ML20032E693
| ML20032E693 | |
| Person / Time | |
|---|---|
| Issue date: | 11/13/1981 |
| From: | Sreniawski D NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20032E683 | List: |
| References | |
| NUDOCS 8111200815 | |
| Download: ML20032E693 (2) | |
Text
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Appendix A NOTICE OF VIOLATION St. Anthony Hospital License No. 13-13144-02 License No. 13-13144-01 As a result of the inspection conducted on November 3, 1981, and in accordance with the Interim Enforcement Policy, 45 FR 66754 (October 7, 1980), the following violations were identified:
License No. 13-13144-02 1.
License Condition No. 20 requires that licensed material be possessed and used in accordance with statements, representations, and procedures contained in application dated January 25, 1979.
Item No.19 of the above referenced application states for patients receiving radiotherapeutic doses greater than 30 millicuries of Iodine-131 that all pe rsonnel entering the patient's room must wear assigned dosimeter badges at all times.
Contrary to the above requirement, it was determined through statements by licensee representatives and the NRC inspector's review of records that this condition is not being met.
Specifically, on October 28, 1981, a patient was treated with 148.5 millicuries of Iodine-131 and nurses caring for the patient were not assigned dosimeters or film badges.
This is a Severity Level V violation (Supplement VII).
License No. 13-13144-01 2.
The order modifying all teletherapy licenses dated May 7, 1980, requires each teletherapy room to be equipped with a radiation monitoring device which continuously monitors the teletherapy beam condition and is equipped with a back-up battery power supply for emergency operation. This device shall energize a visible signal to make the operator continuously aware of teletherapy beam condition in order that appropriate emergency procedures may be instituted to prevent unnecessary radiation exposure.
Contrary to the above requirement, it was determined through observa-tions of the NRC inspector and statements of licensee representatives that this requirement is not being met.
Specifically, on the day of inspection, your radiation monitor was in e location where the operators could not continuously access the condition of the beam.
In addition, the radiation monitor was not equipped with a back-up battery power supply.
This is a Severity Level V violation (Supplement VII).
8111200815 811116 NMS LIC30 i
13-13144-02 PDR
Appendix A 3.
10 CFR 35.22(b) requires that the monthly spotcheck measurements on teletherapy units required by 35.22(a) include a determination of timer accuracy.
Contrary to the above requirement, it was determined through statements by licensee representatives and the NRC inspector's review of records that this condition is not being met.
Specifically, a licensee repre-sentative stated that timer accuracy checks have not been included as part of the routine monthly spotcheck procedure.
This is a Severity Level V violation (Supplement VII).
4.
10 CFR 35.25 requires the licensee to maintain, for inspection by the Commission, records of calibration of instruments used to make measure-ments under 10 CFR 35.23 and records of the licensee's evaluation of the qualified experts training and experience.
Contrary to this requirement, the above records were not maintained for review on the day of this inspection.
This is a Severity Level VI violation (Supplement VII).
Pursuant to the provisions of 10 CFR 2.201, you are required to submit to this office within thirty days of the date of this Notice a writter statement or explanation in reply, including for each item of noncompliance:
(1) cor-rective action taken and the results achieved; (2) corrective action to be taken to avoid further noncompliance; and (3) the date when full compliance will be achieved. Under the authority of Section 182 of the Atomic Energy Act of 1954, as amended, this response shall be submitted under oath or affirmation. Consideration may be given to extending your response time for good cause shown.
u 13/gi il Dated
/
I D. J. Srehiawski, Chief Materials Radiation Protection Sectiod2
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