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FOREST HILLS HOSPITAL 102 - 01 66TH ROAD FOREST HILLS, NY March 4, 2015
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, the review of medical records and other documents, it was determined the facility failed to develop and implement policies that ensure the safety of patients in the Emergency Department (ED). This finding was noted in 1 of 30 Emergency Department records reviewed (Patient #1).

Findings include:

Patient #1 is a [AGE]-year-old male who was brought to the Emergency Department by ambulance on 1/12/15 and he underwent a quick registration upon arrival at 1:11 AM. The Prehospital Care Report Summary by the ambulance service notes the patient was found in his house restrained by police with his wife present. The patient stated he has been drinking alcohol and got into a fight with his wife. He alleged the wife attacked him with a knife, but the wife denied the allegation. The prehospital assessment notes a scratch on patient's chest.

The triage nurse failed to conduct a timely assessment of the patient and determine the patient's needs. The triage nurse notes the patient's chief complaint as alcohol intoxication on 1/12/15 at 1:11 AM. However, additional notes by the triage nurse indicated the patient eloped after he was taken to and left in the bathroom by an Emergency Medical Technician. The patient was not triaged prior to his elopement from the ED on 1/12/15 at 1:28 AM.

There was no documentation in the patient's record of measures taken by staff to ensure patient's safety after an eyewitness confirmed the patient had eloped.

At interview with Staff #1 on 3/4/15 at 12:30 PM, she stated the facility does not have a written policy that addresses patients who elope prior to triage. She stated the usual practice would be to announce the patient's name three times using the Public Address System, if there is no response, a search of the immediate environment is conducted, and if indicated, security is informed to conduct a more extensive search for the patient. She added that if patient's contact information is available, patient/family is contacted and given instructions to return to ED for appropriate screening and evaluation.