A review by the Joint Commission found several problems at Carlisle Regional Medical Center.  The Commission gathers information about accredited medical centers through direct observations by employees and other interviews. 

This comes after an investigation by the State Health Department into whether the deaths of two patients in June were from low staffing levels.  The State found the hospital was out of compliance with some state regulations but that the deaths were not due to staffing issues. 

The Joint Commission says it foundthe following regulations to be out of compliance:


  • A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.

  • Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.

  • Report critical results of tests and diagnostic procedures on a timely basis.

  • Resuscitation services are available throughout the hospital.

  • Staff and licensed independent practitioners are familiar with their roles and responsibilities relative to the environment of care.

  • Staff are competent to perform their responsibilities.

  • The governing body is ultimately accountable for the safety and quality of care, treatment, and services.

  • The hospital evaluates the effectiveness of its infection prevention and control plan.

  • The hospital has an Emergency Operations Plan. Note: The hospital’s Emergency Operations Plan (EOP) is designed to coordinate its communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities during an emergency (refer to Standards EM.02.02.01, EM.02.02.03, EM.02.02.05, EM.02.02.07, EM.02.02.09, and EM.02.02.11). Although emergencies have many causes, the effects on these areas of the organization and the required response effort may be similar. This 'all hazards' approach supports a general response capability that is sufficiently nimble to address a range of emergencies of different duration, scale, and cause. For this reason, the Plan’s response procedures address the prioritized emergencies but are also adaptable to other emergencies that the organization may experience.

  • The hospital identifies risks for acquiring and transmitting infections.

  • The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.

  • The hospital maintains the integrity of the means of egress.

  • The hospital makes food and nutrition products available to its patients.

  • The hospital manages risks associated with its utility systems.

  • The hospital manages risks related to hazardous materials and waste.

  • The hospital plans the patient’s care.

  • The hospital provides and maintains operating features that conform to fire and smoke prevention requirements.

  • The hospital provides care to the patient after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia.

  • The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.

  • The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.

  • The hospital safely prepares medications.

  • The hospital traces all tissues bi-directionally.

  • The hospital uses standardized procedures for managing tissues.

To read more from the Joint Commission, click here.