HospitalInspections.org

Based on random observations, review of Regulatory Guide 6.2 Guide for the Preparation of a Radiation Protection and Safety Program for use of Radiation Machines in the Healing Arts and staff interview, the CAH failed to ensure patient exposure to radiation was reduced as evidenced by failing to check annually for defects (holes, cracks, or tears) in protective devices (gloves, shields and lead aprons). This failed practice had the potential to affect all patients exposed to radiation that required the use of protective devices. The CAH completed 11,156 radiology procedures in fiscal year 2022.

Findings:

A. Random observations of the radiology department (1/22/24 at 2:50 PM- 3:38 PM) revealed a rack of lead aprons and shields for patient protection. Random observations of the Surgery department ( 1/23/24 at 1:51 PM- 2:33 PM) revealed a rack of lead aprons and shields for patient protection.

B. Review of the Regulatory Guide 6.2 Regulatory Guide 6.2 Guide for the Preparation of a Radiation Protection and Safety Program for use of Radiation Machines in the Healing Arts (Dated 7/09) revealed under "Use of Protective Devices" the following:
"Protective devices should be checked annually for defects, such as holes, cracks, or tears. This check can be done by visually inspecting or feeling the protective devices or may also be done by x-raying these items."

C. Interview with Director of Radiology (1/24/24 at 8:05 AM) confirmed the facility failed to check annually for defects (holes, cracks, or tears) in patient protective devices (gloves, shields and lead aprons).