HospitalInspections.org

Based upon observation and interview, the facility failed to maintain a safe environment (lead lined operating rooms) resulting in the potential for all staff and patient harm and exposure to radiation. Finding include:

On May/03/2017 and between the hours of 800 and 1230 it was observed that a C-Arm machine in use at the typical operating room serving the surgery department. The typical operating room does not have the required lead shielding. After further investigation it was determined that the use of the C-Arm machine is limited to 20 hours a month per the statement provided by the surgery department head and accompanying staff, however, no document(s) could be provided to support the claim. The radiation monitoring report shows all normal exposure within allowable limit but still no document could be provided to verify the limitation of the use of the C-Arm machine. Properly safety measures are required to comply with the required safety standard for all staff and patients at any healthcare facility.

Above finding was confirmed by accompanying staff M and N on May/03/2017 at the time of the observation/inspection.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 5/3/17 , the facility does not comply with the applicable provisions of the 2012 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 5/3/17 for Life Safety Code.

K-0211
K-0372
K-0511