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Based on observation, interview, record review and policy review, the hospital failed to follow their policy to ensure that radioactive (emitting or relating to the emission of ionizing radiation or particles) nuclear waste was disposed of properly and appropriate logs were maintained for the rescanning of nuclear waste. This failure had the potential to place all patients and staff at risk to exposure of radiation. The hospital census was 441.

Based on observation, interview, record review and policy review, the hospital failed to follow their policy to ensure that radioactive (emitting or relating to the emission of ionizing radiation or particles) nuclear waste was disposed of properly and appropriate logs were maintained for the rescanning of nuclear waste. This failure had the potential to place all patients and staff at risk to exposure of radiation. The hospital census was 441.

Findings included:

1. Review of the hospital's policy titled, "SOUTH IMS Radiation Portal (device used to scan trash for radioactive material) Monitor," dated 03/09/21, directed Environmental Services (EVS) staff to:
- Move all hospital trash items through the portal monitor prior to disposal;
- If the portal monitor alarm sounded and the reading was above six microSieverts (a unit of ionizing radiation equal to 10 to the negative six sieverts [unit of radiation absorption in the International System of Units]), follow the directions on the sign next to the monitor display instructing people to contact the Security Office;
- Walk each bag of trash through the monitor location until the source is found;
- Transport the bag (radioactive source) to the biohazard storage room;
- Recheck the contaminated bag 24 hours after stored in the biohazard room by walking through the portal monitor again, and dispose of if under six microSieverts; and for Security staff (when notified by EVS of radioactive trash) to:
- Instruct the EVS staff to transport the bag of trash (radioactive source) to the biohazard storage room;
- During the hours of 7:30 AM to 4:00 PM, contact the following, in order until someone is reached; the Radiation Safety Officer (RSO)/Senior Medical Physicist, Nuclear Medicine, or Medical Physicists;
- After business hours, send an email to the individuals listed above to notify of the alarm; and
- Prior to the end of the shift, a report should be written on the incident to include the person who was transporting the material, where the material was being transported from, and where the material was being transported to.

No further instructions were given to staff regarding the documentation of the second scan, or what to do with a bag (radioactive source) that triggered the portal monitor a second time.

Observation on 10/18/22 at 10:45 AM, showed the portal monitor display was set at a 3.3 microSieverts threshold. The signage next to the portal monitor instructed staff to contact Security if the reading was over six microSieverts.

Review of the untitled hospital document, dated 08/06/22 at 00:10 AM, showed the portal alarm level reading was documented as 10.5. The document also showed the person transporting the material, that the source was the trash cart, the trash was being taken to the dumpster and the source was documented as "don't know what floor it came from." The radioactive source bag was documented as placed in the biohazard room and marked with a date.

Although requested, the hospital failed to provide logs documenting the recheck/rescanning of previously identified radioactive waste stored in the biohazard room.

During interviews on 10/18/22 at 9:15 AM and on 10/19/22 at 8:30 AM, Staff Q, Lead Nuclear Medicine Technician and Assistant RSO, stated that:
- She had received an email notification from security that a bag of waste had set off the portal monitor on 08/06/22 with a reading of 10.5.
- If the trash triggered the portal monitor, the bag of waste would be moved to the biohazard room and rescanned by EVS in 24 hours.
- EVS staff were responsible for scanning and rescanning waste.
- She could not confirm that the second scan had been performed on the isolated bag of radioactive waste, because there were no current logs for documentation of the rescanning of the radioactive waste.

During a telephone interview on 10/19/22 at 9:40 AM, Staff HH, Radiation Safety Officer, stated that he was not sure that the bag of isolated radioactive waste had been rescanned but it should have been rescanned prior to release from the hospital.