HospitalInspections.org

Based on observation, document review, and interview, the hospital failed to ensure the safe and secure storage of radioactive dye (Intravenous Contrast) in 2 of 2 Computed Tomography (CT) rooms in the Radiology Department. The hospital failed to follow its "Contrast Agents-Handling and Storage" policy.

Findings include:

A tour was conducted in the Radiology Department on 11/10/2025 at 10:25 AM with Staff #4 and Staff #7. In CT Room #1 (Next to the ED), it was observed that single-dose and multidose intravenous (IV) contrast dye bottles were stored in a standalone cabinet next to the door of the room. The cabinet was observed to be unsecured, the room was unattended, and the door to the CT room was propped open. This had the potential of allowing any unauthorized staff, patients or visitors to have access to radioactive contrast agents.

In CT Room #2 (Next to the Chapel), it was observed that single-dose and multidose IV contrast bottles were stored in a cabinet on the wall. The cabinet was observed to be unsecured.

A review of the hospital's "Contrast Agents-Handling and Storage" policy dated 06/2024 revealed the following:

"GUIDELINE STATEMENT:

Personnel will adhere to manufacturer's recommendations for proper handling and storage of contrast agents throughout the Radiology Department.

B. Storage/ Control

General Stores maintain some stock of Oral Contrast. Pharmacy keeps a PAR level of IV contrast and Gadolinium.

Oral, IV, and Gadolinium in the radiology department are kept locked or in restricted areas. Contrast in the General Stores is limited to access by authorized personnel. General Stores is a restricted (locked) area."


An interview was conducted with Staff #4 on 11/10/2025 at 10:40 AM. Staff #7 reported that IV contrast agents are to remain locked up at all times. Staff #4 and Staff #7 confirmed the surveyor's findings of unsecured IV contrast agents in the Radiology Department.

Based on observation, record review, and staff interviews, the hospital's infection control and prevention program failed to provide and maintain a sanitary environment to avoid sources of transmission of infections in 2 (Emergency Department and Radiology Department) of 2 departments of the hospital. The hospital failed to follow the "Infection Prevention and Control Plan" policy.

Findings include:

During a tour of the hospital on 11/10/2025 at 10:30 AM with Staff # 3 and # 4 the following infection control issues were identified:

Emergency Department

*There was a red cart on wheels labeled "Treatment Cart" that had a thick layer of dust and dirt. The dust was collecting on top of sterile patient supplies. The second and third shelves of the cart had large clumps of dust and dirt collecting on the inside of the cart and the patient supplies.

*The medication room had a build-up of dust inside the cabinets, which contained sterile patient supplies such as intravenous needles and lab collection tubes.

Radiology Department

*The emergency code cart inside of the CT room, located across the hall from the chapel, was covered in a thick layer of dust and dirt buildup. The dust and dirt were on the top of the emergency code cart and the top of the defibrillator.

*There was an intravenous contrast bottle and an intravenous saline bag hanging from an IV (intravenous) pole next to the CT scanner located across the hall from the chapel. The bag of IV saline was labeled "11/07 2155". The surveyor asked Staff # 7 (Radiology Director) when the IV bag and associated tubing expired. Staff # 7 replied, "It is only good for 12 hours".

*There was a metal storage rack inside the CT scanner room, located across the hall from the chapel. The metal rack was used to store 150 ml (milliliter) Sterile Disposable Syringes with Spikes. The bottom shelf of the metal rack did not contain a clear plastic liner to prevent any dust, dirt, cleaning liquids, etc. from coming into contact with the sterile patient supplies stored on the bottom shelf.

A review of the hospital's "Infection Prevention and Control Plan" policy with a date of 07/25 revealed,

" ...The following responsibilities and authorities apply to Infection Prevention departments in all CHRISTUS ministries:
*Independently identify, report, and analyze the incidence of healthcare-associated infections (HAI) utilizing Center for Disease Control (CDC)/National Healthcare Safety Network (NHSN) HAI surveillance definitions.
*Analyze infection data to identify clusters of infections, outbreaks, sentinel events, or emerging pathogens.
*Develop and implement a preventive and corrective program designed to minimize infection hazards detected in any clinical setting.
*Implement emergency prevention measures if significant infection risk trends are identified.
*Facilitate an Infection Prevention and Control Council to educate and standardize prevention practices.
*Development and approval of all policies and procedures related to infection surveillance, prevention, and control activities.
*Promote the application of enterprise policies relating to infection prevention.
*Identification of environmental risks or regulatory deficiencies related to the physical environment of the clinical setting.
*Identification of clinical best practices related to prevention of infection and validation of best practice implementation in patient care areas, including ED, outpatient/ambulatory, procedural, surgical, and inpatient settings.
*Validation for isolation precautions, barrier precautions, or environmental cultures are required for prevention of infection transmissions.
*Infection Prevention has the authority to determine when a higher level of precautions is needed than observed and will communicate these needs when identified.
*Infection Prevention must be contacted prior to the removal of airborne precautions to ensure that removal is appropriate and safe.
*Collaborate with ministry and enterprise leadership to institute emergency measures to prevent infections.
*Participate in multidisciplinary committees, including but not limited to:
*Pharmacy and Therapeutics Committee and/or Antimicrobial Stewardship Committee related to antibiotic utilization practice patterns ....Data Collection and Reporting: Data Collection: System-wide surveillance is performed via an electronic infection prevention reporting and tracking system. Notifications are monitored from public health and federal resources. Alerts are reviewed from the Centers for Disease Control for impact to the patient populations. Items identified for action are communicated to the Chief Clinical Officer for discernment on action
plans for system-wide impact to mitigate the risk for spread of infection.
*Surveillance focuses on high-volume, high risk and problem prone procedures ...."

An interview was conducted with Staff # 2, and # 3 on 11/10/2025 at 11:30 AM which confirmed the hospital's infection control issues in the hospital's emergency department radiology department.