The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST JOSEPH'S HOSPITAL, INC 555 ST JOSEPH'S BLVD ELMIRA, NY 14902 Nov. 17, 2017
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on document review and interview the facility failed to ensure all individuals presenting to the Emergency Department (ED) are entered into the central log for 1 of 21 patients. (Patient #1). This failure could result in a patient not receiving a medical screening exam.

Findings:

Review of the facility's EMTALA Review dated 11/10/17 revealed at approximately 02:45 AM on 11/03/17 a couple presented via private vehicle to the Emergency Department. Staff Q, Public Safety Officer approached the vehicle and the driver stated that his girlfriend, who was a passenger in the car, was in active labor. The public safety officer informed the couple that this facility did not have a labor and delivery unit, but that another hospital, which was 5 minutes away did. After being provided with directions to the other facility, the couple left.

Interview with Staff Q, Public Safety Officer on 11/16/17 at 11:00 AM revealed Patient #1 presented to the Emergency Department ambulance bay via private vehicle on 11/3/17 at approximately 02:45 AM. The driver informed Staff Q that his girlfriend, who was a passenger in the car, was in active labor. Staff Q stated he directed the couple to another hospital, as this hospital does not have a labor and delivery unit. Staff Q stated he was not aware that all patients presenting to the hospital for emergency care must be entered into the central log and receive a medical screening exam.

Review of policy# A-34c , Emergency Department Triage, last revised 01/2014 revealed a registered professional nurse will perform a rapid assessment and initial triage on patients presenting for emergency care, following which the patient will be taken to the Emergency department where a medical screening examination and treatment will be provided.

Review of the facility Emergency Department log dated 11/3/17 revealed Patient #1 was not entered into the log.

Interview with Staff A, Quality Director on 11/17/17 verified the above findings.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based upon document review and interview the facility did not comply with all the provisions for maintaining a central log and conducting a medical screening exam. Please reference findings under Tag A205 and Tag A2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on document review and interview the hospital did not provide a medical screening exam (MSE) for 1 of 21 patients who presented to the hospital for emergency care (Patient # 1). A lack of a MSE could result in an emergency medical condition not being identified and treated.

Findings include:

Review of the facility's EMTALA Review dated11/10/17 revealed at approximately 02:45 AM on 11/03/17 a couple presented via private vehicle to the Emergency Department. Staff Q, Public Safety Officer approached the vehicle and the driver stated that his girlfriend, who was a passenger in the car, was in active labor. The public safety officer informed the couple that this facility did not have a labor and delivery unit, but that another hospital, which was 5 minutes away did. After being provided with directions to the other facility, the couple left.

Review of policy# LE.900, Emergency Medical Treatment and Active Labor Act (EMTALA), last revised 06/17 revealed all individuals presenting to the hospital requesting examination or treatment shall be offered a medical screening examination to determine if the individual has an emergency medical condition.

Interview with Staff Q, Public Safety Officer on 11/16/17 at 11:00 AM revealed Patient #1 presented to the Emergency Department ambulance bay via private vehicle on 11/3/17 at approximately 02:45 AM. The driver informed Staff Q that his girlfriend, who was a passenger in the car, was in active labor. Staff Q stated he directed the couple to another hospital, as this hospital does not have a labor and delivery unit. Staff Q stated he was not aware that all patients presenting to the hospital for emergency care must be entered into the central log and receive a medical screening exam.

Interview with Staff A, Quality Director on 11/17/17 verified the above findings.