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, appropriate labs were drawn, the informed consent was signed and information about the length of surgery and recovery time were discussed with the patients mother. The mother stated to the pre-operative nurse that she would be leaving the hospital to attend to another child, she left her cell phone number with the Pre-Operative Nurse who proceeded to write this number into a personal notebook that she carries. The specific instructions to the pre-op nurse were to call the mom when the surgery was over. At this point the patient was ready for surgery, at the appropriate time the patient was taken to surgery and care transitioned into the care of the OR nurse, surgeon and the OR staff. Upon completion of the surgery the patient was transferred from the care of the surgeon and OR nurse to post-operative nursing care. She was then transferred to the care of the recovery nurse. At the point that the patient arrived in recovery the patient’s mother could not be located. Standard procedures are such that the recovery nurse, “pages” or calls for the recovering patient’s family or guardian. According to the recovery nurse the mothers name