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TRINITY MEDICAL CTR EAST &TRINITY MEDICAL CTR WEST
MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY
Tag No.: A0347
Based on medical record review, interview and policy review, the facility failed to ensure licensed personnel operated the radiology equipment in the catheterization labs. This affected all patients receiving services from the catheterization labs and one staff member.
Findings include:
The facility's radiology staff's licensure status was reviewed and revealed all of the staff were licensed except for Staff F.
The personnel file of Staff F was reviewed. The job description in Staff F's personnel file was titled: Invasive Cardiac Specialist. The personnel file review revealed Staff F completed a cardiovascular technology series on 12/19/89 and was hired at the facility on 08/13/01. The personnel file did not contain documentation Staff F was licensed.
The job description stated qualifications included Graduates of an approved invasive Cardiovascular Technology Program with registered or registry eligible status in invasive cardiovascular technology. The job specific tasks included "operate imaging equipment to achieve optimal views and projections of the cardiac/peripheral anatomy for diagnostic and interventional procedures while maintaining safety precautions at all times as permitted by appropriate registry status.
On 03/24/16 at 7:38 AM, Staff C was interviewed. Staff C reported a recent survey determined Staff F was not registered.
On 03/24/16 at 7:40 AM, Staff A reported Staff F had been instructed not to touch any radiology equipment under any circumstance after the recent finding. The facility is currently changing the job description of Staff F to list what tasks Staff F cannot perform.
On 03/24/15 at 7:50 AM, Staff C reported Staff F touched or moved the radiology equipment but never dosed or operated the fluoro equipment. Staff C reported Staff F physically touched the equipment and was not registered as a radiology technician.
On 03/24/16 at 12:39 PM, Staff E stated operating the equipment included moving the table.
On 03/24/16 at 1:39 PM, Staff D reported Staff F admitted to moving the tables used in the cath labs.
On 03/24/16 at 3:50 PM, Staff C reported the scrub assigned to the case is normally the person who moves the table, unless the physician does.
Ten procedure reports were reviewed. Five of the reports revealed Staff F was the "scrub" on duty 02/29/16, 03/02/16, 03/09/16 and 03/10/16. The reports revealed Staff F was the only scrub on 02/29/16 and 03/02/16. On 03/09/16 and 03/10/16, the facility assigned two scrubs to each procedure with Staff F.
The facility's Cardiology Statistical Report from 12/24/15 through 3/24/16 was reviewed. The report revealed Staff F worked 40 shifts.
The facility's Safe and Operating Procedure and Heart Center policy was reviewed. The policy stated all individuals providing technical diagnostic services are licensed or registered (according to applicable state laws and regulations) and have appropriate training and levels of competence.
The facility's Right and Left Heart Cath, Left Coronary Angiography & Left Ventricular policy was reviewed. The policy stated cath lab personnel will assist the physician throughout the procedure in accordance with the scope of position. The procedure included to position the imaging equipment per physician preference to obtain diagnostic images of appropriate structures.
The facility's Medical Staff Bylaws were reviewed. The bylaws stated its purpose was to make recommendations to the board to promote medical care consistent with accepted standards of care, and available resources, personnel, and facilities. The Medial Staff Code of Conduct stated practitioners agree to provide care to patients consistent with generally recognized standards of care and applicable laws.