Title Page
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Conducted on
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Prepared by
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Location
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Unit
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Types of Staff Interviewed (RN, Tech, EVS, Pharmacist, etc.)
Staff & Staff Knowledge
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All staff must wear names badges at chest level with photo ID visible
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Staff can identify nearest fire alarm pull station.
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Staff know the location of the nearest fire extinguisher.
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Staff can verbalize how to use a fire extinguisher (P.A.S.S.)
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Staff can describe what to do in case of fire (R.A.C.E.).
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Staff know the process for notifying primary care physicians and/or family of their hospitalization if asked by the patient.
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Pt information (White board, WOWs & Chart) secured to ensure privacy
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Check for expired meds or supplies throughout the unit
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Staff are using 2 patient identifiers in compliance with hospital policy (patient identification, specimen labeling, etc.)
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No other non-compliant findings.
EOC Exits & Egress
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Egress is clear. Exit doors are not blocked and clear of clutter
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Fire rated doors must latch & close properly
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No flammable items on fire rated doors
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Hallways clear with all equipment parked on one side or in alcoves
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Nothing in front of medical gas valves, fire extinguishers or pull stations
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No doorstops used or doors propped open
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No food or beverages in patient care areas or nurse’s stations
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No supplies stored within 18 inches from bottom of sprinkler head
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No unattended meds on Pyxis, WOWs, or throughout the unit
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All Pt. equipment labeled with clinical engineering sticker & current PMs
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O2 tanks upright in holder, full and empty tanks separated with signage
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No other non-compliant findings.
Med Room
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Med Prep areas are clean, uncluttered and separated from other areas
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Med rooms locked with access for authorized personnel only
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All insulin or multi-use vials are dated w/discard date in 28 days
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Pill cutters are individual use only. Must be labeled with patient name
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Med refrigerator and freezer temp logs documented daily
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Out of range temperatures are addressed.
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Med room checked for expired meds & supplies
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No other non-compliant findings.
Crash Cart
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Defibrillator is plugged in.
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Crash Cart tidy and clean. No dust or excessive supplies on crash carts
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Crash cart logs and Defibrillator check documented daily. Lock is intact and matches log documentation.
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Patches for leads are closed and sealed in their original packages.
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No other non-compliant findings.
Waived Tests
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Glucometers cleaned, Controls and Strips dated w/date opened/expiration date; toss after 90 days
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No expired supplies.
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No other non-compliant findings.
Infection Control
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Staff can verbalize or demonstrate proper donning and doffing of PPE.
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Contact Precaution sign posted and isolation cart placed outside of room
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Overall cleanliness of unit (floors, walls, clutter, dust)
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Nothing stored under sinks throughout unit
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Hand hygiene performed when staff entering & exiting patient rooms
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Hand gel stocked in all dispensers
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No open Sani-Cloth containers
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No gloves, booties, hanging face masks while in hallway or public areas
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No other non-compliant findings.
Patient Pantry/Kitchen
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Patient food must be labeled with Pt. name and date
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No staff food to be stored in patient refrigerator
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Refrigerator temp checked daily & documented daily by dietary services
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No other non-compliant findings.
Clean Utility Room
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Linen carts must be covered and have solid bottoms
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All linen and supply carts must have solid bottom on lower shelf
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No supplies stored on the floor. Must be on pallets or wire shelving
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No corrugated shipping boxes. Remove immediately
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No other non-compliant findings.
Soiled Utility Room
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Equipment requiring cleaning or service must be clearly marked
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Used instruments for reprocessing are stored in a biohazardous-labeled rigid container and wet with enzymatic detergent.
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Enzymatic detergent, rigid biohazardous-labeled bin and PPE are available for contaminated instrument storage until delivered to SPD.
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No clean supplies or items to be stored in soiled utility rooms
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All biohazard containers must be clearly labeled and covered with a lid
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No other non-compliant findings.
Other
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Was any Service Recovery required? If yes, please explain:
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Please share any Staff Recognition:
