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OAK HILL HOSPITAL 11375 CORTEZ BLVD BROOKSVILLE, FL 34613 May 28, 2021
VIOLATION: SAFETY POLICY AND PROCEDURES Tag No: A0535
Based on interview and medical record, policy and procedure review the facility failed to ensure safe operation of equipment according to hospital policy. Failure of Medical Technologist to use medical scanning wand per hospital policy for 1 patient (Patient# 1).

Findings:
During a medical record review patient # 1 came to the Emergency Department (ED) at the facility on 12/29/2020 at 11:05 PM with a complaint of back pain. A Magnetic Resonance Imaging (MRI) was completed on 12/30/2021 at 2:19 AM.

During an interview with patient 1 on 5/27/2021 at 3:10 PM, patient # 1 stated, "When the pulsing started from the MRI, I started to feel a burning on my side. As the test continued the burning got worse and I began to scream and kick my feet. The test was stopped. I reached down to where I felt the burning and found an electrode that was not removed prior to the MRI. The area of skin was red and very sore. Upon review of my medical records, there was no notation of the injury which occur during the MRI."

During a medical record review of documentation of Staff L, MRI Technologist, stated, "When the scan started the patient started screaming wildly and banging on the side of the machine. The patient told me something was burning him. Patient # 1 pulled up his shirt, and I saw 4-5 more electrodes that had not been removed prior to MRI. I had not used the wand prior to the MRI. Patient # 1 had a reddened area from removing the electrodes, but I saw no injury and did not complete an incident report."

During a record review of hospital policy titled Screening of Individuals Entering MRI, with an approval date of 06/2020. The objective of policy is noted, "To maintain a safe environment in the MRI unit". Under section labeled screening is noted, "All patients will be scanned with metal detection wand prior to entering Zone IV". Under section noted, precautions taken to prevent patient burns during scan is noted, "Technologist will ensure all leads are off the patient before entering the exam room".

During an interview on 5/28/2021 at 10:20 AM, with Staff J, Director of Radiology, stated, "It is my expectation that if a patient reports pain and requires to be removed from the MRI unit, an incident report is to be filed. In the case of Patient # 1, no incident report was filed."