The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|LAKE CHARLES MEMORIAL HOSPITAL||1701 OAK PARK BLVD LAKE CHARLES, LA 70601||Dec. 3, 2014|
|VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING||Tag No: A0144|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, record reviews, and interviews, the hospital failed to ensure that patients on the Adult Psych Unit received care in a safe setting as evidenced by:
1) Having two unsecured wall thermostats that contained sharp metal interiors when the thermostat cover was removed. Record review revealed that Patient R4 had broken a piece of metal off the thermostat and put it in his mouth on 08/17/14.
2) Having an approximate 6-7 foot electrical cord not secured that could be used as a ligature risk;
3) Having sharp edges on the paper towel dispenser located in the patient day area; and
4) Having plastic trash liners in receptacles in patient care areas.
1) Having two unsecured wall thermostats that contained sharp metal interiors when the thermostat cover was removed:
Observation on the Adult Psych Unit on 12/01/14 at 3:15 p.m. revealed two thermostats attached to the wall, one next to the entrance to the laundry room and one next to the entrance to the seclusion room. Further observation revealed the covers to the thermostat could be easily removed by pulling on the cover. Further observation revealed that once the thermostat cover was removed, the interior of the thermostat contained small, sharp metal components. This observation was made in the presence of S4Director of the Psych Unit and S5Assistant Director of Nursing (DON) of the Psych Unit.
Observation on the Adult Psych Unit on 12/02/14 at 8:45 a.m., with S4Director of the Psych Unit and S5Assistant DON of the Psych Unit present, revealed the two thermostats remained unsecured with the covers able to be easily removed.
Review of an incident report revealed that Patient R4 had run down the hall during other peers' altercations, broken a piece of metal off the thermostat, and put the metal in his mouth. Further review revealed that when the nurse asked Patient R4 if he had swallowed the metal, Patient R4 spit the metal onto the floor. Review of the incident report revealed that the action taken to address the event was that the MHT (mental health tech) was educated on the definition of one-to-one observation and patient safety. There was no documented evidence that the unsecured thermostat had been addressed.
Review of the medical record of current inpatients on the Adult Psych Unit revealed the following:
Patient R1 was admitted on [DATE] with a diagnoses of Depression and Suicidal Ideations with a plan. Further review revealed as of 12/01/14 Patient R1 remained depressed with suicidal ideations.
Patient #1 was admitted on [DATE] and CEC'd (Coroner's Emergency Certificate) on 11/29/14 as being a danger to self and gravely disabled.
In an interview on 12/02/14 at 8:45 a.m., S4Director of the Psych Unit indicated that maintenance had ordered covers for the thermostats. She gave no explanation for the thermostats remaining unsecured since Patient R4 had removed metal from the interior of the thermostat and placed it in his mouth.
2) Having an approximate 6-7 foot electrical cord not secured that could be used as a ligature risk:
Observation in the patient dining area on the Adult Psych Unit on 12/01/14 at 2:50 p.m. revealed an approximate 6 to 7 foot electrical cord laying across the back fixtures of the refrigerator that was not plugged into the wall socket that presented a ligature risk.
In an interview during the above observation on 12/01/14 at 2:50 p.m., S5Assistant DON of the Psych Unit confirmed the long cord could be used as a ligature risk.
3) Having sharp edges on the paper towel dispenser located in the patient day area:
Observation in the patient dining area on the Adult Psych Unit on 12/01/14 at 2:50 p.m. revealed a paper towel dispenser that had sharp edges on each side, where one's hand had to be placed to obtain a paper towel, that could cause injury.
In an interview during the above observation on 12/01/14 at 2:50 p.m., S5Assistant DON of the Psych Unit confirmed the edges of the paper towel dispenser were sharp.
4) Having plastic trash liners in receptacles in patient care areas:
Observation in the patient dining area on the Adult Psych Unit on 12/01/14 at 2:50 p.m. revealed a covered trash can and a large uncovered trash can that has a plastic liner in each can. Further observation in the Psych emergency room (adjacent to the Adult Psych Unit) revealed 3 patients were present, and the trash can had a plastic liner in it.
In an interview on 12/01/14 at 2:50 p.m., S4Director of the Psych Unit indicated that she thought it was alright to have plastic trash liners in garbage cans in patient care areas if the patients were not left unattended. When told that the state licensing regulations required no plastic trash liners be used in patient care areas, S4Director of the Psych Unit had no comment.
|VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION||Tag No: A0171|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record reviews and interview, the hospital failed to ensure that physician orders for the use of restraint or seclusion for violent or self-destructive behavior were renewed in accordance with hospital policy for 1 (#3) of 2 (#3, #4) patients' records reviewed for use of restraint or seclusion from a total of 10 sampled patients. The hospital policy allowed for restraint or seclusion orders to be renewed only one time, and Patient #3's restraint order was renewed twice. Findings:
Review of the hospital's policy titled "Seclusion &/or (and/or) Restraint", revised and reviewed in May 2014 and presented as the current policy for restraint and seclusion by S4Director of Psych, revealed that the initial and all subsequent restraint orders shall expire in 4 hours for patients 18 years of age and older. Further review revealed that at the end of the timeframe, if the continued use of restraint or seclusion to manage violent or self-destructive behavior is deemed necessary based on an individualized patient assessment, another order is required. The original restraint or seclusion order may only be renewed within the required time limits one time.
Review of Patient #3's medical record revealed he was a [AGE] year old male who was admitted on [DATE] with diagnoses of Violent behavior and Mental Retardation. Review of his "Behavior Management Seclusion-Restraint (Violent) MD (medical doctor) Order" revealed the following physician orders were written:
11/13/14 at 8:15 p.m. - hard 4 point restraints started at 8:10 p.m. with end time at 1:10 a.m. on 11/14/14 for risk of self-injury, substantial risk of serious physical assault, occurrence of serious physical assault, and substantial risk of self-destructive behavior;
11/14/14 at 12:15 a.m. - renewal order for hard 4 point restraints started at 12:15 a.m. with end time of 4:00 a.m. for less restrictive interventions insufficient, substantial risk of serious physical assault, substantial risk of self-destructive behavior, and occurrence of self-destructive behavior;
11/14/14 at 4:00 a.m. - renewal order for hard 4 point restraints started at 4:15 a.m. with end time of 7:15 a.m. for less restrictive interventions insufficient, risk of self-injury, substantial risk of serious physical assault, substantial risk of self-destructive behavior, and occurrence of self-destructive behavior.
There was no documented evidence that a new restraint order was obtained on 11/14/14 at 4:00 a.m. as required by hospital policy.
In an interview on 12/03/14 at 1:40 p.m. with S4Director of Psych and S5Assistant DON of Psych present, S4Director of Psych indicated that the third restraint order (the second renewal order) should have been a new original restraint order and not a renewal order. She confirmed that hospital policy was not followed, since policy allows a restraint order to be renewed only once.
|VIOLATION: NURSING CARE PLAN||Tag No: A0396|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record reviews and interviews, the hospital failed to ensure that the nursing staff kept a current nursing care plan for each patient as evidenced by not developing nursing care plans for identified patient problems, not updating care plans in response to assessments, and not stating patient goals in observable behavioral terms that could be measured to determine when the goal was met as required by hospital policy for 7 (#1, #2, #3, #5, R1, R2, R3) of 8 (#1, #2, #3, #4, #5, R1, R2, R3) patient records reviewed for nursing care plans from a total of 10 sampled patients and 5 random patients.
Review of the hospital policy titled "Treatment Planning", reviewed January 2014 and presented as a current policy by S4Director of Psych. revealed that patients will have an individualized treatment plan as determined by assessments of clinical needs. Preliminary patient and family goals will be assessed at the time of admission, reassessed during the course of treatment, and as needed. The Master Treatment Plan is based on observations and assessments by members of the interdisciplinary team, which reflects the patient's clinical needs, strengths, liabilities, and as appropriate, the patient and family goals for treatment. Each time a problem is identified during the course of the assessment/evaluation process it should have an indication of resolution. If there is no resolution, the problem should be placed on the Treatment Plan Problem List. Further review revealed that discharge goals should be realistically achievable during treatment and described in behavioral terms. Short-term goals/objectives should be written in a manner that describes the patient's observable behavior.
Review of patient #1's medical record revealed she was a [AGE] year old female who was admitted on [DATE] with chief complaints of Behavior Change and Suicidal Thoughts. She was PEC'd on 11/28/14 at 10:55 a.m. due to being gravely disabled. She was CEC'd (Coroner's Emergency Certificate) on 11/29/14 at 8:45 a.m. due to being a danger to herself and gravely disabled.
Review of Patient #1's physician orders revealed an order from S8Psychiatrist on 11/28/14 at 7:35 p.m. to maintain 1:1 (one-to-one) safety monitoring due to sexual inappropriate gestures and self-care deficit. Review of S8Psychiatrist's "Patient Daily Treatment Progress" note revealed he documented "poor hygiene."
Review of Patient #1's Master Treatment Plan revealed the problems identified on 11/28/14 included risk for self harm and poor activities of daily living. There was no documented evidence that Patient #1's care plan was developed to include interventions and goals for sexually inappropriate gestures as identified by S8Psychiatrist. Further review revealed the long term goal for risk for self harm was stated as "patient will develop better coping skills for anger and anxiety. There was no documented evidence that this goal was described in behavioral terms as required by hospital policy.
Review of Patient #2's medical record revealed she was a [AGE] year old female who was admitted on [DATE] with a diagnosis of Paranoid, Delusional Behavior. Further review revealed she had an Order For Protective Custody completed on 10/21/14 at 3:25 p.m., a PEC (Physician's Emergency Certificate), signed on 10/21/14 at 5:43 p.m. (danger to self and gravely disabled), and a CEC signed on 10/22/14 at 9:30 a.m. (gravely disabled).
Review of Patient #2's "Order For Protective Custody" revealed she had been diagnosed as a Paranoid Schizophrenic and was suffering from paranoia and delusions. Further review revealed she was not bathing and had locked herself in her apartment.
Review of Patient #2's progress notes documented by S43Case manager revealed the following:
10/22/14 at 12:15 p.m. - poor ADLs (activities of daily living);
10/31/14 at 1:05 p.m. - poor hygiene, disheveled;
11/14/14 at 12:46 p.m. - disheveled;
12/01/14 at 12:04 p.m. - patient disheveled.
Review of S8Psychiatrist's progress note documented on 11/14/14 revealed "ADLs are poor."
Review of Patient #2's Master Treatment Plan revealed the problems identified on 10/21/14 were altered thought process and knowledge deficit related to mental illness. There was no documented evidence that the problem related to poor hygiene had been identified with interventions and goals developed. Further review revealed the goal for altered thought process was that the patient would decrease her acute psychotic symptoms, and her goal for knowledge deficit was that she would verbalize accurate information related to mental illness. There was no documentation that these goals were described in behavioral terms as required by hospital policy.
Review of Patient #3's medical record revealed he was a [AGE] year old male who was admitted on [DATE] with diagnoses of Violent behavior and Mental Retardation. Further review revealed he was PEC'd on 11/13/14 at 11:00 p.m. due to being a danger to self and others and gravely disabled. He was CEC'd on 11/15/14 at 3:30 p.m. due to being gravely disabled.
Review of Patient #3's medical record revealed documentation on 11/18/14, 11/19/14, and 11/20/14 that he had "scattered self-inflicted scabs to left hand."
Review of an incident report dated 11/17/14 at 6:35 a.m. revealed that Patient #3 had hit a peer on the right side of her face with no warning while he was on 1:1 observation. Further review revealed that the action was that Patient #3 would remain 1:1 with a 5 feet restriction from other patients. There was no documented evidence in the medical record that he had orders for 5 feet restriction from peers prior to or after the event on 11/17/14.
Review of Patient #3's Master Treatment Plan revealed the problems identified at admission on 11/14/14 included high risk for injury to others and poor impulse control. Further review revealed the problem of high risk for injury to self due to restraints was added on 11/15/14. There was no documented evidence that interventions and goals were developed and implemented for self-injury related to Patient #3 biting his hands and causing scabs to form. Further review revealed no documented evidence that his care plan was revised on 11/17/14 to include the 5 feet restriction to peers as stated in the incident report.
Review of Patient #5's medical record revealed he was a [AGE] year old male who was admitted on [DATE] with diagnoses of Bipolar Disorder and Delusions. He had a PEC signed on 11/29/14 at 10:00 p.m. due to being a danger to himself and gravely disabled and a CEC signed on 11/30/14 at 9:30 a.m. due to being gravely disabled.
Review of Patient #5's Master Treatment Plan revealed the problems identified on 11/30/14 included altered thought process and elevated mood. Review of the long term goal for altered thought process revealed that it was stated as the patient will decrease acute psychotic symptoms and improve thinking. The long term goal for elevated mood was written as the patient will achieve controlled behaviors, moderated moods, and be less impulsive. There was no documented that these goals were described in behavioral terms as required by hospital policy.
Review of Patient R1's medical record revealed she was a [AGE] year old female who was admitted on [DATE] with diagnoses of Depression and Suicidal Ideations with a plan.
Review of Patient R1's Master Treatment Plan revealed the problems identified on 11/24/14 included high risk for injury to self, depressed mood, and fall risk. Review of the long term goal for depressed mood revealed it was written as the patient will verbalize and demonstrate improved affect and mood prior to discharge. There was no documented evidence that the goal was written in observable behavioral terms as required by hospital policy.
Review of Patient R2's medical record revealed he was a [AGE] year old male who was admitted on [DATE] with diagnoses of Psychosis, Paranoia, and Bizarre Behavior. Further review revealed he was PEC'd on 11/30/14 at 12:25 p.m. due to being gravely disabled and CEC'd on 12/01/14 at 9:55 a.m. due to being gravely disabled.
Review of Patient R2's Master Treatment Plan revealed the problems identified on 11/30/14 included anxiety related to paranoid delusions, disturbed thought process related to manic behaviors, and at risk for seizures related to seizure disorder. Review of the long term goal for anxiety revealed it was written as the patient will effectively manage anxiety responses to stress, and the long term goal for disturbed thought process was written as the patient will be free of paranoid delusions. There was no documented that these goals were described in behavioral terms as required by hospital policy.
Review of Patient R3's medical record revealed he was a [AGE] year old male who was admitted on [DATE] with a diagnosis of Psychosis.
Review of Patient R3's Psychiatric Evaluation completed on 11/26/14 by S8Psychiatrist revealed that Patient R3 was brought to the hospital by his wife who reported that he had been going to strip clubs and had sex with 6 women. Review of S8Psychiatrist's progress note documented on 11/26/14 revealed he spoke with Patient R3's wife by phone, and she reported that her husband had been hypersexual all of the previous week before his admission
Review of Patient R3's Master Treatment Plan revealed his problems identified on 11/26/14 included altered thought process and elevated mood. There was no documented evidence that Patient R3 had a care plan developed and implemented for inappropriate sexual or hypersexual behavior. Further review revealed the long term goal for altered thought process ("pt [patient] will have decrease in acute psychotic symptoms & improve thinking") and "elevated mood ("pt will achieve controlled behavior & be less impulsive") were not described in behavioral terms as required by hospital policy.
In an interview on 12/03/14 at 1:40 p.m., S4Director of Psych confirmed that patient goals have to be measurable and stated in behavioral terms. She indicated that the patient's identified problems need to be addressed in his/her care plan, and the care plan needs to be revised when additional problems are identified.
|VIOLATION: SCOPE OF RADIOLOGIC SERVICES||Tag No: A0529|
|Based on observation, record review, and interview, the hospital failed to ensure the radiology department implemented its policies and procedures to ensure the services would meet the needs of outpatients in accordance with acceptable standards of practice. This was evidenced by having no documentation of assessment(s), allergies, or a complete record of care for Patient R5 during his outpatient admission 12/02/14 during an invasive procedure performed in the Radiology Department.
Review of the Louisiana State Board of Nursing ' s Administrative Rules defining the practice of Registered Nursing revealed the following, in part:
Administrative Rules Defining RN [Registered Nurse] Practice
Chapter 39. Legal Standards of Nursing Practice
?3901. Legal Standards
A. The Louisiana State Board of Nursing recognizes that assessment, planning,
intervention, evaluation, teaching, and supervision are the major responsibilities of the
registered nurse in the practice of nursing. The standards of nursing practice provide a
means of determining the quality of care which an individual receives regardless of
whether the intervention is provided solely by a registered nurse or by a registered nurse
in conjunction with other licensed or unlicensed personnel as provided in Lac
B. The standards are based on the premise that the registered nurse is responsible for and
accountable to the individual for the quality of nursing care he or she receives.
Documentation must reflect the quality of care.
C. The standards of practice shall:
1. be considered as base line for quality nursing care...
3. apply to the registered nurse practicing in any setting;
4. govern the practice of the licensee at all levels of practice.
Review of a policy and procedure Titled "Radiology Surgical Site Verification Policy, issue date of August 2002, and provided by S20Radiology Director as current, revealed the following, in part:
1. Circulator refers to the technologist in the examination room who is not scrubbed in for the case.
2. Invasive Radiology Team refers to the Physician, the Radiologic Technologist, Tech Assistant, and the Registered Nurse...
...2. All patients scheduled for surgery shall have a surgeon's History and Physical, or pre-op surgical consultation note on the chart prior to the procedure. The History and Physical shall be either typed from transcription services, faxed from the doctor's office, or hand written by the physician...
-Radiologic Technologist, Tech Assistant, and Registered Nurse.
An observation was made 12/02/14 from 1:45 p.m. to 2:50 p.m. of Patient R5, in the special procedure room located in the radiology department, where he had a Lumbar Epidural Steroid Injection as an outpatient. No assessment of the patient's vital signs or history, including any allergies, was observed to occur prior to or preceding the procedure. The patient walked out of the room after a discharge instruction sheet was provided.
Review of the medical record for Patient R5 revealed no documentation of a History and Physical. Further review revealed no documentation of an assessment of the patient, and no documentation if the patient had any allergies, and if so, to what he was allergic. There were no nursing notes documenting the times of the patient's arrival in the procedure room, times of injections, of the patient's discharge from the procedure room, or the manner in which he left (ambulatory).
In an interview 12/02/14 at 3:40 p.m., S2CNO (Chief Nursing Officer) reported that the hospital did not have policies and procedures related to outpatients and outpatient admissions. S2CNO reported that each department had policies, and the outpatient procedures would fall under the individual departments where the patient was to receive care.
In an interview 12/3/14 at 1:50 S15RN verified that he was in the special procedure room 12/02/14 for Patient R5's procedure. He reported that he usually worked in ICU (Intensive Care Unit) but did work part-time in Radiology for special/invasive procedures. S15RN reported that he was not the circulator in the procedure. He further reported when he worked in Radiology, he usually administered Conscious Sedation (CS) and monitored the patient. Since Patient R5 did not receive CS, S15RN reported that he called and documented the time-out procedure, but did not provide other specific care to the patient. S15RN said he was there to help, if needed. S15RN confirmed that Patient R5 did not have his vital signs assessed at any time during his outpatient admission and was not assessed for verification of any allergies. S15RN further verified that he only documented a record of care and assessments for a patient during an invasive procedure in Radiology if they received CS.
In an interview 12/02/14 at 3:15 p.m., S20Radiology Director reported that RNs worked in the Radiology Department when special/invasive procedures were scheduled, but did not work in radiology full time. S20Radiology Director further reported an RN did not function as a circulator in Radiology. He stated the RNs were in Radiology to administer Conscious Sedation and monitor patients that received the sedation. S20 Radiology Director confirmed no nursing notes were documented as to assessments, care provided, and events occurring during a patient's outpatient admission. After reviewing the medical record for Patient R5, S20Radiology Director agreed that the documentation on the fluoroscopic images and the dictated procedural note did not reflect accurate times, did not include an assessment of the patient's vital signs and any allergies, even though the patient was being injected with contrast material and medications.
|VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES||Tag No: A0749|
|Based on observation, record review, and interview the hospital failed to ensure staff followed infection control procedures and standards as evidenced by an observed breech of infection control procedure when a radiology technician contaminated a sterile tray while preparing for an outpatient invasive procedure by not using sterile gloves, and touching the sterile drape with the palms and fingers of both hands. The other staff in the procedure room failed to identify contamination of the sterile tray.
Review of Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings by AORN (Association of periOperative Registered Nurses), 2013 Edition, revealed the following, in part:
Recommended Practices for Aseptic Practice: Sterile Technique-...Recommendation V: A sterile field should be prepared for patients undergoing surgical or other invasive procedures. V.e. Perioperative personnel should perform a surgical hand scrub and don a sterile gown and gloves before setting up sterile supplies...Donning a sterile gown and gloves before setting up sterile supplies minimizes the potential of wound contamination and reduces patient risks for surgical site infections that may result from contact with perioperative team members' skin or clothing.
V.f. Only sterile items should come in contact with the sterile field.
Review of hospital policy IC 4-7, titled Asepsis, dated 03/15/12 with the most recent review
date of 03/12 and provided by S6Dir. of I.C. (Director of Infection Control) as current, revealed the following in part:
Aseptic Technique is the purposeful prevention of transfer of organisms form one person to another...It may also be referred to as sterile technique...
Policy: ...Hospital personnel will strictly adhere to aseptic technique while performing duties in all patient care settings. Procedure: I. Aseptic Technique-Involves using barriers, such as gloves, gowns, masks, and drapes to prevent transferring microorganisms from the environment to the patient during a procedure being performed...
Review of Department of Radiology Policy and Procedure G.9.1, Subject: Setting up sterile trays, formulated by the Administrative Director of Radiology and the Medical Director of Radiology, with an effective date of 07/94, the most recent revision date of 10/14, and provided by S20Rad. Dir. (Radiology Director), revealed the following:
* The tray must be setup using sterile procedure.
* Sterile procedure shall include the employee to use a hat, mask, and sterile gloves.
* The tray must be setup immediately prior to the procedure.
An observation,12/02/14 from 1:45 p.m. to 2:50 p.m. in a special procedure room in the Radiology department accompanied by S6Dir. of I.C.,revealed the preparation of a sterile tray for a Lumbar Epidural Steroid Injection (LESI) by S16RT (Radiology Tech). Further observation revealed S16RT placed her bare, opened hands palms down, on top of the sterile sheet on the portable instrument stand, and smoothed out the sterile sheet. Further observation revealed no staff acknowledgment of the breech in sterile procedure by S16RT. Staff present in the special procedures room for the invasive procedure included a Registered Nurse (RN), 2 Radiology Technicians, 1 Scrub Technician, 1 Physician, and 1 Infection Control Officer.
A review of the training records for S16RT, S17RT, S18Rad ST ( Radiology Surgical Technician) revealed no documentation of training or competency for use of sterile technique or setting up sterile trays and fields.
In an interview 12/02/14 at 1:55 p.m., S6Dir.of I.C. verified S16RT breeched infection control policy and procedure when she prepared the sterile tray and supplies without gloves, and by touching the sterile area with her bare hands.
In an interview 12/02/14 at 2:45 p.m., S16RT verified she had not followed the correct technique for sterile procedure when she opened the sterile pack without gloves and touched the sterile field with her bare hands. S16RT reported that she was trained in sterile technique for special procedures by another radiology technician when she started working in the hospital's radiology department.
In an interview 12/03/14 at 1:50 p.m., S15RN confirmed he was present 12/02/14 in the special procedure room of the radiology department during the outpatient LESI performed on Patient R5. S15RN agreed that the procedure was an invasive procedure and required that the instrument and supply tray be set up and maintained as sterile. S15 RN reported that he did not observe S16RT contaminate the sterile tray during set-up or that she was setting up the sterile tray with bare hands.
In an interview 12/02/14 at 3:15 p.m., S20Rad. Dir. reported that Radiology Technicians are trained by department Radiologists in techniques for special procedures performed in Radiology, including sterile technique. S20Rad. Dir. further reported competencies for use of sterile technique were not performed for the employees in radiology that assisted with special and/or invasive procedures. After review of a Radiology Department policy and procedure on setting up sterile trays, S20Rad. Dir. verified the procedure was not complete, with only the time the tray must be set up and what Personal Protective Equipment (PPE) was to be used (hat, mask, and sterile gloves) documented.