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Aft2 Task 3

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Nightingale Community Hospital
Corrective Action Plan

In reviewing Nightingale Community Hospital’s Surgical Patient Tracer Worksheet, it has come to our attention that the Primary Focus Area (PFA) in regards to Assessment and Care/Services needs to be addressed immediately. In particular, the nursing plan of care documentation. The nursing plan of care for this particular tracer patient has not been updated since the patient was out of surgery. This lack of documentation, specifically information that has not been updated may place the patient at risk of not providing proper care from the nursing staff. Below is the JCAHO Standard and the Element of Performance where Nightingale Community Hospital may be at risk of being non compliant.
JCAHO Standard PC.02.01.03-The standard states that hospitals must provide care, treatment, and services as ordered or prescribed, and it must be in accordance with law and regulation (www. jointcommission.org/). * NNightingale Community Hospital is not completely compliant with JAHCO’s Standard of Element of Performance. The following is the Element of Performance number 7 that needs to be addressed immediately by the Director of Nursing and the Manager of Nursing. * T7. The Element of Performance JCAHO Standard PC.01.03 states that hospitals must provide care, treatment, and services that are based on the most recent patient order(s) (www. jointcommission.org/). Prior to providing patient care, treatment and services, Nightingale Hospital’s staff involved in patient care must make sure that the patients’ information has been documented and updated on the Surgical Patient Tracer Worksheet. All Interdisciplinary Rounds and or Caring Rounds must be documented. All patient care plans must be reviewed and updated daily. Staff providing patient care will be educated and trained by the Director of Nursing and

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