HospitalInspections.org

Based on interview and document review, in one (1) of 18 personnel files reviewed, it was determined that staff was not appropriately trained to maintain a safe environment in the facility's Department of Radiology.

FINDINGS INCLUDE:
On 12/17/2015 at 12:30 PM, during staff interview, Staff # 1 (Director of Accreditation and Regulatory Compliance) stated that the facility performed a root-cause analysis of an incident that occurred in the Department of Radiology on 10/01/2015.
Review of an Incident Report dated 10/01/2015, revealed that on 10/01/2015, Staff #2 (Registered Nurse) brought a metal object into the Magnetic Resonance Imaging (MRI) Zone 4. The object was a vital signs monitoring device that was unsafe for use in Zone 4. It was noted in the facility's investigation report that there was no harm to the patient and the staff. The equipment did not sustain damages.

A review of Staff's #2 personnel file, revealed that this employee worked in a Medical Surgical unit prior to transfer to the Department of Interventional Radiology in January 2015. There was no documented evidence that the employee was trained in the safe use of all equipment in the MRI room. Also, there was no documented evidence of orientation and competency evaluation regarding the safe use of equipment and patient care in the Department of Interventional Radiology.

On 12/18/2015 at approximately 11:00 AM, during the staff interview, Staff #3 (The Administrator of Diagnostic Imaging) and Staff #4 (Director of Diagnostic Services), acknowledged that they cannot provide documented evidence of training and orientation related to the Department of Interventional Radiology for Staff #1, prior to time she started working in that department.

Based on observation, document review and staff interview, it was determined that the facility did not provide an environment free from hazards in the MRI unit of Diagnostic Imaging Services.

The findings are as follows:

1) On 10/1/15, a patient receiving an MRI went into distress. A staff member entered the MRI scan room carrying a vital signs monitor that was not approved for use with MRI equipment, because the appropriate monitor was not readily available. The vital signs monitor contained ferromagnetic parts and was pulled into the MRI machine; the patient was uninjured.

This incident was confirmed upon interview on 12/18/2015, approximately 11:00 AM to 11:30 AM, with The Director of Accreditation and Regulatory Compliance, the Director of Outpatient Diagnostic Imaging, the Administrator of Diagnostic Imaging and two (2) MRI Technologists. The incident was also noted in the facility's incident response notes.

2) On 12/22/15, during a tour of the MRI unit, a number of ferromagnetic (upon test with a magnet) objects were noted in the MRI control room. These objects included, but were not limited to; binders, patient charts, and padlocks on metal lockers. When such items are stored in the control room, they have the potential to be carried by staff into the MRI scan room where they can be drawn into the machine and pose an injury hazard to patients and staff.