Information

  • Facility Surveillance Audit

  • Facility Audit Conducted and Address

  • Conducted on

  • Prepared by

  • Signature

  • Personnel Participating in Drill

SAFETY

  • 1. Are all "E"oxygen cylinders secured and large "H" oxygen and medical air cylinders in Med Gas room chained/secured and room locked?

  • 2. Temperature Track operational? (confirm through TempTrak)

  • 3. All Fire Extinguishers in building within expiration date and marked with month, day, and year of inspection?

  • 4. All Sharps Containers less than ¾ full?

  • 5. All Eye Wash bottles within expiration date?

  • 6. All hallways free & clear of stored items and/or obstructions?

  • 7. Are the patient nutrition refrigerators clean/defrosted and free of staff items?

  • 8. Are the patient microwaves clean and in good working order?

  • 9. The building is void of any space heaters?

  • 10. If applicable, were all Interim Life Safety Measures implemented during the last month reported to the Quality Department? (typically related to construction projects)

INFECTION CONTROL

  • 1. Every room, closet, and enclosure inspected for visible contaminants?

  • 2. Clean and soiled linen stored off ground and covered?

  • 3. Clean linen stored separately from dirty linen?

  • 4. Soiled linen stored in proper linen bags in soiled utility room?

  • 5. All ventilation openings check and are free from visible dust or contaminants?

  • 6. Ceiling tiles clear of stains?

  • 7. Are hand washing posters posted?

  • 8. All negative pressure room(s) check and functioning properly (indicator lights green and small piece of tissue pulled into room form hallway under the closed door).

  • 9. Dietary room clean and no boxes stored on floor.

PHARMACY/MEDICATIONS

  • 1. Medication room door(s) locked.

  • 2. Medication room is clean and clear of food/drink?

  • 3. Narcotic cabinet locked.

  • 4. Controlled substances log checked and has no blanks or omissions (signatures, physician name, quantity dispensed, waste amount, time and date, and patient name?

  • 5. Medication refrigerator clear of food and drinks and open multi-dose medications correctly initialed, dated, and properly stored?

  • 6. Opened room temperature multi-dose medications are correctly initialed, dated, and properly stored?

  • 7. Topical Medications are kept separate from PO and IV Medications?

  • 8. Poison Control telephone number clearly posted in Medication Room?

  • 9. Crash cart medications within expiration dates? (check Epinephrine 1:10,000, Atropine, and Dopamine)

  • 10. Crash carts re-locked and secured with yellow plastic locks?

  • 11. Crash cart log completed every shift?

  • 12. Suture cart locked, secure, and no opened medication (to include multi dose) are present?

  • 13. CT closet where IV Contrast is stored is locked and secured?

LAB

  • 1. Are the following lab testing supplies within expiration date? CMP, Qualligen test packs, Urine drug tests. <br>

  • 2. Lab clean and clear of food and drink?

  • 3. Lab refrigerator clean and clear of food and drink?

  • 4. Glucometer log completed every shift?

  • Monthly QA Review sent by the Regional Lab Manager been reviewed and corrective actions updated on log?

OTHER

  • 1. All Safety Recalls and Alerts that have been received been addressed?

  • 2. All previous month’s EOC discrepancies (questions answered “NO”) addressed and closed?

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