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Based on observation, interview, and record review the facility failed to ensure the Condition of Participation for Patient Rights was met as evidenced by:

1. The facility failed to ensure a safe environment for one of 30 sampled patients (Patient 1), in the radiology magnetic resonance imaging (MRI - noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles, and blood vessels) department, outpatient building, when a MRI Technician (MRI Tech 1) wheeled a non-MRI-safe wheelchair into the MRI procedure/scanning room where metal objects were not allowed due to the magnetic field, in accordance with the facility's policy and procedure regarding MRI Safety and Screening Policy. MRI Tech 1 lost control of the non-MRI-safe wheelchair which got drawn into the gantry (contains the main magnet and several other electromagnetic devices essential to producing images) of the MRI machine.

This deficient practice resulted in injury to facility staff, who sustained bleeding in his (MRI Tech 1) neck requiring a medical screening examination in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), after getting injured from the wheelchair that got sucked by the magnetic field and Patient 1, who complained of pain in her (Patient 1) head after being abruptly moved from the MRI table to the floor. The deficient practice also had the potential for serious harm including death to the patient (Patient 1) and/or staff (MRI Tech 1). (Refer to A-0144)

The effect of this deficient practice resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatment.

Based on observation, interview and record review, the facility failed to ensure a safe environment for one of 30 sampled patients (Patient 1), in the radiology magnetic resonance imaging (MRI - noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles, and blood vessels) department, outpatient building, when a MRI Technician (MRI Tech 1) wheeled a non-MRI-safe wheelchair into the MRI procedure/scanning room where metal objects were not allowed due to the magnetic field, in accordance with the facility's policy and procedure regarding MRI Safety and Screening Policy. MRI Tech 1 lost control of the non-MRI safe wheelchair which got drawn into the gantry (contains the main magnet and several other electromagnetic devices essential to producing images) of the MRI machine.

This deficient practice resulted in injury to facility staff, who sustained bleeding in his (MRI Tech 1) neck requiring a medical screening examination in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), after getting injured from the wheelchair that got sucked by the magnetic field and Patient 1, who complained of pain in her (Patient 1) head after being abruptly moved from the MRI table to the floor. The deficient practice also had the potential for serious harm including death to the patient (Patient 1) and/or staff (MRI Tech 1) resulting from the non-MRI-safe wheelchair sucked by the MRI magnet.

On 2/8/2024, at 3:37 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the facility's Vice President of Regulatory Affairs (VP). The facility failed to provide a safe environment for one of 30 sampled patients (Patient 1), in the radiology magnetic resonance imaging (MRI - noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles, and blood vessels) department, outpatient building.

On 2/6/2024, at 1:58 p.m., the Vice President of Quality Management, the Vice President of Operations, and the Radiology Manager stated an accident happened on 1/10/2024 at approximately 5 p.m., in the outpatient building, when an MRI Technician 1 (MRI Tech 1) had Patient 1 on the MRI table. The Hospital Assistant 1 (HA 1) wheeled Patient 1 (a minor) to Zone 2 (waiting and screening area) using a non-MRI safe wheelchair for the MRI procedure. The non-MRI safe wheelchair was left in Zone 2 where there were other MRI safe wheelchairs available. The HA 1 assisted the patient (Patient 1) to Zone 4 (procedure/scanning room) using the MRI safe walker and placed Patient 1 on the MRI table. To accommodate the patient's (Patient 1) father to be present during the procedure, MRI Tech 1 brought in a non-MRI-safe wheelchair by the MRI scanning room past Zone III (Metal Detector walk area). The MRI Tech 1 then lost control of the wheelchair in his (MRI Tech 1) hands. HA1 saw the MRI Tech 1 wheeling the non-MRI safe wheelchair for Patient 1's father and shouted "not that wheelchair" as HA 1 saw that the wheelchair was colored blue (the common metal wheelchair used by the hospital). The MRI safe wheelchairs were colored maroon. The HA 1 immediately removed Patient 1 from the table and placed Patient 1 on the floor for safety. The non-MRI safe blue colored wheelchair started to lift off the ground and got drawn into the gantry of the MRI machine.

On 2/6/2024, at 1:58 p.m., the Radiology Manager stated the MRI Tech 1 brought in an unsafe equipment past the facility's metal detector alarms in Zone III and entered the MRI scanning room (designated as Zone IV), where metal objects were not allowed to enter, with a vulnerable pediatric patient (Patient 1) positioned on the MRI table.

On 2/7/2024, at 2:27 p.m., MRI Tech 1 stated he (MRI Tech 1) worked on 1/10/2024. MRI Tech 1 stated after he (MRI Tech 1) received hand-off (communication that occurs whenever the treatment team for a patient changes in which there is a transfer of patient information) from MRI Tech 2, regarding Patient 1, who was a minor and was positioned on the MRI table for a procedure with assistance from HA 1, MRI Tech 1 spoke with Patient 1, who wanted her (Patient 1) parent with her (Patient 1) during MRI scanning. Afterwards, MRI Tech 1 left the MRI scanning room and went to the waiting area (designated Zone II), where Patient 1's parent was and proceeded to do MRI safety scan for Patient 1's parent, in order to enter the MRI scanning room to be beside his (Patient 1's parent) child. After MRI Tech 1 did MRI screening for Patient 1's parent, MRI Tech 1 stated he (MRI Tech 1) entered zones III and IV with Patient 1's parent, with a non-MRI-safe wheelchair, for the father to sit on, during MRI scanning. MRI Tech 1 stated he (MRI Tech 1) did not remember hearing the metal detector alarms go off upon entering Zone III and into Zone IV with the non-MRI safe wheelchair. Likewise, there was no documentation of Patient 1's father's MRI Outpatient Screening was completed.

On 2/8/2024, at 11:40 a.m., the Radiology Manager stated there were environmental safeguards in place in Zone III (where metal detectors were located), prior to entrance to Zone IV (procedure/scanning room) where MRI machine was located, which had an audible alarm to warn staff of metal detection.

On 2/9/2024, at 6:55 PM, IJ was removed in the presence of the Vice President of Regulatory Affairs after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The IJ Removal Plan indicated the following:

1. Re-education of the MRI staff, revision of the MRI Screening Tool, quality control for environmental safety devices, and removal of non-MRI safe equipment in the MRI suite.
2. Verbal and written one-to-one education of MRI staff.
3. Definition of MRI zones, revised MRI Safety and Screening policy for patient and/or their support person, including documentation of MRI screening for patient and/or patient's support person in patient's medical record, emergency procedure during MRI scanning, and environmental checks for safety devices and for ensuring MRI safe equipment in the MRI suite.

Findings:

During an initial tour of the facility on 2/6/2024, at 12:40 p.m., with the Vice President of Regulatory Affairs (VPRA), the Director of Operations (Dir Ops), the Vice President of Quality Management (VPQM), and the Manager of Radiology (MRD), the MRD stated the facility's Magnetic Resonance Imaging (MRI- noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles, and blood vessels) department follows the nationally recognized guidelines of the American College of Radiology (ACR - a professional medical society representing diagnostic radiologists [involves undertaking a range of imaging procedures to obtain images of the inside of the body], radiation oncologists [specializing in cancer treatments], interventional radiologists [diagnose and treat diseases using imaging techniques], nuclear medicine physicians [uses imaging technology for better visualization of the body's internal organs], etc.).

During an interview on 2/6/2024, at 1:58 p.m., with the Manager of Radiology (MRD), in the facility's board conference room, MRD stated an accident happened on 1/10/2024, at approximately 5 p.m., in the MRI department, outpatient building, when MRI Technologist (MRI Tech) 1 had Patient 1 on the MRI table for a scanning procedure. The hospital assistant (HA) 1 wheeled Patient 1 from the lobby into Zone 2 (waiting and screening area of the MRI suite), using a non-MRI-safe wheelchair, for the scheduled outpatient MRI procedure. The non-MRI-safe wheelchair was left in Zone 2, where there was other MRI-safe equipment available, including MRI-safe wheelchair.

During the same interview on 2/6/2024, at 1:58 p.m., with the Manager of Radiology (MRD), MRD said, the HA 1 assisted Patient 1 into Zone 4 (procedure/scanning room) using the MRI-safe walker and placed Patient 1 on the MRI table. To accommodate Patient 1's father to be present during the procedure with Patient 1, MRI Tech 1 brought in a non-MRI-safe wheelchair, for Patient 1's father to sit on, passed Zone 3 (metal detector walk area) into Zone 4, where MRI Tech 1 then lost control of the non-MRI-safe wheelchair in his hands due to the magnetic field in the area. MRD further stated, as MRI Tech 1 was bringing in the non-MRI-safe wheelchair into Zone 4, HA 1 observed the incident and noticed the blue-colored wheelchair (common metal wheelchair used by the facility). The MRI-safe wheelchairs are maroon-colored. The HA 1 immediately removed Patient 1 off the table and abruptly placed Patient 1 on the floor. The blue-colored wheelchair (non-MRI safe) started to lift off the ground and got drawn into the gantry (contains the main magnet and several other electromagnetic devices essential to producing images) of the MRI machine.

Concurrently, MRD stated, MRI Tech 1 brought in an unsafe equipment (a non-MRI-safe wheelchair) past the facility's metal detector's alarms, in Zone 3, and entered the MRI scanning room (Zone 4), where metal objects were not allowed to enter, with a vulnerable pediatric patient (Patient 1) positioned on the MRI table.

During an interview on 2/7/2024, at 2:27 p.m., with MRI Tech 1, MRI Tech 1 stated the following:

1. He (MRI Tech 1) worked on 1/10/2024, in the MRI department, at the outpatient building.

2. He received hand-off report (communication that occurs whenever the treatment team for a patient, changes in which there is a transfer of patient information) from MRI Tech 2, regarding Patient 1, who was a child and was positioned on the MRI table for a procedure with the assistance of HA1.

3. He interviewed Patient 1, who stated she (Patient 1) wanted her father with her (Patient 1) during the MRI scanning.

4. He left the MRI scan room (Zone 4) and went into the waiting area (Zone 2) where Patient 1's father was waiting and proceeded to do the MRI screening for Patient 1's father, in order to allow Patient 1's father to enter the MRI scan room (Zone 4) to be beside his (Patient 1) child.

5. He took Patient 1's father past Zone 3 (metal detector walk area) and then to Zone 4, using a blue wheelchair (non-MRI-safe wheelchair) from the waiting area, for Patient 1's father to sit on, during the MRI scanning procedure of Patient 1.

6. MRI scanning takes 30 minutes, and he (MRI Tech 1) did not want Patient 1's father to have to stand the entire time.

7. He (MRI Tech 1) did not remember hearing the metal detector alarms go off upon entering Zone 3 and into Zone 4, while pushing the blue wheelchair (non-MRI-safe wheelchair).

8. After entering the MRI scan area (Zone 4) with the blue wheelchair (non-MRI-safe wheelchair), he (MRI Tech 1) felt the MRI scanner pulling on the blue wheelchair and getting stronger.

9. Blue wheelchair then lifted off the ground, left his (MRI Tech 1) hands, and flew into the gantry (contains the main magnet and several other electromagnetic devices essential to producing images) of the MRI scanner.

10. HA 1 noticed the situation, when he (MRI Tech 1) entered MRI scan room (Zone 4) and abruptly grabbed Patient 1 off the MRI table and onto the floor, like a person diving in to save the child, as the blue wheelchair lifted off the ground and was pulled off MRI Tech 1's hands towards the gantry.

11. After the incident, he (MRI Tech 1) checked on Patient 1 and observed Patient 1 was breathing okay and had no signs of injury.

12. Patient 1 complained that her (Patient 1) head hurt.

13. He (MRI Tech 1) left the MRI scan room into the control room to call the emergency number #12999, for assistance, and returned to the scan room.

14. The emergency response team started to arrive in the MRI suite to assist and check on Patient 1.

15. He (MRI Tech 1) couldn't remember who showed up for help.

16. Emergency response team called 9-1-1 to take Patient 1 to another facility for further evaluation and care.

17. Someone from the emergency response team instructed him (MRI Tech 1) to go to the emergency department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) to get evaluated because there was blood observed on his (MRI Tech 1) neck.

Concurrently, during a review of Patient 1's outpatient records, dated 1/10/2024, MRI Tech 1 stated there was no documentation of Patient 1's father's MRI Outpatient Screening being completed.

During an interview on 2/7/2024, at 4:10 p.m., with Hospital Assistant (HA) 1, HA 1 stated he worked on 1/10/2024, at the MRI department outpatient building. HA 1 said he (HA 1) remembered the MRI incident. HA 1 stated the following:

1. Picked up Patient 1 from the lobby with her (Patient 1) father and observed the patient (Patient 1) dragged her leg while walking with her (Patient 1) walker.

2. Grabbed a blue wheelchair (non-MRI-safe wheelchair used throughout the facility) from the lobby and transported Patient 1 into the MRI suite.

3. Left the blue wheelchair in the waiting area (Zone 2).

4. Took patient (Patient 1) to get dressed in gown and accompanied Patient 1 into the MRI scan room (Zone 4) using a MRI-safe walker, after getting screened by MRI Tech 2

5. MRI Tech 1 arrived after meal break and received hand-off from MRI Tech 2.

6. MRI Tech 1 entered the MRI scan room and asked Patient 1, who was a minor, if she (Patient 1) wanted her father with her and Patient 1 stated she wanted her father with her (Patient 1).

7. MRI Tech 1 screened Patient 1's father and brought the father in using a blue wheelchair (non-MRI-safe wheelchair). The purpose for bringing in the wheelchair was to have something for Patient 1's father to sit on while waiting for Patient 1 inside the MRI scanning room since patient 1 requested for her father to be present during the procedure

8. Everyone in the MRI department knows that the blue wheelchair is not MRI-safe.

9. When he (HA 1) saw MRI Tech 1 brought in the blue wheelchair to the MRI scan room (Zone 4), while Patient 1 was on the MRI table and was getting her ear plugs and getting ready for the procedure, he (HA 1) shouted to MRI Tech 1, "NO!" but it was too late.

10. He (HA 1) saw the blue wheelchair (non-MRI-safe wheelchair) lift off the ground and take off.

11. At the same time, he (HA 1) abruptly picked up the patient (Patient 1) from the MRI table fast and put her (Patient 1) on the floor.

12. He (HA 1) felt the blue wheelchair fly into the air and into the MRI scanner where Patient 1 was moments prior to the incident.

13. Afterwards, Patient 1 complained that her (Patient 1) head was hurting after being abruptly taken off the MRI table and on to the floor while the non-MRI-safe wheelchair was being pulled by the magnetic field into the MRI scanner.

14. Emergency team was called and arrived to assist with Patient 1.
During an interview on 2/8/2024, at 11:40 a.m., with the Manager of Radiology (MRD), MRD stated there were environmental safeguards in place in Zone 3 (metal detector walk area), prior to entrance of Zone 4 (procedure/scanning room), where the MRI machine was located, which had an audible alarm to warn others of metal detection.

During a concurrent interview and record review on 2/8/2024, at 11:40 a.m., with the Manager of Radiology (MRD), the facility's MRI System Quality Assurance (a systematic continuous process, used to determine if MRI equipment meets quality standards) policy, dated 3/31/2023, was reviewed. MRD stated there was no documentation for quality control (QC - how a company measures product quality) by MRI Technologists prior to each use of the MRI machine.

During a review of Patient 1's face sheet (a document that gives a patient's information at a quick glance), dated 1/10/2024, the face sheet indicated the following:

1. Dependent minor (Patient 1)
2. Patient's (Patient 1) reason for visit was low back pain.

During a review of Patient 1's history and physical (H&P - the most formal and complete assessment of the patient and the problem), dated 1/8/2024, the H&P indicated the following:

1. History - 11-year-old who had severe pain in the lower back and radiating down the left leg

2. Patient (Patient 1) reported constant and sharp pain that worsened with prolonged walking and standing, bending, stooping, lifting, and twisting.

3. Plan for MRI and for patient (Patient 1) to walk with the use of a walker and to limit physical activities.

During a review of Patient 1's physician notes - Code Blue (used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention), dated 1/10/2024, the physician notes indicated the following:

1. Responded to Code Blue in MRI department at the outpatient building.
2. Patient (Patient 1) was on the ground, awake and alert.
3. There was no cardiopulmonary arrest (sudden unexpected loss of heart function, breathing, and consciousness).
4. Was informed that a wheelchair (non-MRI-safe wheelchair) was magnetically attracted to the MRI machine and was drawn into the gantry.
5. Patient (Patient 1) fell to the ground from the MRI table.
6. Patient (Patient 1) had no gross visible (visible to the naked eye) traumatic head injuries and recommended c-spine (cervical spine- neck region of the spinal column or backbone) immobilization (used to prevent further injury to the spinal column).
7. Patient (Patient 1) appeared hemodynamically stable (blood pressure and heart rate are stable) and grossly neurologically intact (no problem with brain function that can be found on a physical exam).
8. Paramedics were called and were on the way to have patient (Patient 1) transported for further evaluation.

During a review of the facility's policy and procedure (P&P) titled, Patient Rights and Responsibilities, dated 8/19/2019, the P&P indicated the following:

1...the right to receive care in a safe setting...

During a review of the facility's document titled, Metal Detector's manufacturer's instructions for use, dated 2023, the document indicated the following:

1. Metal detector is a ferromagnetic (materials that are noticeably attracted to a magnet) detection system designed to be placed immediately outside the MRI entryway door (Zone IV entrance).

2. Metal detector device that warns trained staff whether potentially dangerous ferromagnetic objects, that could become projectiles and cause physical harm, are approaching the MRI room.

3. Metal detector device is used to augment MRI facilities of existing safety practices.

4. Final objective safety check immediately prior to the MRI room.

5. Device is not a replacement for any aspect of existing safety protocols and methods.

6. The audible alarm is triggered when a ferrous object is being detected.

7. The primary alert is using a visual early warning to alert users to the presence of potentially dangerous ferromagnetic material, in advance of the sensor units. The safe response to observing the visual indication, while approaching the MRI door is to stop, think and check before proceeding into the MRI room.

8. The secondary alert method is audible with an audible alarm triggered only if the primary alert is ignored and the object passes between the two sensor units.

9. The combination of visual and audible alerts is designed to allow staff and healthcare workers to undertake their duties without disruption.

10. The safe response to hearing an audible indication as one passes through the metal detector system, is to stop, retreat away from the door, think and check before proceeding into the MRI room.

During a review of facility's policy and procedure (P&P) titled, MRI Safety Zone Definitions and Access policy, dated 8/13/22, the P&P indicated the following:

1. Zone I (1) - public areas including hallway adjacent to MRI suite.

2. Zone II (2) - holding area upon entry to MRI suite, where exam preparation occurs, including MRI safety screening, medical history, and patient gowning.

3. Zone III (3) - designated space inside holding area immediately outside the threshold to Zone IV of screened MRI patients and hospital personnel with Level 2 MRI staff and technologist control room.

4. Zone IV (4) - MRI scanner room with persons after screened must remain supervised by Level 2 MRI staff with posted signage warning of potential dangers and indicating, "The Magnet is On."

During a review of facility's policy and procedure (P&P) titled, MRI System Quality Assurance policy, dated 3/31/2023, the P&P indicated the following:

1. MR system and/or other applicable medical equipment is to be maintained by authorized personnel.

2. Facility will adhere to all manufacturer's specifications and government regulations.

3. Quality Control (QC) shall be performed by MRI technologist, prior to each use.

4. QC testing involving use of imaging phantom will occur weekly with records maintained by staff.

5. Preventative maintenance of equipment (PM - the regular and routine maintenance of equipment and assets to keep them running and prevent any costly unplanned downtown from unexpected equipment failure) will be performed, as outlined by manufacturer, and will be done by contracted service provider.

6. Physiological monitors and gating equipment will undergo PM annually with Biomedical department responsible for maintaining inventory list and schedule of maintenance intervals.

During a review of the facility's policy and procedure (P&P) titled, MRI Safety and Screening policy, dated 9/28/2023, the P&P indicated the following:

1. Purpose is to ensure safety and to establish procedures for screening patients, medical personnel, and anyone entering MRI examination room and/or exposed to magnetic field.

2. All patients, medical staff, and other individuals must be screened by authorized MRI personnel before entering Zones III and IV of the MRI suites.

3. MRI technologist must screen all equipment or materials before placing them inside Zone IV.

4. Inpatients will have MRI Screening completed by a Registered Nurse (RN) along with the patient and/or family member, prior to being transferred to MRI department. Afterwards, the MRI technologist will check the patient's medical records for completion of the screening tool. Then the radiology transporter will transport the patient off the unit into the MRI department. Upon arrival to the MRI suite in Zone II, MR technologist will review screening tool. After initial safety screening is completed, patient will be screened by the MR technologist using a metal detection device, prior to patient entering Zone IV, or transferred to an MR conditional gurney or wheelchair for a 2-person visual screening, prior to entering Zone IV.

5. Outpatients will be given an Outpatient MRI Screening tool upon arrival to reception area. Outpatient will be taken to MRI suite, by Hospital Assistant (HA) or Radiology Transporter, to Zone II. In Zone II, MR technologist will review outpatient's screening tool. Afterwards, outpatient will be screened by MR technologist using a metal detection device, prior to patient proceeding into Zone IV, or will be transported to MR safe gurney or wheelchair for a 2-person visual screening, prior to patient proceeding into Zone IV.

6. All persons who enter Zones III or IV will be informed of the potential risk when placed in proximity and/or inside the static magnetic field.

7. All MR staff shall be instructed on importance of carefully screening all persons, equipment, and materials place inside examination room.

Based on observation, interview and record review, the facility failed to ensure there was preventive maintenance or quality control performed to ensure safe equipment use for one of one sampled medical equipment (non-MRI-safe wheelchair) in the MRI equipment room of the radiology magnetic resonance imaging (MRI - noninvasive medical imaging test that produces detailed images of almost every internal structure in the human body, including the organs, bones, muscles, and blood vessels) department, outpatient building in accordance with the facility's policy regarding equipment inspection and maintenance in the MRI department.

This deficient practice had the potential to result in patient or staff injury when a broken wheelchair or a non-MRI-safe wheelchair was used in the MRI department.

Findings:

During a concurrent observation and interview on 2/6/2024, at 12:53 p.m., with the Manager of Radiology (MRD), it was observed that (1) broken non-MRI-safe wheelchair was left inside the MRI equipment room in the radiology MRI department. MRD stated MRI staff was responsible in identifying and tagging broken equipment in the MRI department. MRD said the staff should also put in a work order request to have the facilities department people remove the broken equipment. MRD concurred that there was no tag indicating a broken equipment and MRD was not sure if a work order was placed to have the broken non-MRI-safe wheelchair removed from the MRI equipment room. MRD further said that the non-MRI-safe wheelchair had been in the equipment room since 1/10/2024, when it was damaged when MRI Tech 1 brought the non-MRI-safe wheelchair inside the procedure/scanning room (Zone 4), which had the magnetic field. Thus, the non-MRI-safe wheelchair was drawn into the gantry (contains the main magnet and several other electromagnetic devices essential to producing images) of the MRI machine.

During a concurrent interview and record review on 2/8/2024, at 11:10 a.m., with the Manager of Radiology, the facility's MRI System Quality Assurance (a systematic continuous process, used to determine if MRI equipment meets quality standards) policy, dated 3/31/2023, was reviewed. MRD stated that the facility had a Medical Safety Officer overseeing the facility's operation safety but had no dedicated MRI Safety officer, the facility was working on creating a MRI Safety Committee to improve MRI related safety practices. MRD further said the Radiology leadership team had oversight on MRI safety practices. Likewise, MRD stated there was no documentation for quality control (QC - how a company measures product quality) by MRI Technologists prior to each use of the MRI machine.

During a review of the facility's policy and procedure (P&P) titled, MRI System Quality Assurance policy, dated 3/31/2023, the P&P indicated the following:

1. MRI system and/or other applicable medical equipment is to be maintained by authorized personnel.

2. Facility will adhere to all manufacturer's specifications and government regulations.

3. Quality Control (QC) shall be performed by MRI technologist, prior to each use.

4. Preventative maintenance of equipment (PM - the regular and routine maintenance of equipment and assets to keep them running and prevent any costly unplanned downtown from unexpected equipment failure) will be performed, as outlined by manufacturer, and will be done by contracted service provider.