1. Outstanding Patient Care Issue:
There were several deficiencies made evident by the tracer patient during the survey conducted at Nightingale Community Hospital. There was no documentation of a medical history for the 67-year-old female patient who was admitted to the hospital. Furthermore, the female patient did not receive a physical until 72 hours after she was admitted. In addition, a function assessment was triggered based on the patient’s admission assessment but no record was found. It is crucial to gain knowledge of the patient’s history and perform a physical within 24 hours of admission to provide the patient with safe and quality medical care. Another deficiency noted in the survey was the initial nursing plan of care was documented but was not updated since surgery. During treatment, it is important to collect and record accurate and most up-to-date information from the patient to ensure the best possible care. Other deficiencies made evident by the tracer patient were a nurse’s inability to explain the range order policy when administering medication to patients. Pain medications are to be check for effect within 1 hour after ingestion but documentation showed the last 4 times that checking for effect exceeded 1 hour after administering pain medication to the patient. It is recommended to start with the lowest dose ordered and work up if necessary. Finally, the hand-off process noted in the survey as disjointed as well as the use of hand-off form was inconsistent. According to the Joint Commission, passing critical and necessary information at the time of transfer has been a pain point for many healthcare organizations. It is estimated that 80% of serious medical errors involve miscommunication when patients are transferred between caregivers. (Kulczycki, 2012)

2. Corrective Action Plan:
Nightingale Community Hospital is deficient in following