As per Joint Commission standards Nightingale community Hospital is reporting within 45 days a Sentinel Event that occurred at our hospital last week. To summarize this event; 3 yr old T.G. was admitted to the Ambulatory Surgery Unit (ASU) for a routine procedure with Dr. Carlos Munoz. After a brief visit with the registrar to fill out all appropriate paperwork the patient and her mother waited in the pre-admission area. The patient and her mother were then called into pre-admission. The Pre-operative nurse proceeded to go through the standard steps prior to being taken into surgery. According to the nurse an assessment was completed, the patient was changed into a surgical gown, and her belongings taken care of. An IV was started,
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The recovery nurse then transferred the patient who was awake and alert to the care of the discharge nurse on duty. The discharge nurse monitored the patient and it is unclear at this time if more attempts were made to locate the patient’s mother. A period of time expired and the recovery nurse came back to the discharge staff and informed the discharge nurse that the patients father was at the front desk. He was allowed to come back to see the patient. The discharge nurse reports that the young patient expressed excitement to see her father, seemed comforted and glad to see him. The Discharge nurse thought nothing of the fact that the mother was not on site as the patient seemed quite at ease with her father. The father offered to take his daughter home. The discharge nurse discussed the details of the surgery and information with the father, and the patient was discharged to the care of her father.
Approximately 30 minutes later the mother arrives and finds that the child is gone, she had been discharged to the care of her father, a security guard is alerted and a code pink is issued hospital wide. A code pink for missing a child is quite serious, therefore local law enforcement got involved. The mother is distraught and quite upset at the staff. She explains to the staff that the childs father is not allowed to care for the children, there is a divorce that has occurred and the mother has retained full custody rights. The local