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Based on interview and record review, the facility failed to document the Aldrete Score for 1 (#6) of 6 patients prior to discharge. Findings include:

Record review of patient #6's medical record revealed that she had a Right Fistulagram with balloon angioplasty and stent of the right subclavaian performed on 2/23/12. Interview with Physician #K, on 5/29/12 at approximately 1230, revealed that the patient was discharged per established criteria (Aldrete Score). Review of the facility Policy #TX 20 titled "Moderate Sedation and Analgesia", dated 3/11, documented "G. Discharge from Sedation Observation 1. Patients require: a. An Aldrete score of 8 - 10 X 2, 15 minutes apart, or return to baseline Aldrete to be discharged..." This had not been documented prior to patient #6's discharge.

During interview with the Radiology Manager, on 5/29/12 at approximately 1600, it was stated that in her investigation, the Nurse had performed the Aldrete Score assessment, but was too busy to document it.