A1. Tracer Patient Evaluations
Five weeks prior to admit our tracer patient a 67-year-old female patient received a
laparoscopic hysterectomy that was converted to an open procedure due to excessive bleeding.
After her discharge she became febrile with surgical site drainage. She was admitted seven days
ago because of these complications and possibility of an infection. She was then taken back to
the OR 5 days ago to treat an abscess that occurred because of her previous surgery. They placed
a central line while in the OR for long term antibiotic treatment for her post op infection. Her
discharge plan is to go home with home health to provide oversight of antibiotic treatment.
This patient had many nurses take care of her as she moved from Surgical Unit, OR,
PACU, and back to the Surgical Unit. With each movement the patient there was no assessment
documented within the EMR within the first 24 Hours. Joint Commission PC.01.02.03 it states,
“The patient receives a medical history and physical examination no more than 30 days prior to,
or within 24 hours after, registration or inpatient admission, but prior to surgery or a procedure
requiring anesthesia services (Joint Commission 2018).” The lack of assessment of the patient
within the first 24 hours and many handoffs to nursing between the OR, PACU, and the floor
nurse has led to missed information about the patient’s condition.
A2. Plan of Action
Nightingale Community Hospital will put the following actions in place to make sure they are
meeting the requirements of the Joint Commission standards of care.
