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Accreditation Readiness Rounding
Accreditation Readiness Rounding
Ryan Jordan

Accreditation Readiness Rounding

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Free Accreditation Readiness Rounding Checklist

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Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Untitled Page

Quality

NPSG 1: Patient Identification

  • Do staff use at least two patient identifiers when administering medication or blood products?

  • Blood transfusion per hospital policy?

  • Are specimen containers labeled in the presence of the patient?

NPSG 2: Staff Communication

  • Critical test results

NPSG 6: Alarm Safety

  • Alarm Management

NPSG 15: Suicide Prevention

  • Suicide risk assessment

Universal Protocol

  • PHI is protected

  • Correct patient, correct site

  • Site marking

  • Safety pause

Medication Practice

  • Medication labeling

  • Medications secure

  • PRN pain medication

  • Medication cart secure

  • Code cart

Nursing Required Documentation

  • Patient care plan

  • Patient goals

  • Pain assessment/reassessment

  • Are nursing orders current and being followed?

  • Are ordered routes (PO, NGT) for all medication orders appropriate for the patient?

Surgical/Procedural Required Documentation

  • Consent

  • H&P; H&P update

  • Anesthesia pre-procedure eval.

  • Brief operative note

  • Full operative note

  • Anesthesia post-op note

  • Discharge written instructions

Medication Management

  • Open medication/ supply expiration, open multiuse vials/containers dates not expired?

  • Irrigation fluid has not reached their expiration dates?

  • Open medications labeled with date?

  • The medication room is clean, neat, and wellorganized?

  • The medication room is locked? (lock type? i.e. Pyxis)

  • Only authorized drugs are present. Discontinued drugs are returned to pharmacy

  • Sample drugs, if present, are controlled in accordance with the facility's policy?

  • Patients' personal drugs (from home), NOT INTENDED for administration within the facility, have been returned to the patients' family or secured within the pharmacy in accordance with the facility's policy?

  • Externals are separated from internals (and parental)?

  • Drugs requiring special storage conditions are properly stored (i.e. protected from light or refrigerated)?

  • There are no expired, recalled, broken, contaminated, or mislabeled/unlabeled drugs

  • A thermometer (or equivalent) is present in each medication refrigerator and is working properly?

  • Refrigerator temperature is between 2 and 8 C (3646F)?

  • The refrigerator is clean and free of excessive frost?

  • No food or other nondrug items are stored in refrigerator

  • Single use vials are not reused

  • Multidose vials are properly dated (up to 28 days from opening)

  • Reconstituted drugs are labeled the date beyond which the drug should NOT be used

  • The concentration of reconstituted drugs is noted on labels

  • Medication cart (if used) is locked and in a secure area

  • Automated dispensing machine (ADM) is locked and in a secure area

  • There are no unresolved discrepancy icons displayed on the ADM screen

  • Audited controlled substance is dated and actual count is correct

  • Extemporaneously prepared patient medications are accurately labeled with strength, lot number, expiration date and cautionary statements as per policy (when needed)

  • Floorstock drugs are stored under locked storage or in a secure area

  • Controlled substances and narcotics are securely stored and accurately accounted for?

  • Emergency drug supplies are sealed or intact, and all required drugs are present?

  • Investigation drugs are stored and records are maintained according to policy

Public Safety

Fire Safety

  • Are exit doors and stairwells clear? Main, corridor, and stairwell exits cannot be blocked by any means

  • Are exit doors clearly marked "exit" and illuminated? Check for burnt out bulbs

  • Do fire doors latch properly? Close the fire doors to see if they latch properly and see that there is no gap<1/8 inch in the middle

  • Are corridors and passageways free of obstructions? The corridors can have mobile items (wheels on them) that are emergency needed items and are in use

  • Are pull stations and fire extinguishers clear from any obstructions? There must be nothing to obstruct access

  • Doorstops or homemade held open devices are not being used?

  • Are materials stored a minimum of 18 inches from sprinkler deflectors? The distance between sprinkler deflector and stored items is 18 inches for sprinkled buildings

  • Are stored rooms and equipment rooms free from clutter and unsafe conditions? Make sure that items are not falling down or overstocked

  • Sprinkler heads clean and free from debris?

Fire Safety Knowledge Questions

  • Does staff know the meaning of R.A.C.E.?

  • Does staff know the location of exit route?

  • Does staff know the meaning of P.A.S.S.?

Safety & Security Management Physical Inspection

  • Is area free from smoking?

  • Are heavy items stored at low levels or mid levels in storage? Make sure heavy items are stored at waist level or lower shelves

  • Are staffs personal items properly secured?

  • Are all employees wearing their I.D badges properly?

  • Are mechanical, electrical, janitorial, and communications rooms locked?

  • Are punch code doors working properly?

  • Are there Security cameras in the area and are they functioning properly?

  • Does area have access control or intercom system and are the functioning properly?

  • Are general areas clean and free of clutter?

  • Are compressed gases stored properly?

Safety & Security Staff Knowledge Questions

  • Does staff know to dial "33333" for an emergency?

  • Does staff know how to contact Security?

  • Does staff know "Armed Intruder alert" procedures?

  • Does staff know "Security alert" procedures?

Hazardous Materials & Waste

  • Is medical waste kept in red biohazard bags or containers?

  • Is hazardous chemical inventory adequate and available to all employees?

  • A spill kit is available for chemical spills?

  • Regular and infectious waste trash are separated?

  • Hazardous waste is collected and disposed of properly?

  • An eyewash station is readily available and functioning properly?

Facilities

  • Walls are free from damage (chips, scuffs. or gouges)?

  • All lighting is operational?

  • GFCI's within 3foot of water? Tested and worked?

  • All penetrations in the walls and ceilings have been appropriately filled?

  • Drawer/ cabinet handles function properly (no loose handles)?

  • All electrical outlets have cover plates?

  • Circuit breaker boxes are unobstructed and properly labeled?

  • There are no extension cords being used?

  • Door hinges are working properly (no loose hinges)?

  • Cords/Wires are in good physical condition (no cracks, tears, or exposed wires)?

  • Are ceiling tiles clean, stain free, and in good condition? Indicate where these bad tiles are located in the comments

  • Are floors and hallways in good condition?

  • Are all mechanical, electrical, janitorial, communications rooms clean with no storage?

  • Does staff know how to identify an emergency outlet?

  • Does staff know how to submit a work order?

  • Does staff know the procedure to equipment's cleanliness, paint, wiring, and covers appear satisfactory?

  • The equipment storage room doors will self close and latch?

  • Is all equipment appropriately stored? Equipment if not in use should be stored in its designated area or in equipment store room

  • Does medical equipment have an asset tag and current maintenance sticker?

  • Are temperature and other logs current, and are there notes for actions taken if device is operating outside of parameters?

  • Do staff understand lock out / tag out (process to tagging broken equipment )

  • Area is Pestfree: insects, rodents, and all other varmint PowerStrip

  • Room temperature is between 2025 degrees (6877F)?

Infection Control

  • Contaminated linens containers readily accessible?

  • Collection times appropriate: dirty linen not overflowing?

  • Clean linen is stored in clean area?

  • Clean linen is covered?

  • Blanket warmer temperatures are appropriate?

  • Clean supplies are stored appropriately in clean area? (off floors, on open shelves, in defined clean utility areas)

  • Clean and/or dirty supplies are clearly labeled?

  • All areas under sinks are clear of all stock or items?

  • Cardboard boxes are being stored off floor and out of original container?

  • Sharps and instruments are placed in "sharp safety" containers?

  • Sharps container are readily accessible?

  • Sharps containers are <3/4 full?

  • Handwashing soap dispensers are easily accessible, with proper amount of cleaning agent?

  • Alcohol hand sanitizers are easily accessible and not expired?

  • Hand hygiene is performed according to policy?

  • Handwashing towels are easily accessible?

  • Staff is aware of dwell/ wet time for disinfectant?

  • Staff is aware of bleach wipes for cDiff/ Norovirus?

  • Staff able to explain proper PPE for ERI, Contact and Contact Plus?

  • Proper signage posted for correct precautions (not applicable in ambulatory/clinic area)?

  • Pediatric areas: Toys are removed from social areas and confined to patient rooms?

  • Pediatric areas: Log completed for cleaning toys and multiuse pedi items?

  • PPE (gloves, gowns, face masks, protective eyewear, and respirators (N95) are readily accessible or staff able to explain where to obtain PPE (Emergency Management)

  • PPE is donned or doffed according to Policy

  • Are employee eating areas kept clean? (microwave and refrigerator)

  • Refrigerator temperaturethermometer in refrigerator/ freezers follow organizational policy

  • Has appropriate action taken place for refrigerators with out of range temperatures?

  • Are refrigerators identified as "food only" and "medication only"?

  • Food items are not stored or eaten in areas where blood or other infectious material is present?

  • Supplies stocked have not reached their expiration date?

  • Behavior eating, drinking, applying cosmetics where there is likelihood of exposure to blood/ bodily fluid and social distancing of 6feet from other staff

  • **HLD areas only: Expiration dates on test strips, resert, and biologic logs UTD per Policy

  • **HLD areas only: Instruments transported per policy?

  • **HLD areas only: Staff wearing proper PPE in processing area?

  • **HLD areas only: Clean scopes stored appropriately, instruments cleansed appropriately

Notes/Comments

  • Comments?

Accreditation Readiness Rounding
Ryan Jordan

Accreditation Readiness Rounding

Use this Template
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