ask patients’ families immediately after a patient’s death whether they want an autopsy performed. The commission requires that the family’s answer be immediately recorded in the medical records.

Los Robles physicians were inquiring about autopsies on the day of the death, but the hospital did not require them to make note of the family’s response until 30 days afterward, Quist said. That has been corrected, he said.

The second citation concerned doctors’ orders for continuation of patient restraints. Hospitals occasionally use cloth restraints on disoriented patients to prevent them from falling out of bed, pulling out intravenous tubing or otherwise harming themselves.

The hospital previously allowed doctors to merely limit the maximum amount of time any patient might be placed in restraints. It now complies with commission regulations stipulating that doctors must periodically sign off on the restraints during the course of a day, Quist said.