2013 - MSRMC EOC ROUNDS

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Mat-Su Regional Medical Center

• Physical Environment & Infection Control Rounds - Non-Clinical Areas 2013

• EC.04.01.01.14.a

• Surveyed By:

• Surveyed By:

PATIENT SAFETY MANAGEMENT

• Are corridors kept clear to allow adequate space for:

• A) Patients, visitors and staff to walk safely?

  Yes

  No

  N/A

• B) Are floors clear and slip-resistant finishes in place?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

FIRE SAFETY MANAGEMENT

• Are the means of egress corridors/exit doors:

• A) Clearly and correctly marked for EXIT, including when fire doors are closed?

  Yes

  No

  N/A

• B) Are lights in exit signs functional?

  Yes

  No

  N/A

• C) Clear of any obstructions/equipment?

  Yes

  No

  N/A

• D) Are exterior patios, if in the exit passageway marked & EXIT are free of obstructions?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

• Are all fire extinguishers:

• A) Clearly marked for identification and installed at correct height (maximum of sixty inches)?

  Yes

  No

  N/A

• B) Inspection tags current? (monthly and annual)

  Yes

  No

  N/A

• C) Safety seals intact and in place?

  Yes

  No

  N/A

• D) Accessible, with three foot clearance in all directions?

  Yes

  No

  N/A

• E) Within seventy five feet in any direction in the area? (main corridors only)

  Yes

  No

  N/A

• F)Is there a roll of orange masking tape in the extinguisher box? (main corridors only)

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

• Are the fire alarm pull stations:

• A) Accessible, with three foot clearance in all directions?

  Yes

  No

  N/A

• B) In good condition, free from tampering and glass bar in place where applicable?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

• Are combustible materials: cardboard, boxes, paper, linen, wastes)

• A) Stored in proper containers? (32 gallons or less)

  Yes

  No

  N/A

• B) Kept to a minimum for daily use in department? (no over flowing containers)

  Yes

  No

  N/A

• C) Properly labeled and identified?

  Yes

  No

  N/A

• D) Are alcohol-based hand rubs properly mounted from electrical devices? (6 inch's from the center)

  Yes

  No

  N/A

• E) Kept in a safe and acceptable location?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

• Fire Building Systems, components and Safety Practices:

• A) Are all doors free from being propped, wedged or held open in any way?

  Yes

  No

  N/A

• B) Are all doorways clear to close properly?

  Yes

  No

  N/A

• C) Are escutcheons in place on sprinkler heads and are they clean and free of debris?

  Yes

  No

  N/A

• D) Do fire and stairwell doors latch positively and maintain closure?

  Yes

  No

  N/A

• E) Are all doors physically in good condition to prevent the spread of smoke or fire?

  Yes

  No

  N/A

• F) Is the area free from portable heaters and heating devices? (No heaters in the hospital per CHS)

  Yes

  No

  N/A

• G) Is the area free from any evidence of smoking in the area?

  Yes

  No

  N/A

• H) Are furnishing and decorations fire-rated?

  Yes

  No

  N/A

• I) Is there at least 18 inches; clearance between storage and sprinkler heads?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

SAFETY MANAGEMENT

• Are the floors in hallways:

• A) In good physical condition?

  Yes

  No

  N/A

• B) Clean and dry?

  Yes

  No

  N/A

• C) Free from trip/fall hazards?

  Yes

  No

  N/A

• D) Wet floor signs used properly?

  Yes

  No

  N/A

• E) Carpet free of wrinkles or tears?

  Yes

  No

  N/A

• F) Free from obstruction? ( wires/cords etc.)

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

• Are the walls:

• A) Painted and in good physical condition? (Free of holes or water damage)

  Yes

  No

  N/A

• B) Free from exposed wiring of any kind?

  Yes

  No

  N/A

• C) Are electrical covers/plates in place and in good condition?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

• Are ceiling tiles:

• A) In place and in good condition?

  Yes

  No

  N/A

• B) Free of dirt, mold, dust and stains?

  Yes

  No

  N/A

• C) Free from evidence of water stains?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

INFECTION CONTROL & RISK MANAGEMENT

• Infection Control Practices:

• A) Are refrigerators labeled to identify - Patient; Staff; Medication; use?

  Yes

  No

  N/A

• B) Are cardboard boxes off the floor, with no corrugated shipping containers present?

  Yes

  No

  N/A

• C) Is personal protective equipment readily available for use?

  Yes

  No

  N/A

• D) Are the cabinets under the sinks free from storage of clean supplies/equipment?

  Yes

  No

  N/A

• E) Have all product recalls been corrected by department?

  Yes

  No

  N/A

• F) Are floors, fixtures and equipment in clean condition?

  Yes

  No

  N/A

• G) Are emergency showers and eye washes tested?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

HAZARDOUS MATERIAL AND WASTE MANAGEMENT

• Hazardous chemicals used in the area:

• A) Are janitor closets and other rooms with chemicals secured and stored correctly? (flammables, corrosives, etc.)

  Yes

  No

  N/A

• B) Labeled correctly?

  Yes

  No

  N/A

• C) Disposed of correctly? (Are there procedures for disposal?)

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

• MSDS Manual in the Area:

• A) Are the department inventory (online) & updated within the past 12 months?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

UTILITY MANAGEMENT

• Are emergency power outlets:

• A) Clearly marked by red covers and outlets?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

• Electrical panels and devices:

• A) Are breakers in distribution panels labeled?

  Yes

  No

  N/A

• B) Are mechanical/electrical rooms or exposed distribution panels kept locked, except to essential personnel?

  Yes

  No

  N/A

• C) Are all covers free from damage and securely in place?

  Yes

  No

  N/A

• D) Are waiting rooms provided with tamper-resistant outlets?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

SECURITY MANAGEMENT

• SECURITY

• A) Are all employees wearing identification badges in plain view?

  Yes

  No

  N/A

• B) Are all computer rooms locked?

  Yes

  No

  N/A

• C) Are all computers that are not in use - logged out?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

EMERGENCY MANAGEMENT

• EOP

• A) Are the Emergency Procedures flip charts easily accessible? (Red Flip charts)

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

HAZARDOUS AREAS - (LS 19.3.5.4)

• Soiled Utility Rooms and Storage Rooms > than 50 Square Feet (example 5X10ft)

• A) Clean, neat and orderly?

  Yes

  No

  N/A

• B) Items stored greater than 18 inches from fire sprinklers, unless fixed shelving against the wall?

  Yes

  No

  N/A

• C) Rooms are constructed as hazardous areas (i.e. 1 hour fire rated or smoke resistive and sprinklered)?

  Yes

  No

  N/A

• D) Do doors to Hazardous Areas have automatic closers?

  Yes

  No

  N/A

• E) Do doors to corridors and rated rooms positively latch?

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

STAFF QUESTIONS: 1 (Must Interview a minimum of one staff member)

• Staff Member Job Title:

• FIRE SAFETY MANAGEMENT

• A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate)

  Yes

  No

  N/A

• B) How do you alert everyone that there is a fire? (Dial 6999 and have the operator announce "Code Red" and the location - or Pull a fire alarm box)

  Yes

  No

  N/A

• SAFETY MANAGEMENT

• A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)

  Yes

  No

  N/A

• B) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. Examples like PPE)

  Yes

  No

  N/A

• C) Do you know where to find a current copy of the EOC/Safety manual online? ( On the Intranet Home page. Click on the EOC/Safety Manual Link)

  Yes

  No

  N/A

• HAZARDOUS MATERIALS & WASTE:

• A) What is a MSDS for? (Safety Precautions, hazards, and PPE to be used)

  Yes

  No

  N/A

• B) Can staff explain how to obtain MSDS information? (MSDS Sheets link on the Intranet Home Page)

  Yes

  No

  N/A

• D) Can staff explain what the Code is for a large HazMat spill? (Code Orange)

  Yes

  No

  N/A

• SECURITY:

• A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 6999 & Code Silver called with a location)

  Yes

  No

  N/A

• B) Can staff explain their role to get help with an uncontrollable person? (Dial 6999 & call a Code Strong)

  Yes

  No

  N/A

• C) Can staff explain where to go and what to do when a Code Pink is called? ( Should know what exit their department is assigned to cover during a Code Pink. )

  Yes

  No

  N/A

• EMERGENCY MANAGEMENT:

• A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)

  Yes

  No

  N/A

• B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

STAFF QUESTIONS: 2 (Must Interview a minimum of one staff member)

• Staff Member Job Title:

• FIRE SAFETY MANAGEMENT

• A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate)

  Yes

  No

  N/A

• B) How do you alert everyone that there is a fire? (Dial 6999 and have the operator announce "Code Red" and the location - or Pull a fire alarm box)

  Yes

  No

  N/A

• SAFETY MANAGEMENT

• A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)

  Yes

  No

  N/A

• B) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. Examples like PPE)

  Yes

  No

  N/A

• C) Do you know where to find a current copy of the EOC/Safety manual online? ( On the Intranet Home page. Click on the EOC/Safety Manual Link)

  Yes

  No

  N/A

• HAZARDOUS MATERIALS & WASTE:

• A) What is a MSDS for? (Safety Precautions, hazards, and PPE to be used)

  Yes

  No

  N/A

• B) Can staff explain how to obtain MSDS information? (MSDS Sheets link on the Intranet Home Page)

  Yes

  No

  N/A

• D) Can staff explain what the Code is for a large HazMat spill? (Code Orange)

  Yes

  No

  N/A

• SECURITY:

• A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 6999 & Code Silver called with a location)

  Yes

  No

  N/A

• B) Can staff explain their role to get help with an uncontrollable person? (Dial 6999 & call a Code Strong)

  Yes

  No

  N/A

• C) Can staff explain where to go and what to do when a Code Pink is called? ( Should know what exit their department is assigned to cover during a Code Pink. )

  Yes

  No

  N/A

• EMERGENCY MANAGEMENT:

• A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)

  Yes

  No

  N/A

• B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)

  Yes

  No

  N/A

• Deficiency

• Responsible Person for Addressing Deficiency:

• Date Corrected:

• Comments/Observations

• Responsible Person for Addressing Deficiency:

• Date Corrected:

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