AHS Nursing Station Inspection

• Conducted on

  Date

• Prepared by

• Location
  Address

REFRIGERATOR

• Refrigerator temperature too cold at 34 degrees Fahrenheit (FDA med storage: 36-46 degrees F)

  Yes

  No

  N/A

• Monthly temperature log present and complete for the current month. If vaccines are present, temperature log is completed at least twice per day

  Yes

  No

  N/A

• Refrigerator is locked with only authorized personnel having access and/or keys

  Yes

  No

  N/A

• A lock box is permanently affixed ensuring that controlled medications are double locked

  Yes

  No

  N/A

• All expired and discontinued drugs are out of refrigerator

  Yes

  No

  N/A

• All refrigerated drugs are properly labeled and appropriately dated if opened

  Yes

  No

  N/A

• Medications not requiring refrigeration not present

  Yes

  No

  N/A

• Refrigerator is clean and well organized (i.e., ophthalmic, otic, injectable, etc)

  Yes

  No

  N/A

• Food in refrigerator separated from medications and IF OPENED, dated

  Yes

  No

  N/A

• No medication is stored on the door of the refrigerator

  Yes

  No

  N/A

EMERGENCY KIT

• Emergency kits accessible to staff and not locked in nursing room

  Yes

  No

  N/A

• Emergency kit sealed and is within posted expiration date.

  Yes

  No

  N/A

• Current list of emergency items is posted

  Yes

  No

  N/A

• Medications listed on emergency kit list are present and accounted for

  Yes

  No

  N/A

MEDICATION ROOM & CUPBOARDS AND DRAWERS:

• Medication room locked with only authorized personnel having access and/or keys

  Yes

  No

  N/A

• Medication room temperature is okay (less than 77 degrees F)

  Yes

  No

  N/A

• Medication room clean and well organized

  Yes

  No

  N/A

• All drugs are properly stored (i.e., injectables, oral, topical, etc separated)

  Yes

  No

  N/A

• Items not belonging in medication room are not present. (i.e., no personal items such as pocketbooks, backpacks, cell phones)

  Yes

  No

  N/A

• All expired and discontinued medications removed

  Yes

  No

  N/A

• All drugs are properly labeled and appropriately dated if opened. Note that the item itself must be dated. Dating the containing box or vial is recommended, but not required

  Yes

  No

  N/A

MEDICATION CART

• Cart is locked. Only licensed staff has access to keys

  Yes

  No

  N/A

• Cart is clean and well organized. Loose tablets/capsules are not present in the cart

  Yes

  No

  N/A

• Medications are properly stored. Medication requiring refrigeration not present

  Yes

  No

  N/A

• All expired and discontinued medication out of cart.

  Yes

  No

  N/A

• All drugs are properly labeled and appropriately dated if opened. Note that the item itself must be dated. Dating the containing box or vial is recommended, but not required

  Yes

  No

  N/A

• House supply labeled correctly (blood glucose test strip, blood glucose test solution, alcohol, etc)

  Yes

  No

  N/A

• Scheduled medication receipt signatures present

  Yes

  No

  N/A

• Schedule II-V medications are double locked

  Yes

  No

  N/A

• Scheduled medication count matches corresponding audit sheets

  Yes

  No

  N/A

MEDICATION CART

• Cart is locked. Only licensed staff has access to keys

  Yes

  No

  N/A

• Cart is clean and well organized. Loose tablets/capsules are not present in the cart

  Yes

  No

  N/A

• Medications are properly stored. Medication requiring refrigeration not present

  Yes

  No

  N/A

• All expired and discontinued medication out of cart

  Yes

  No

  N/A

• All drugs are properly labeled and appropriately dated if opened. Note that the item itself must be dated. Dating the containing box or vial is recommended, but not required

  Yes

  No

  N/A

• House supply labeled correctly (blood glucose test strip, blood glucose test solution, alcohol, etc)

  Yes

  No

  N/A

• Scheduled medication receipt signatures present

  Yes

  No

  N/A

• Schedule II-V medications are double locked

  Yes

  No

  N/A

• Scheduled medication count matches corresponding audit sheets

  Yes

  No

  N/A

GENERAL

• Conversion chart available

  Yes

  No

  N/A

• Poison antidote information available

  Yes

  No

  N/A

• Reference sources available:

  Yes

  No

  N/A