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’s 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:

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.