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Based on record review and interview the facility failed to provide documentation of competencies for personnel assigned to work in the emergency room on 6 out of 10 personnel records reviewed.

Findings:
Review of Emergency Room personnel files on 7/1/2010 in administrative office revealed the following documentation was missing from files.

1. Personnel file for staff #3 had no documentation of completion of employee orientation packet to facility when hired or an Emergency Room (ER) skills check off list prior to assignment in the emergency room.

2. Personnel file for staff #4 had no documentation of completion of employee orientation packet when hired or documentation of completion of an ER skills check off list prior to assignment in the emergency.

3. Personnel file for staff #5 had no documentation of completion of an employee orientation packet when hired.

4. Personnel file for staff #6 had no documentation of completion of an employee orientation packet when hired or an ER skills check off list prior to assignment in the emergency room.

5. Personnel file for staff #10 had no documentation of completion of an employee orientation packet when hired or an ER skills check off list prior to assignment of emergency room
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6. Personnel file for staff # 11 had no documentation of a Performance Appraisal since 2008.

Interview with staff #2 on 7/1/2010 confirmed the required documentation was missing from personnel files.

Based on record review and interview the facility failed to ensure documentation on emergency room record of the following Standards of Care for the Trauma Patient: an accurate and ongoing assessment, monitoring patient responses to treatments, and documentation of ongoing data concerning patient. This occurred on 18 of 30 charts.

Findings: Review of emergency room records at Cozby-Germany Hospital on 7/1/2010 revealed the following policy found in the emergency room Policy and Procedure book: Essential Components of Triage Documentation for Emergency Room and Emergency Department Trauma Team Nurses Roles and Responsibilities: which require following nursing interventions- Assesses and documents, patient vital signs per policy, until stable and then at least every one hour, and assesses and documents patient trauma score.

1. On 3/5/2010 patient #53 presented to emergency room(ER) with complaint of nausea/vomiting and diarrhea. Patient was triaged at 11:05 am by Registered Nurse(RN), classified as urgent, and initial nurse assessment was completed. Vital signs were taken upon admit at 11:05 am and documented on chart. No documentation of vital signs or nurse reassessment documented on patient record until discharge at 2:25 pm. Medical Screen Exam(MSE) was performed by Staff # 12 at 11:30 am and lab work was ordered with no documentation on emergency nursing record to notify what was done and what time it was done.
2. On 4/9/2010 patient #1 presented to ER with complaint of laceration to the mouth. Patient was triaged at 8:30 pm by RN, classified as emergent, and initial nurse assessment was completed. Vital signs were taken upon arrival at 8:30 pm and documented on chart. No other vital signs were documented until patient left "against medical advise" (AMA) at 11:10 pm. Mother refused for patient to be transported to another hospital in ambulance. Copy of records were given to mother to take with her to another facility for continued care.
3. On 4/12/2010 patient #3 presented to ER with complaint of feeling a lump in his throat. Patient was triaged at 7:50 pm by RN, no classification of status documented on record. Vital signs and nurse assessment were documented on arrival. No documentation of any other vital signs or reassessment of patient condition noted. Staff #12 started MSE at 8:00 pm with no documentation of any type of physical exam being done on record.
4. On 4/14/2010 Patient #6 presented to ER with complaint of being shot in right hip with nail gun. Patient was triaged at 7:30 pm by RN with classification of status documented as urgent. Vital signs and nurse assessment were documented on arrival. No documentation of any other vital signs or reassessment of patient was documented on record, including discharge vital signs. Patient left AMA at 9:50 pm., refused to be transferred to hospital in Greenville.
5. On 4/22/2010 patient #12 presented to ER with complaint of Right upper dental pain. Patient was triaged at 6:45 pm by RN with classification urgent. Vital signs and nurse assessment were documented on arrival. No other vital signs or reassessment of patient was documented on record, including discharge vital signs. MSE was started at 6:00 pm per staff #12. Timeline is not accurate based on arrival to ER and time documented that MSE was started. Lab work was ordered and patient was to be admitted to staff #12 service. Patient left AMA at 7:45 pm and refused admit into hospital.
6. On 4/25/2010 patient #14 presented to ER with complaint of feeling achy all over. Patient was triaged by RN at 4:45 am with classification of non-urgent. Vital signs and nurse assessment were documented on arrival. No other vital signs or reassessment of condition documented until patient was discharged home at 6:30 am.
7. On 4/26/2010 patient #16 presented to ER with complaint of bone stuck in throat. Patient was triaged by RN at 11:18 pm with classification of patient status not documented. Vital signs and nurse assessment were documented on arrival. No other vital signs or patient reassessment were documented on patient record until transferred receiving hospital at 12:10 am. .
8. On 4/26/2010 patient #15 presented to the ER with complaint dizziness, shortness of breath, diarrhea, and joint pain. Patient was triaged by RN at 12:40 pm with classification of non-urgent. Vital signs and nurse assessment were documented on arrival. No nurse reassessment completed until patient was transferred to receiving hospital for further evaluation. MSE started by staff #12 at 1:00 pm and lab work, chest x-ray, and electrocardiogram(EKG) ordered. No documentation found on nurse notes of tests being done. Patient was transferred at 4:00 pm.
9. On 4/29/2010 patient #18 presented to ER with complaint of cough and epigastric pain. Patient was triaged by RN at 6:55 pm with classification of non-urgent. Vital signs and nurse assessment were documented on arrival. No follow-up vital signs or nurse reassessment were documented until patient was discharged at 9:55 pm. MSE started at 6:45 pm per staff #12. Timeline is not accurate based on arrival time to ER and time documented when MSE started. Lab work and Chest X-ray ordered. Patient transferred to receiving hospital for further evaluation at 9:55 pm.
10. On 4/30/2010 patient presented to ER with complaint of left hip pain after fall. Patient triaged by RN ar 1:26 pm with nurse assessment and vital signs documented. Classified as emergent. No other vital signs or nurse reassessment was documented until patient transferred to receiving hospital at 4:50 pm.
11. On 5/5/2010 patient #21 presented to ER with complaint of seizure activity. Patient triaged at 1:04 am by RN and nurse assessment completed and vital signs documented. Classified as emergent. No vital signs documented until patient left AMA at 2:00 am. MSE started at 1:00 am with lab work, Cat scan, and EKG ordered. Patient refused Cat scan and EKG, but did have lab work drawn. Timeline is not accurate based on arrival to ER and time documented that MSE was started.
12. On 5/6/2010 patient #23 presented to ER with complaint of burn to right hand. Patient was triaged by RN at 4:50 pm with vital signs and nurse assessment documented. Classified as urgent. No other vital signs documented on chart. MSE started at 5:10 pm with no documentation of exam noted. Discharged home at 6:40 pm with scripts and discharge instructions.
13. On 5/7/2010 patient #24 presented to ER with complaint of dog bite to face. Patient triaged at 6:20 pm by RN with vital signs and nurse assessment documented. Classified as emergent. No other vital signs were documented on chart. Transferred to receiving hospital for further care.
14. On 5/8/2010 patient #25 presented to ER with complaint of hitting head on step when he fell. Patent triaged at 8:30 pm by RN with vital signs and nurse assessment completed. Classified as non-urgent. No other vital signs or nurse reassessment documented on chart. No documentation on chart when MSE started. MSE was completed by Physician Assistant (PA).
15. On 5/10/2010 patient presented to ER with complaint of rash on chin. Patient was triaged at 1:35 pm by RN with vital signs and nurse assessment documented. No other vital signs or nurse reassessment documented on chart. Discharge vital signs were documented, but no time of discharge was documented on chart.
16. On 5/12/2010 patient presented to ER with complaint of left ankle and leg pain after a fall off a ladder. Patient triaged at 2:05 pm by RN with vital signs and nurse assessment documented. No other vital signs documented on chart until patient transferred to receiving hospital at 3:50 pm. MSE started at 2:00 pm per staff #12. Timeline is not accurate based on arrival to ER and time documented that MSE was started.
17. On 6/2/2010 patient #49 presented to ER with complaint of headache and high blood pressure. Patient was triaged at 11:05 am by RN with vital signs and nurse assessment documented. No discharge vital signs were documented on chart.
18. On 6/24/2010 patient #56 presented to ER with complaint of dizziness and headaches. Patient triaged at 9:15 am by RN with vital signs and nurse assessment documented. No other vital signs or nurse reassessment was documented on chart.

Interview on 7/1/2010 with staff #2 confirmed that the required information per policy was not documented on the emergency room records.
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Based on record review and interview the facility failed to provide access to emergency room services and/or Medical Screening Exam(MSE) when patient presented requesting services. This has the potential to cause patient harm when patients are not assessed and provided MSE.

Findings:

Interview on 7/6/2010 at 2:30 pm with patient #57 revealed that patient felt like she was treated very rudely the first visit at emergency room on 6/21/2010. " I returned back to emergency room on 6/22/2010 and was told at front desk that I'd been seen by Staff #12 the night before and he wouldn't see me again."

Interview on 7/1/2010 at 9:00 am with staff #14 in his office revealed that he was concerned about the emergency room practices concerning Staff #12. He had many complaints from his patients concerning long wait times to see Staff #12 and unnecessary hospital admission. He also advised that his patient #57 was turned away form emergency room on 6/22/2010 when she returned with complaint of increased pain and this had concerned him.

Review of emergency room log for 6/22/2010 revealed no documentation that patient had come to emergency room for evaluation.