1. Violation of License Condition:

Radioactive material has been used by physicians other than those authorized under the license. According to statements by the Director of Radiology and the nuclear medicine technologist, Physician 1, Physician 2, and Physician 3 have used radioactive material for diagnostic purposes at this hospital (read and interpreted nuclear medicine studies) between December 1 and December 5, 1996. Additionally, physicians identified as Physician 4 and Physician 5 have used radioactive material for diagnostic purposes at this hospital within the last 30 days. None of the named physicians were authorized to perform these activities at this facility during those time periods. (NOTE: Physicians 1, 2 and 3 were added by license amendment effective December 6, 1996).

Severity III Violation

2. Violation of License Condition:

Contrary to statements, representations, and procedures submitted with documents submitted by the Agency referenced in this License Condition, the following deficiencies were noted:

Daily flood field and bar phantom images have not been performed and documented prior to each day in which nuclear medicine studies were performed. Reference: Radiation Safety Manual " Daily Camera Check" , page 1. During the period of October 4 to December 5, 1996, fifteen instances were noted where no such quality control measures were performed on days where nuclear medicine studies were performed.
Linearity checks of the dose calibrator have not been performed and documented at intervals not exceeding three months. Reference: Radiation Safety Manual " Calibrator Check" , page 1. The quarterly interval for these tests was exceeded between the following dates: February 14,1995 to June 2, 1995, June 2, 1995 to October 24, 1995, October 24, 1995 to February 13, 1996, and February 13, 1996 to June 4, 1996. Additionally, the record of the linearity test performed on June 2, 1995 was not available for inspection.
Severity IV Violations

3. Violation of TRCR 21.1107(a):

Records were not maintained showing the radiation exposures of a person monitored pursuant to TRCR 21.502. Records of the extremity exposure for an employee for the period of April 4, 1996 to May 4, 1996 were not maintained. Records supplied by the personnel monitoring service indicate that employee’s ring badge for this period was not returned for processing, with no assessment of her estimated exposure for the period made and recorded.

Serverity IV Violation