HospitalInspections.org

Observation and interview revealed that the facility failed to provide proper safety precautions against radiation hazards. This includes appropriate storage of X-ray apron shields.

Findings:

1. Observation on 01/03/2012 at 2:30 PM revealed two X-ray apron shields draped over a chair in the X-ray examination room.

2. Observation on 01/03/2012 at 2:35 PM revealed one X-ray apron shield hanging on a hook, draped in half, on the back of a portable X-ray machine in the X-ray examination room.

3. Observation on 01/03/2012 at 2:40 PM revealed one X-ray apron shield hanging, draped in half, on the back of a C-ARM X-ray machine in the X-ray examination room.

4. Interview on 01/03/2012 at 2:50 PM with the Lead of the Radiology Department confirmed that these X-ray shield aprons used to protect and shield personnel and patients, were not properly stored.

Based on staff interviews the facility failed to ensure the Quality Improvement Program for the Radiology Department was included in order to ensure over site of patient/staff safety.

Findings:

Interview with the Technical Director of the Radiology Department on 01/03/2012 at 10:00 AM revealed that the Director reviews the quarterly radiation exposure reports for the technical and medical staff. The Director stated that medical director would be notified of any high individual readings and that the medical director did not routinely review the findings and that the findings were not provided to the Quality Improvement or Safety Committees.

Interview with the Lead of the Radiology Department on 01/05/2012 11:30 AM revealed that facility does not have a Radiologist in the facility on a 24 hour basis. She stated that the physician will review X-rays performed on patients and provide treatment based on their interpretation of the report from the radiograph's interpretation that is conducted by the outside contracted company. The Radiology Lead stated that there is no a formal system in place that compares the physician's interpretation with the official interpretation preformed by the Radiologist that goes to the Quality Assurance committee.

Interview with the Chief Nursing Officer on 01/04/2012 at 12:00 PM revealed that the Quality Improvement Committee did not have a system in place to monitor radiation exposure reports or a system to review the accuracy of X-ray interpretations performed by radiology physician from the contracted outside services.