HospitalInspections.org

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Based on observation, document review and interview, the Radiology Staff did not ensure that medications used in radiologic contrast studies were stored as per facility policy.

This lapse in environmental safety potentially placed patients at increased safety risk.

Findings include:

During observations in the facility's Radiology Department on 06/11/19 between 10:30AM and 12:45PM, multiple bottles of Barium and Gastrografin [medications used for contrast radiology studies] were stored on an open and accessible cart in the Patient Care Area of the Emergency CT-Scan Room.

This observation was made in the presence of Staff A (Director of Radiology) who confirmed that the medications should have been stored in locked cabinets and not on open carts accessible to patients/visitors.

The facility Policy and Procedure titled "The Safety and Security of Medications" last revised 02/2019, contained the following statement: "All medications outside the secured pharmacy are to be secured either in a lockable cabinet or locked down room as interpreted by CMS standards to prevent unauthorized access."
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Based on observation, document review and interview, the facility did not ensure that radiology equipment was inspected daily as required per policy.

These lapses in daily inspections potentially placed patients at risk for injury.

Findings include:

Observations in the facility's Radiology Department during a tour conducted on 06/11/19 between 10:30AM and 12:45PM identified the following:

The manual Daily Quality Control checks for the Emergency CT-scan equipment [table lock, smoothness, movement, control booth, lights etc.] were not performed on 05/14/19, 05/26/19, from 06/01/19 through 06/05/19, and from 06/08/19 through 06/10/19 (a total of ten {10} days).

No documented evidence that the manual Daily Quality Control checks for the Emergency x-ray equipment [overhead tube crane, lights, table, Bucky lock etc.] was found. Per Staff C (Administrator Manager of Radiology), the Log Book could not be located, and staff were unaware of how long the Log Book had been missing.

These observations were made in the presence of Staff A (Director of Radiology) who confirmed the Daily Quality Control checks should have been performed and documented in the Logs daily as per facility policy.

Guidelines from the "Bureau of Environmental Radiation Protection" dated 04/16/08 and provided by the facility at the time of the observation, contained the following statement: "Records shall be maintained for each unit currently in operation ... Quality Control records may be maintained in either a hardcopy or softcopy format, but must be available for review during inspections and whenever else they are needed."
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Based on document review and interview, the facility did not ensure that Medical Staff completed an updated Annual Health Assessment (AHA) in three (3) of six (6) Medical Staff Employee Health Records reviewed.

This lapse in the completion of AHAs placed patients and facility staff at increased risk for injuries or infections.

Findings include:

On 06/13/19 at 3:15PM, review of Staff F's (Physician) Employee Health File revealed that the last documented Mantoux Test and Influenza Vaccines were administered in October 2017. There were no updated AHAs available for review.

Review of Staff G's (Physician) Employee Health File revealed that the last documented Mantoux Test was administered in June 2017, and the last Influenza Vaccine was administered in October 2017. There were no updated AHAs available for review.

Similar findings of missing AHAs was found for Staff E (Chair of Radiology).

These observations were made in the presence of Staff H (Director of Occupational Health) who confirmed the findings.

The facility Policy and Procedure titled "Annual Health Assessments" last revised July 2017, contained the following statement: "Faculty, staff and volunteers must complete an annual health assessment (AHA) to ensure they are free of health impairments which pose a potential risk to patients or personnel."