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Based on medical record review, staff interview, and review of policies and procedures and facility documentation, the failed to ensure a post-anesthesia evaluation was completed prior to discharge for 2 of 7 patients (#2, #4). The findings were:

1. Review of the medical record showed patient #2 had a laporascopic appendectomy on 8/21/24 under general anesthesia. The patient was discharged from the facility on 8/22/24. Further review of the medical record showed no evidence a post-anesthesia evaluation was completed. On 6/12/25 at 9:52 AM the director of nursing for inpatient confirmed she was unable to locate a post-anesthesia evaluation.

2. Review of the medical record showed patient #4 had surgery on 4/19/24 under general anesthesia. The procedure performed was an open diverting loop sigmoid colostomy. The patient was discharged on 4/24/24. Further review of the medical record showed no evidence a post-anesthesia evaluation was completed. On 6/12/25 at 8:52 AM the director of nursing for inpatient confirmed she was unable to locate a post-anesthesia evaluation.

3. During an interview on 6/12/25 at 9:09 AM the director of nursing for inpatient stated she called certified registered nurse anesthetist (CRNA) #1 who stated the post-anesthesia evaluation should be documented in the medical record under the consultation section. The director of nursing further stated there were no post-anesthesia evaluations for patients #2 or #4 in the medical record.

4. During an interview on 6/12/25 at 10:07 AM the director of risk stated post-anesthesia evaluations was not something that was being monitored in quality assurance. She stated some chart audits were done in the anesthesia department, but review of the audit forms she provided showed post-anesthesia evaluation was not included as a specific indicator.

5. Review of the facility's policy "Postanesthetic Visits for Inpatients," revised 8/31/12, showed "...Postanesthetic visits shall be made on all patients who have undergone anesthesia and at least one note shall be made describing the presence or absence of anesthesia-related complications...When the postanesthetic visit and chart entry by Anesthesia personnel is not feasible because of early patient release from the hospital, the physician or dentist who discharged the patient from the hospital shall be responsible for satisfying this requirement."