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Based on document review and interview, it was determined that the facility failed to re-evaluate the Patient's condition and document discharge to include date, time, mode of transport and where the Patient was discharged to for one (1) of two (2) Patients (Patient # 1).

The findings include:

On October 5, 2023 at 1:00 p.m., the Clinical Record review for Patient # 1 revealed the following:

Physician General Surgery note dated July 18, 2023 at 7:31 a.m. reads in part "Underwent mastopexy, abdominoplasty, liposuction in office OR (operating room) under GA (general anesthesia). Initial recovery in office PACU (post anesthesia care unit) then transfer via Medical Transport to [Name of facility] for continued recovery and observation. Anticipated LOS (length of stay) 2-3 days. Chart material, including H & P (history and physical), sent in packet with Patient upon transfer. Orders placed. Has RX for Post - Op (post - operative): Keflex, Flexeril, Percocet, Xarelto (medications)."

Discharge summary dated July 19, 2023 at 8:59 p.m. reads in part "Underwent procedure as noted in office OR. Transferred via medical transport for scheduled recovery and observation. Foley out POD (post operative day) 1. Voided. Advanced on diet and activity. CBC (complete blood count) noted. Discharged stable for office F/U (follow up)."

Progress note dated July 20, 2023 at 9:35 a.m. reads in part "IV (intravenous) catheter removed. Discharge instructions provided and reviewed with patient. Drain log and drain care supplies provided."

There was NO documentation of a re-evaluation of the Patient's condition and documented discharge to include date, time, mode of transport and where the Patient was discharged to.

On October 5, 2023 at 1:50 p.m., an interview with Staff Member # 8 revealed "documentation of July 20, 2023 at 9:35 was done by the "ADT" (Admission, Discharge and Transfer) nurse. The ADT nurse does paperwork for admission, discharge and transfer of Patients. The ADT nurse then lets the primary nurse know the Patient is ready for admission, discharge and/or transfer. For discharge, the primary nurse will evaluate Patient's readiness for discharge and transportation available. The primary nurse will take the Patient out via wheelchair to the exit. The Patient's discharge transport is told to meet them with the vehicle for transport at the nearest exit. Patient is assisted into vehicle for discharge transport. The primary nurse will then make a note of the discharge."

On October 5, 2023 at 2:00 p.m., a review of the facility's policy titled "Discharge of a Patient" reads in part "Following discharge, the nurse will document date and time the patient was discharged and transferred, how the patient was transported from the unit, and where the patient was discharged to."

On October 5, 2023, the findings were discussed with Staff Members # 1, # 2 and # 10 during the exit interview.