Title Page

  • Conducted on

  • Prepared by

  • Location

  • Unit

  • Types of Staff Interviewed (RN, Tech, EVS, Pharmacist, etc.)

Staff & Staff Knowledge

  • All staff must wear names badges at chest level with photo ID visible

  • Staff can identify nearest fire alarm pull station.

  • Staff know the location of the nearest fire extinguisher.

  • Staff can verbalize how to use a fire extinguisher (P.A.S.S.)

  • Staff can describe what to do in case of fire (R.A.C.E.).

  • Staff know the process for notifying primary care physicians and/or family of their hospitalization if asked by the patient.

  • Pt information (White board, WOWs & Chart) secured to ensure privacy

  • Check for expired meds or supplies throughout the unit

  • Staff are using 2 patient identifiers in compliance with hospital policy (patient identification, specimen labeling, etc.)

  • No other non-compliant findings.

EOC Exits & Egress

  • Egress is clear. Exit doors are not blocked and clear of clutter

  • Fire rated doors must latch & close properly

  • No flammable items on fire rated doors

  • Hallways clear with all equipment parked on one side or in alcoves

  • Nothing in front of medical gas valves, fire extinguishers or pull stations

  • No doorstops used or doors propped open

  • No food or beverages in patient care areas or nurse‚Äôs stations

  • No supplies stored within 18 inches from bottom of sprinkler head

  • No unattended meds on Pyxis, WOWs, or throughout the unit

  • All Pt. equipment labeled with clinical engineering sticker & current PMs

  • O2 tanks upright in holder, full and empty tanks separated with signage

  • No other non-compliant findings.

Med Room

  • Med Prep areas are clean, uncluttered and separated from other areas

  • Med rooms locked with access for authorized personnel only

  • All insulin or multi-use vials are dated w/discard date in 28 days

  • Pill cutters are individual use only. Must be labeled with patient name

  • Med refrigerator and freezer temp logs documented daily

  • Out of range temperatures are addressed.

  • Med room checked for expired meds & supplies

  • No other non-compliant findings.

Crash Cart

  • Defibrillator is plugged in.

  • Crash Cart tidy and clean. No dust or excessive supplies on crash carts

  • Crash cart logs and Defibrillator check documented daily. Lock is intact and matches log documentation.

  • Patches for leads are closed and sealed in their original packages.

  • No other non-compliant findings.

Waived Tests

  • Glucometers cleaned, Controls and Strips dated w/date opened/expiration date; toss after 90 days

  • No expired supplies.

  • No other non-compliant findings.

Infection Control

  • Staff can verbalize or demonstrate proper donning and doffing of PPE.

  • Contact Precaution sign posted and isolation cart placed outside of room

  • Overall cleanliness of unit (floors, walls, clutter, dust)

  • Nothing stored under sinks throughout unit

  • Hand hygiene performed when staff entering & exiting patient rooms

  • Hand gel stocked in all dispensers

  • No open Sani-Cloth containers

  • No gloves, booties, hanging face masks while in hallway or public areas

  • No other non-compliant findings.

Patient Pantry/Kitchen

  • Patient food must be labeled with Pt. name and date

  • No staff food to be stored in patient refrigerator

  • Refrigerator temp checked daily & documented daily by dietary services

  • No other non-compliant findings.

Clean Utility Room

  • Linen carts must be covered and have solid bottoms

  • All linen and supply carts must have solid bottom on lower shelf

  • No supplies stored on the floor. Must be on pallets or wire shelving

  • No corrugated shipping boxes. Remove immediately

  • No other non-compliant findings.

Soiled Utility Room

  • Equipment requiring cleaning or service must be clearly marked

  • Used instruments for reprocessing are stored in a biohazardous-labeled rigid container and wet with enzymatic detergent.

  • Enzymatic detergent, rigid biohazardous-labeled bin and PPE are available for contaminated instrument storage until delivered to SPD.

  • No clean supplies or items to be stored in soiled utility rooms

  • All biohazard containers must be clearly labeled and covered with a lid

  • No other non-compliant findings.


  • Was any Service Recovery required? If yes, please explain:

  • Please share any Staff Recognition:

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