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UF HEALTH LEESBURG HOSPITAL 600 E DIXIE AVE LEESBURG, FL 34748 Aug. 1, 2017
VIOLATION: MONITORING RADIATION EXPOSURE Tag No: A0538
Based on interview and record review, the facility failed to test the radiation workers' badges for radiation exposure time specific in the cardiac catheterization laboratory area of the facility.

Findings:

An interview was conducted with the Heart Care Coordinator (HCC)/a Cardiovascular Technician (CVT) on 8/1/2017 at 11:31 AM. She stated she has worked here for 7 and a half years in the same capacity. HCC stated that each radiology technician is trained regarding submission of badge for testing every month. Staff are also educated on proper shielding to minimize exposure during a radiological procedure. At the end of each month, the badges are turned in to a basket and taken to the radiology department to be sent out for reading/testing. The Chief Nuclear Medicine Technologist (CNMT) is responsible for the logging in and out of the badges to make sure everyone has turned in their badges. The CNMT will then send the badges out to a third party company that reads the badge exposure time. CNMT receives the badges, then rotates and dispenses them when they are returned from the third party company. HCC stated that she is not aware of any staff that failed to turn in their badge.

During an interview with the Chief Nuclear Medicine Technologist (CNMT) on 8/1/2017 at 1:43 PM, he stated he is the Chief of Nuclear Medicine Technology (CNMT) and has worked here for 13 years. When asked what is the facility's policy on badge reading for personnel exposed to ionizing radiology; he replied, we do badge reading every quarter. The Interventional Radiology and Nuclear Medicine badges are read monthly. I collect the badges and send them to a third party company that processes the badges. They read the badges and send the report back approximately in 2 to 3 weeks. When the exposure number is too high beyond the threshold/parameter, I notify the Safety Officer. We also inform the badge owner about the exposure.

CNMT provided a Radiation Dosimetry (Badge) Report conducted by the third party company for personnel in the main radiology department, nuclear medicine and interventional radiology. The Dosimetry reports include the radiology employee names, historical customer average control dose and control dose used. The reports were conducted on the following dates:
10/15/2016 to 11/14/2016
11/15/2016 to 12/14/2016
12/29/2016 to 1/3/2017
5/5/2017 to 6/10/2017
5/25/2017 to 6/30/2017

When asked about the quarterly dosimetry report for personnel in the cath lab, CNMT produced a Dosimetry Report dated 5/5/2017. The report does not have any cath lab personnel names on it. On the document, CNMT confirmed he had a hand written note that reads: CCL (Cardiac Cath. Lab) did not return any dosimetry badge for the period of 1/15/2017 to 4/14/2017. CNMT stated he called the Department Director then and reported the failure of badge submission and has not received any response. CNMT confirmed on 8/1/2017 at 2:10 PM that the cath lab employees have failed to submit their dosimetry badge since January. He stated he will submit them today, 8/1/2017.

During an interview with Staff L, a physician, on 8/1/2017 at 2:13 PM, he stated that he is the Radiology Safety Officer (RSO) of this hospital. He stated one of his responsibilities is to review the badge test of employees quarterly and annually when he gets the report from the third party company that reads the badges. Radiology Safety Officer stated that he was not made aware of the failure of cath lab employees to submit their badges for testing.

During an interview with the Heart Care Coordinator (HCC) on 8/1/2017 at 2:45 PM, she stated and confirmed that the cath lab employees' badges have not been read or submitted. She stated she was just made aware of it today. HCC confirmed that the badges of the cath lab employees have not been read since January 2017.

Review of the Encounter Data report provided by the Risk Manager on 8/1/2017 at 2:36 PM, dated 3/15/2017, revealed an encounter with fluoroscopy exposure time of 140 minutes during a procedure requiring a closure of a brachial artery. Even with rotating staff, all involved had been exposed to well over the limit of radiation.

During a telephone interview with the Risk Manager on 8/8/2017 at 8:40 AM, she stated this encounter report was just an opinion of the writer and is not confirmed, as the badges have not been read. The badges were just sent out and they have not received the report to confirm over exposure.

Review of the policy and procedure entitled: ALARA and Radiation Safety - Diagnostic Imaging, revised on 6/6/2016. Page 1 of 3 of the policy under Standard reads: The management and professional staff at Leesburg Regional Medical Center (LRMC) and the Villages Regional Hospital (TVRH) endorse the ALARA concept. We are committed to this concept to keep all radiation exposures to both our patients and ourselves as Low As Reasonably Achievable (ALARA).

Policy: LRMC/TVRH will perform a formal annual review of the radiation safety program, including ALARA considerations. This shall include reviews of operating procedures, past exposure records, inspection and consultations with the Radiation Physicist and be reported at the Radiation Safety Committee meetings.
Film badges will be changed on either a monthly or quarterly basis depending on the area assigned. Employees are responsible for their badges.
Film badge reports will be reviewed by the Chief Nuclear Medicine Technologist and/or the Medical Physicist. Any exposures above acceptable levels will be reported to the Radiation Safety Officer (RSO) for investigation and variances reported to the Radiation Safety Committee.