HospitalInspections.org

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure radiological services personnel were wearing radiation badges while working near radiation sources. During the initial tour of the facility conducted on 02/29/12, at 3:30 PM, observations revealed two of three facility personnel (Radiological Technicians #1 and #2) were working in the Radiology Department of the facility without wearing a radiation monitoring device.

The findings include:

Review of facility policy, "Personnel Dosimetry - Radiation Film Badges - Wearing and Reporting", dated 12/11, revealed all personnel who could be exposed to ionizing radiation on a routine basis as a part of their job duties, were issued a personnel radiation monitoring device (radiation film badge). The policy further revealed employees must wear the monitoring device at all times while on duty.

Observation on 02/29/12, at 3:30 PM, revealed two of three facility personnel (Radiological Technicians #1 and #2) were working in X-Ray Room One of the Radiology Department without wearing a radiation monitoring device. When the personnel were asked to reveal their radiation film badge, they left the area to retrieve their badges and returned to X-Ray Room One to continue working. The initial tour observations were conducted with the Radiology Department Director present. Observation revealed facility personnel were performing a radiological examination of Patient #2's left and right feet.

Review of Patient #2's medical record on 03/01/12, revealed the patient was seen in the Emergency Department of the facility on 02/29/12. The record revealed Patient #2 had fallen and presented with pain in the left foot. The physician ordered x-ray examinations of the right foot and left foot.

Interview with Radiological Technician (RT) #1 on 03/01/12, at 3:10 PM, revealed RT #1 worked in X-Ray Room One on 02/29/12. RT #1 admitted she was not wearing a radiation monitoring device on 02/29/12, at 3:30 PM. RT #1 stated her normal routine was to put a radiation monitoring device on the collar of her outside apron at the beginning of every shift and remove the badge at the end of every shift. RT #1 stated she forgot to put a radiation monitoring device on at the beginning of her shift on 02/29/12.

Interview with RT #2 on 03/01/12, at 3:40 PM, revealed RT #2 worked in X-Ray Room One on 02/29/12. RT #2 admitted she was not wearing a radiation monitoring device on 02/29/12, at 3:30 PM. RT #2 stated her normal routine was to put a radiation monitoring device on the collar of her outside apron at the beginning of every shift and remove the badge at the end of every shift. RT #2 stated she arrived at work on 02/29/12, at 3:00 PM, and had not placed a radiation monitoring device on her apron before entering X-Ray Room One.

Interview with the Radiology Department Director on 03/01/12, at 3:45 PM, revealed staff working in the Radiology Department was required to wear a radiation monitoring device. The Director stated he called an emergency staff meeting on 02/29/12, with all Radiology Department personnel to discuss the importance of wearing a radiation monitoring device at all times while on duty. The Director further stated Department staff was expected to wear a radiation monitoring device at all times while on duty but was not monitored on a daily basis.