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Based on clinical record review and interview, it was determined the Facility failed to assure post anesthesia care assessments and PAR (Post Anesthesia Recovery) scores were performed consistently for patients as defined by Facility policy and practice for 2 (#8 and #12) of 20 (#1-#20) clinical records reviewed. Without an assessment of the patient's PAR score, it could not be assured the patient could safely be discharged to the next level of care or home. The failed practice affected patient #8 and #12 and was likely to affect any patient in the Post Anesthesia Care Unit. The findings were:

A. Clinical record #8 was reviewed on 10/08/14 and revealed Phase I PAR scores were documented on 10/06/14 at 1430. The total score at 1430 was 10. The patient was admitted to Phase I PAR at 1353 and discharged to an inpatient floor of the Facility at 1528. There were no other PAR scores documented for Phase I recovery. The findings were confirmed 10/08/14 at 1330 by RN (Registered Nurse) #5.

B. Clinical record #12 was reviewed on 10/08/14 and revealed Phase I PAR scores were documented on 10/03/14 at 1245. The total score at 1245 was 10. The patient was admitted to Phase I PAR at 1133 and discharged to an inpatient floor of the Facility at 1255. There were no other PAR scores documented by Phase I recovery. The findings were confirmed 10/08/14 at 1445 by RN #5.

C. RN #5 and RN #7 stated by interview 10/08/14 at 1520 "The PAR score is documented every 15 minutes in Phase I."

D. On 10/007/14 at 1115, RN #7 was interviewed and stated, "Patients are discharged if their score is 8. The doctor will order it if he wants the patient to void before they go home."

E. On 10/08/14 from 11-1145, RN (Registered Nurse) #4 was interviewed and stated discharge from PACU is based Aldrete score (PAR) and on the physician order.

F. Facility policy "Discharge Criteria from PACU" was reviewed 10/08/14 and revealed "All patients are discharged from the PACU by order of anesthesia, after appropriate nursing and anesthesia assessment and after the patient has met the postoperative discharge criteria." The procedure lists "Patients are discharged from the PACU when they have achieved a score of eight (8) or greater on the Aldrete Post Anesthesia Recovery Score." Patients are assigned a 0, 1 or 2 in each category. The areas assessed included: vital signs, activity, respiratory, circulation, 02 saturation and level of consciousness.

G. On 10/08/14 the Director of Quality provided Perioperative Standards and Recommended Practices for In patient and Ambulatory Settings, AORN (Association of Operating Room Nurses), 2013 edition as reference that included the statement "The perioperative Registered Nurse should evaluate the patient for discharge readiness based on specific discharge criteria." "Discharge criteria should be developed collaboratively and agreed upon by nursing, surgery, medicine and anesthesia services." "Discharge criteria should be consistently applied to all patients."

Based on clinical record review and interview, it was determined the Facility failed to assure the date (#2, #9, #11 and #18) and time of surgery was included in the signed operative reports for 12 (#1-#3, #5, #7,#9, #11 and #15-#19) of 15 (#1-#5, #7, #9-#11, and #15-#20) clinical records with completed operative reports. The exact date and/or time of the procedure could not be determined in the event of multiple procedures the day of surgery. The failed practice affected 15 clinical records and had the potential to affect any patient who had surgery in the Facility. The findings were:

A. Clinical record #1 was reviewed on 10/08/14 and revealed an Operative Report dated 08/08/14 without a time of the surgery. The findings were confirmed by Registered Nurse (RN) #1 at 1208 on 10/08/14.

B. Clinical record #2 was reviewed on 10/08/14 and revealed an Operative Report with a dictation date of 09/12/14 and without a date or time of the surgery. The findings were confirmed by RN #1 at 0900 on 10/08/14.

C. Clinical record #3 was reviewed on 10/08/14 and revealed an Operative Report dated 09/02/14 without a time of the surgery. The findings were confirmed by RN #1 at 0850 on 10/08/14.

D. Clinical record #4 was reviewed on 10/08/14 and revealed an Operative Report dated 06/25/14 without a time of the surgery. The findings were confirmed by RN #1 at 0950 on 10/08/14.

E. Clinical record #5 was reviewed on 10/08/14 and revealed an Operative Report dated 09/09/14 without a time of the surgery. The findings were confirmed by RN #1 at 1035 on 10/08/14.

F. Clinical record #7 was reviewed on 10/08/14 and revealed an Operative Report dated 10/06/14 without a time of the surgery. The findings were confirmed by RN #1 at 0850 on 10/08/14.

G. Clinical record #9 was reviewed on 10/08/14 and revealed an Operative Report with a dictation date of 10/01/14 and without a date or time of the surgery. The findings were confirmed by RN #1 at 1315 on 10/08/14.

H. Clinical record #10 was reviewed on 10/08/14 and revealed an Operative Report dated 10/02/14 without a time of the surgery. The findings were confirmed by Registered Nurse (RN) #1 at 1340 on 10/08/14.

I. Clinical record #11 was reviewed on 10/08/14 and revealed an Operative Report with a dictation date of 10/06/14 and without a date or time of the surgery. The findings were confirmed by RN #1 at 1410 on 10/08/14.

DJ. Clinical record #15 was reviewed on 10/08/14 and revealed an Operative Report dated 09/26/14 without a time of the surgery. The findings were confirmed by RN #1 at 1500 on 10/08/14.

K. Clinical record #16 was reviewed on 10/08/14 and revealed an Operative Report dated 09/26/14 without a time of the surgery. The findings were confirmed by RN #3 at 1600 on 10/08/14.

L. Clinical record #17 was reviewed on 10/08/14 and revealed an Operative Report dated 09/26/14 without a time of the surgery. The findings were confirmed by RN #3 at 1520 on 10/08/14.

M. Clinical record #18 was reviewed on 10/08/14 and revealed an Operative Report with a dictation date of 09/25/14 without a date or time of the surgery. The findings were confirmed by Registered Nurse (RN) #3 at 1635 on 10/08/14.

N. Clinical record #19 was reviewed on 10/08/14 and revealed an Operative Report dated 09/24/14 without a time of the surgery. The findings were confirmed by RN #3 at 1545 on 10/08/14.

O. Clinical record #20 was reviewed on 10/08/14 and revealed an Operative Report with a dictation date of 09/24/14 without a date or time of the surgery. The findings were confirmed by RN #3 at 1700 on 10/08/14.