EA-98-575 - Hartford Hospital

February 5, 1999

EA 98-575

Mr. John Meehan
President and CEO
Hartford Hospital
Post Office Box 5037
80 Seymour Street
Hartford, Connecticut 06102-5037
 

SUBJECT:

NOTICE OF VIOLATION (NRC Inspection Report No. 030-01239/98-002)

Dear Mr. Meehan:

This refers to the NRC inspection conducted on December 14, 1998, at your facility in Hartford, CT., to determine whether activities authorized by your license were conducted safely and in accordance with NRC requirements. The inspection was conducted after the NRC was notified on December 10, 1998, that waste from your facility containing radioactive material had been detected at the Connecticut Resource Recovery Authority (CRRA) after it had been sent there for incineration. As described in the NRC inspection report enclosed in our letter dated December 30, 1998, five apparent violations of NRC requirements were identified during the inspection. On January 26, 1999, a predecisional enforcement conference was conducted with Mr. John Fagan, and other members of your staff, to discuss the apparent violations, their causes, and your corrective actions. A copy of the enforcement conference report is enclosed.

Based on the information developed during the inspection and the information provided during the conference, three violations of NRC requirements are being cited. The violations are described in the enclosed Notice of Violation (Notice) and the circumstances surrounding them are described in detail in the subject inspection report. The violations being cited include:  (1) the failure to control and maintain constant surveillance of licensed material (3 to 6 millicuries of iodine-131 contaminated waste) that was in a controlled or unrestricted area (an iodine-131 therapy patient's room) and that was not in storage; (2) the failure to make, or cause to be made, surveys which would have prevented the iodine-131 contaminated waste from being removed from the patient's room, placed into the hospital's trash dumpster, and transported to the incinerator facility; and (3) the failure to label the bag containing iodine-131 contaminated waste which would have prevented it from being removed from the patient's room. The failure to adequately train personnel in the performance of their duties during the handling of radioactive waste contributed to these violations.

The NRC is concerned that hospital Environmental Services personnel were not adequately trained to perform surveys to properly determine the extent of radiation levels and/or quantities of radioactive materials when hospital area monitors alarmed. As a result of the inadequate training, the bag was placed into the dumpster, and eventually given to a commercial waste handler who did not have authorization to receive such material. Although the bag was eventually recovered by Hartford Hospital, the loss of control of radioactive material waste is a significant violation. Therefore, the violations collectively have been classified in the aggregate as a Severity Level III problem in accordance with the "General Statement of Policy and Procedures for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600.

In accordance with the Enforcement Policy, a base civil penalty in the amount of $2,750 is considered for a Severity Level III violation. Because your facility has not been the subject of an escalated enforcement action within the last two years, the NRC considered whether credit was warranted for Corrective Action in accordance with the civil penalty assessment process in Section VI.B.2 of the Enforcement Policy. Credit for corrective actions is warranted because your corrective actions were considered prompt and comprehensive. These actions, which were described at the enforcement conference and in your January 25, 1999 letter to NRC, are summarized in the enclosed Enforcement Conference Report. Therefore, to encourage prompt and comprehensive correction of violations, I have been authorized to not propose a civil penalty in this case. However, similar violations in the future could result in further escalated enforcement action.

Two apparent violations set forth in the inspection report are not being cited for the reasons stated below. The apparent violation associated with the unauthorized disposal of licensed material, is not being cited, because the material was recovered by your Radiation Safety Officer and returned to Hartford Hospital, and because, in our view, the problem is more accurately characterized as a security and control problem. The apparent violation associated with the failure to adequately train Environmental Services personnel is not being cited because your June 21, 1993 letter which is incorporated into you license only requires training such personnel to recognize restricted areas and radiation labels.

The NRC has concluded that information regarding the reason for the violations, and the corrective actions taken and planned to correct the violations and prevent recurrence, is already adequately addressed on the docket in your January 25, 1999 letter, as well as the enclosed Enforcement Conference Report. You further indicated in a telephone conversation with J. Dwyer of the NRC on February 5, 1999, that all corrective actions would be completed by February 28, 1999. Therefore, you are not required to respond to this letter unless the description therein does not accurately reflect your corrective actions or your position. In that case, or if you choose to provide additional information, you should follow the instructions specified in the enclosed Notice.

In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," a copy of this letter and its enclosures, will be placed in the NRC Public Document Room (PDR).

 

		Sincerely,
		ORIGINAL SIGNED BY JAMES T. WIGGINS
	FOR	Hubert J. Miller Regional Administrator

 

Docket No. 030-01239
License No. 06-00253-04

Enclosures:
Notice of Violation


cc w/encls:
State of Connecticut

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	ENCLOSURE 1 NOTICE OF VIOLATION
Hartford Hospital Hartford, CT.		License No. 06-00253-04 Docket No. 030-01239 EA 98-575

During an NRC inspection conducted on December 14, 1998, violations of NRC requirements were identified. In accordance with the "General Statement of Policy and Procedure for NRC Enforcement Actions," (Enforcement Policy), NUREG -1600, the violations are listed below:

 

A.	10 CFR 20.1802 requires, in part, that the licensee control and maintain constant surveillance of licensed material that is in a controlled or unrestricted area and that is not in storage. Contrary to the above, on or about December 9, 1998, the licensee did not control and maintain constant surveillance of licensed material that was in a controlled or unrestricted area. Specifically, a bag containing wash cloths, cotton socks, hospital booties, and tissue paper contaminated with 3 to 6 millicuries of iodine-131, was removed from a patient's room and was placed into a dumpster outside the facility. The material was subsequently transported to an incinerator in Hartford, Connecticut, and was not detected until 3:45 p.m. on December 9, 1998, when area radiation monitors located at the incinerator alarmed. (01013)
B.	10 CFR 20.1501 requires that the licensee make, or cause to be made, surveys that may be necessary for the licensee to comply with 10 CFR Part 20 and are reasonable under the circumstances to evaluate the extent of radiation levels; concentrations or quantities of radioactive material; and the potential radiological hazard that could be present. Contrary to the above, on or about December 9, 1998, the licensee did not make, or cause to be made, surveys that were necessary for the licensee to comply with 10 CFR 20.1802 and were reasonable under the circumstances to evaluate the extent of radiation levels, concentrations or quantities of radioactive material, and the potential radiological hazard that could be present. Specifically, the licensee did not make, or cause to be made, surveys necessary to prevent the loss of control of 3 to 6 millicuries of iodine-131 contaminated waste which was removed from a patient's room and placed in a hospital dumpster (located outside the facility) that was reserved for ordinary trash. (01023)
C.	10 CFR 20.1904 requires that the licensee ensure that each container of licensed material bear a durable, clearly visible label bearing the radiation symbol and the words "CAUTION, RADIOACTIVE MATERIAL" or "DANGER, RADIOACTIVE MATERIAL." Contrary to the above, on or about December 9, 1998, the licensee did not ensure that a container of licensed material bore a durable, clearly visible label bearing the radiation symbol and the words "CAUTION, RADIOACTIVE MATERIAL" or "DANGER, RADIOACTIVE MATERIAL." Specifically, a bag containing 3 to 6 millicuries of iodine-131 contaminated waste was removed from a patient's room and was placed into a dumpster reserved for ordinary trash without the required labeling. (01033)

These violations are categorized in the aggregate as a Severity Level III problem (Supplements IV and VI).

The NRC has concluded that information regarding the reason for the violations, and the corrective actions taken and planned to correct the violation and prevent recurrence is already adequately addressed on the docket in the licensee's letter, dated January 25, 1999. The licensee informed the NRC in a February 5, 1999 telephone conversation, that all actions would be completed by February 28, 1999. However, you are required to submit a written statement or explanation pursuant to 10 CFR 2.201 if the description therein does not accurately reflect your corrective actions or your position. In that case, or if you choose to respond, clearly mark your response as a "Reply to a Notice of Violation," and send it to the U.S. Nuclear Regulatory Commission, ATTN:  Document Control Desk, Washington, DC 20555 with a copy to the Regional Administrator, Region I, within 30 days of the date of the letter transmitting this Notice of Violation (Notice).

If you choose to respond, your response will be placed in the NRC Public Document Room (PDR). Therefore, to the extent possible, the response should not include any personal privacy, proprietary, or safeguards information so that it can be placed in the PDR without redaction.

Dated at King of Prussia, Pennsylvania
this 5^th day of February 1999