HospitalInspections.org

Based on the lack of documented evidence, manufacturer's instructions and staff interview, the Critical Access Hospital failed to protect patients from unnecessary radiation exposure by failing to follow the manufacturer's instructions for operating the Computerized Axial Tomographer(CAT) scanner.(CAT scanner combines a series of x-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues of the body.
According to the most recent annual program evaluation, dated 9-2014, the facility performed approximately 300 patient CAT scans.

Findings include:

1. Review of the manufacturer's instructions for use of the CAT scanner (page 78 of the operations manual), "GE recommends that you acquire scans of Sections 1,2, and 3 of the QA(quality assurance) Phantom each day." ( A Phantom is a poly-acrylic device that approximates the size and density of the human head and torso. When the Phantom is subjected to radiation from the CAT scanner, it produces predetermined readings to ensure it is functioning properly, prior to subjecting patients to radiation.)

2. An interview with the Radiology Department Manager on 1-13-2016 at 2:20 P.M. confirmed the Phantom was not tested daily. Interview confirmed, the Phantom was tested only once per year when the bioelectronics maintenance was performed by contracted personnel.