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Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #3) clinical records reviewed for post-anesthesia monitoring, the Hospital failed to document that the discharge criteria for a post-operative patient in the PACU (post anesthesia care unit) was followed, to ensure the registered nurse evaluated the nursing care for each patient.

Findings include:

1. On 7/29/2021, the clinical record of Pt. #3 was reviewed. Pt. #3 came to the Hospital due to midshaft ulnar (bones in the forearm) fracture. The clinical record included:
- The pre-operative assessment dated 10/7/2020 at 6:33 AM indicated that Pt. #3 was awake, alert, and oriented x 3 (person, time, and place) ..."
- The pre-operative screening dated 10/7/2020 included, " ... Informant: (Pt. #3) ... Discharge with (Name of sister) ..."
- The clinical record indicated that Pt. #3 was in the OR (operating room) at 7:37 AM and was out of the OR at 9:29 AM. Report was given to E #12 (Registered Nurse PACU).
- The continuum of care surgery report dated 10/7/2020 included, " ... Procedure/surgery done: Open Reduction Internal Fixation (bones held together with hardware like metal pins or rods) of right ulnar fracture ... Type of Anesthesia: General..."
- A physician's order dated 10/7/2020 indicated, "Discharge to home once meets PACU criteria ..."
- The PACU vital signs monitoring sheet indicated that vital signs were recorded at 9:30 AM. The clinical record also indicated that PACU discharge criteria was met on 10/7/2020 at 11:00 AM. However, no succeeding vital signs were recorded after 9:30 AM until Pt. #3's discharge.
- E #13's (Registered Nurse, PACU) progress note dated 10/7/2020 at 3:13 PM included, " ... Level of consciousness: Awake, alert, oriented x 2 ... Discharge instructions given to (Pt. #3) ..." The clinical record lacked documentation that Pt. #3 was back to her baseline level of consciousness upon discharge.

2. On 7/29/2021, the Hospital's policy titled, "Discharge Criteria/ Post Anesthesia Care Unit (PACU)" (revised on 9/2019) was reviewed and included, "Purpose: To ensure the patient has sufficiently recovered from anesthesia. II. Scope. Registered Nurses (RNs)... PACU ... IV. Guidelines 1. Patients will be discharge from PACU ... when they have sufficiently recovered from anesthesia ... 3. First Criteria: The vital signs must be stable for three (3) consecutive readings at 15-minute intervals. 4. Before discharge, patients who received general anesthesia respond easily to verbal stimuli ..."

3. On 7/29/2021, the Hospital's policy titled, "Discharge Criteria for Phase II Recovery" (revised on 9/2019) included, " ... To provide guidelines for the safe discharge of patients from One Day Surgery ... V. The following criterion applies to the patient ... 5. Be oriented to time, place and person, consistent with pre-surgical baseline level ..."

4. On 7/29/2021, the Hospital's job description for RNs at the PACU was reviewed and included, " ... The staff nurse is accountable for the performance of patient care ... Essential Functions and Duties ... Utilizing the nursing process, identifies complex variables and interrelationships of the assessment data ..."

5. On 7/29/2021, the Hospital's policy titled, "Guideline for the Nursing Process" (revised on 10/2020) was reviewed and included, " ... Providing nursing guidelines for documentation of the nursing process ... Implementation ... The nurse shall document delivery of patient care online or on paper ..."

6. On 7/29/2021 at approximately 10:30 AM, findings were discussed with E #14 (Peri-Anesthesia/Navigation Manager). E #14 stated that the PACU discharge criteria policy and procedure should be followed. E #14 could not provide documentation that the criteria for vital signs and level of consciousness prior to Pt. #3's discharge were followed and documented.