• Facility Surveillance Audit

  • Facility Audit Conducted and Address

  • Conducted on

  • Prepared by

  • Signature

  • Personnel Participating in Drill


  • 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)


  • 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.


  • 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?


  • 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?


  • 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?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.