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HILLCREST HOSPITAL
SAFETY FOR PATIENTS AND PERSONNEL
Tag No.: A0536
Based on review of the facility's Radioactive Biohazard Waste Management monitoring log, interview and policy review, the facility failed to test radioactive waste in accordance with the facility's policy every 48 hours.
Findings include:
1. The facility's Radioactive Biohazard Waste Management monitoring log was reviewed. The log contained evidence of bags triggering the radiation alarm on 18 separate occasions from 11/02/15 through 01/19/16. The log sheet contains a column labeled "Date Disposed" which did not have dates listed for the 18 separate occasions.
2. The facility's Radioactive Biohazard Waste Management monitoring log was reviewed and contained an entry titled "wet vac" dated on 01/14/16. Staff A reported the date on the log was incorrect and the actual date of the radiation alarm was 01/15/16.
The facility's electronic mail correspondences regarding the wet vac were reviewed. The correspondence revealed revealed Staff B rechecked the wet vacuum on 01/18/16 (no time noted) and it no longer had any detectable radiation.
The facility's Radiation Portal Monitoring Standard Operating Procedure policy was reviewed and stated bags which trigger the portal monitors are tagged and placed in a secure cage. After 48 hours, the bag is passed through the portal monitor. If the bag triggers the alarm again then the bag is placed inside the secure cage and passed through the portal monitor every 48 hours up to 29 days. If the container continues to trigger the alarm after one month, then the waste tech will notify the EVS Supervisor who will contact nuclear medicine for evaluation of the radioactive waste.
PERIODIC EQUIPMENT MAINTENANCE
Tag No.: A0537
Based on observation and interview, the facility failed to ensure equipment used to detect radiation was calibrated.
Findings include:
On 01/21/16 at 10:40 AM, Staff C tested a drain in the environmental service room for radioactive substances. The device (inventory #011457) used to measure radioactive substances had a label affixed to it stating calibration was due on 11/2001.
The findings were shared with Staff A at the time of the observation and confirmed.