AFT2
AFT2 Accreditation Audit Task 3
Western Governors University
A1.
Evaluation
Nightingale Community Hospital conducted a tracer study on a surgical patient to
analyze the patient’s experience throughout all phases of care during her hospitalization. The
purpose of the tracer process is to evaluate and identify any safety concerns within the
organization. The tracer report evaluated a 67-year-old female patient who underwent a
laparoscopic hysterectomy converted to an open procedure due to excessive bleeding about five
weeks prior to her hospitalization. She presented to Nightingale Community Hospital seven
days ago febrile and had drainage from her surgical site due to possible postoperative infection.
The patient underwent surgery for an abscess formed from her previous surgery. A central line
was inserted for long-term antibiotics to treat the infection. She will be discharged home with
home health that will oversee her antibiotic therapy.
Upon reviewing the patient’s tracer report, a clear violation was identified. The history
and physical examination were not completed within the first 24 hours of admission. The Joint
Commission standard PC.01.02.03 states, “The hospital assesses and reassess the patient and his
or her condition according to defined time frames.” In the “Elements of Performance” relating
to PC.01.02.03, number four, 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.” Under “Elements of Performance”, number five, it states “a registered nurse
completes a nursing assessment within 24 hours after the patient’s inpatient admission.” (The
Joint Commission, 2021).
