A1. The tracer patient is a 67-year old female who has been admitted to the hospital due to showing signs of a possible postoperative infection after having a laparoscopic hysterectomy. Due to the infection, the patient had surgery to treat the abscess that had formed from her previous surgery. Now the patient is scheduled to go home under the provision of home health care and antibiotic therapy.
While reviewing the patients’ tracer chart, it has been notated that the environment of care for the patient, which includes overall cleanliness and the storage of oxygen tanks, was not the best. There was oxygen tanks found on the floor and not secured. There was also dusty air vents in the patients room and in the clean utility room. The tracer tips states that all oxygen tanks need to be stored in secure stands. The Joint Commission hospital accreditation requirements for environment of care ...view middle of the document...
A2. The following corrective action plan will be implemented in order to address the environment of care standards that were not followed during the patients stay at the hospital.
-Unsafe environment of care for patient due to improper storage of oxygen tanks and the dusty air vents in the patients room and clean utility room. Because the oxygen tanks are not secured in a safe place, patients can easily trip and fall. This poses risk of injury to the staff as well. Dusty air vents can cause illness and discomfort to the patient and the entire hospital because of the lack of clean air.
II. Action Steps
-Update the policies and procedures to specifically give directions on how to arrange the patients’ environment of care, such as proper storage and securing of oxygen tanks and cleanliness of air vents.
-Once policies and procedures are updated, mandatory trainings will take place for all staff in order to stress the importance of establishing and maintaining an environment of care for the patients.
-Training manuals will be developed to show how rooms should be setup and where equipment should be stored. This manual will also give specific instructions on how to clean the vents.
- There will be flyers posted in every patient room that will provide the proper checkpoints to be observed while staff is in the room. If anything is out of place, the proper steps must be taken to correct the error immediately.
-Management will be held responsible for facilitating weekly inspections, to ensure that all policies and procedures are being followed in accordance to the standards set by the Joint Commission.
III. Improvement Timeframe
The corrective action plan will go into effect immediately, in order to establish and maintain patient safety and the safety of the staff as well. If this is not implemented immediately, the hospital will fail audit.
The Joint Commission. (2013). The Joint Commission Comprehensive Accreditation
And Certification Manual. Retrieved September 3, 2013, from