Allegiance Health Multidisciplinary Rounding

• Location/Department

• Conducted on

  Date

• Personnel Assisting

SAFETY MANAGEMENT

• Housekeeping closets are locked (EC.02.01.01 EP8)

  Yes

  No

  N/A

• Soiled utility rooms are locked (EC.02.01.01 EP8)

  Yes

  No

  N/A

• Clean utility rooms are locked (EC.02.01.01 EP8)

  Yes

  No

  N/A

• Oxygen storage rooms are locked (EC.02.01.01 EP8)

  Yes

  No

  N/A

• Medication rooms are locked (EC.02.01.01 EP8)

  Yes

  No

  N/A

• Utility closets are locked (EC.02.01.01 EP8)

  Yes

  No

  N/A

• Handrails are firmly attached to the walls including in bathrooms and in the hallways (EC.02.01.01 EP3)

  Yes

  No

  N/A

• Patient call light cords are no more than 6" from the floor (patient rooms and in restrooms)

  Yes

  No

  N/A

• Are there any slip and fall hazards in the department? (EC.02.01.01 EP3)

  Safe

  At Risk

  N/A

• Staff are able to properly describe the process on how to handle an injury of a patient

  Yes

  No

  N/A

• Staff are able to properly describe the process on how to handle an injury of a visitor

  Yes

  No

  N/A

• Staff are able to properly describe the process on how to handle an injury of an employee

  Yes

  No

  N/A

• Staff know where lifting equipment is located and how to properly use it (gait belts, hoyer lifts, slide boards)

  Yes

  No

  N/A

SECURITY MANAGEMENT

• All staff members are wearing hospital identification badges (EC.02.01.01 EP7)

  Yes

  No

  N/A

• The department has flashlights that work properly and are stored in an easily accessible location. (EC.02.02.09 EP2)

  Yes

  No

  N/A

• Clean sharps are secured and locked in cabinets, carts, or locked containers (EC.02.01.01 EP3)

  Yes

  No

  N/A

• Doors that should be locked are locked to control access into the department from patients and visitors (EC.02.01.01 EP3)

  Yes

  No

  N/A

• Childproof protective outlet covers are located in outlets in lobbies, hallways, and public gathering points

  Yes

  No

  N/A

• Medical records cannot be seen from the "public's" point of view at the workstations/nurse's station

  Yes

  No

  N/A

• Signage in your department is in good condition and reflects the current operational practices for your unit (LD.03.04.01 EP3)

  Yes

  No

  N/A

• Staff's belongings and personal items are not easily accessible by patients and visitors (EC.02.01.01 EP3)

  Yes

  No

  N/A

• Ask staff if they feel safe working at Allegiance Health. How could they feel more safe?

  Yes

  No

  N/A

• Panic alarms are present in high risk areas (ED/ Behavioral Health) and work properly

  Yes

  No

  N/A

HAZARDOUS MATERIALS AND WASTE MANAGEMENT

• Hazardous chemicals in your department are stored appropriately (EC.02.02.01 EP5)

  Yes

  No

  N/A

• Medical waste containers are not full and labeled with the date installed and expired (NOT MORE THAN 90 DAYS) (EC.02.02.01 EP12)

  Yes

  No

  N/A

• BioHazard Waste (sharps) containers are not over filled. If they are please change these appropriately (IC.02.01.01 EP1)

  Yes

  No

  N/A

• Eyewash stations and/or flush bottles are working properly and not expiered

  Yes

  No

  N/A

• Nothing is stored under sinks

  Yes

  No

  N/A

• Verify that the chemicals stored/ used in the department are listed on the eBinder

  Yes

  No

  N/A

• Chemical storage containers and locations are labeled/ identified properly

  Yes

  No

  N/A

• SDS signage is located within this unit and reflects the current information (name and contact info)

  Yes

  No

  N/A

• Staff know how to access MSDS online (eBinder)

  Yes

  No

  N/A

MEDICAL EQUIPMENT MANAGEMENT

• Biomedical inspection labels are placed on equipment inspected by BioMed and they are not expired

  Yes

  No

  N/A

• Refrigerators are labeled for their use (ie: patient, staff, medications)

  Yes

  No

  N/A

• Temperatures in refrigerators are being documents according to department policies and maintain the proper temperature (36-41F OR 2-5C)

  Yes

  No

  N/A

• Equipment that emits heat is labeled as such (ie: coffee pots, blanket warmers, fluid warmers)

  Yes

  No

  N/A

• Blanket warmer temperatures are set within the appropriate range

  Yes

  No

  N/A

• Staff are able to properly describe the process on how to handle defective medical equipment

  Yes

  No

  N/A

INFECTION CONTROL

• Staff's food and beverages are not present in patient care areas (LD.04.01.01 EP2)

  Yes

  No

  N/A

• Personal Protective Equipment (PPE) is adequately stocked and readily available; in good condition; and appropriate for the department (IC.01.02.01 EP3)

  Yes

  No

  N/A

• Does the isolation cart contain ample supplies (i.e., gowns, signs, masks, gloves)?

  Yes

  No

  N/A

• Linen carts are covered with impervious covering (IC.01.02.01 EP4)

  Yes

  No

  N/A

• Metal storage racks have a protective covering (plastic) on the bottom shelf to protect from splash up. (IC.01.02.01 EP4)

  Yes

  No

  N/A

• Soiled linen bags are not overfilled (EC.02.01.01 EP3)

  Yes

  No

  N/A

• Trash bags are not overfilled (EC.02.01.01 EP3)

  Yes

  No

  N/A

• No items are stored under sinks (LD.04.01.01 EP2)

  Yes

  No

  N/A

• Storage is at least 6" from the floor and no boxes are stored on the floor (IC.01.02.01 EP3)

  Yes

  No

  N/A

• Areas are clean, sanitary, and free from reoccurring offensive odors. These include lighting, vents, surfaces, walls, ceilings, and equipment (EC.02.06.01 EP20)

  Yes

  No

  N/A

• Paper towels are placed in the dispenser not placed on the countertops (NPSG.07.01.01 EP1)

  Yes

  No

  N/A

• Alcohol based hand rubs are not empty and dispensing properly (IC.01.02.01 EP3)

  Yes

  No

  N/A

• There are no rips or tears on vinyl covered patient equipment or chairs. (Stretchers, treatment table coverings, ect) (EC.02.06.01 EP26)

  Yes

  No

  N/A

• Verify pressure relationships (Negative/ Positive) <br>Soiled Utility Rooms/ Decontamination Rooms= Negative Pressure <br>Clean Utility Rooms/ Operating Rooms/ Sterile Areas= Positive Pressure<br>Patient Care Rooms= Positive or Negative

  Yes

  No

  N/A

• Graytop and Clorox wipes are not outdated

  Yes

  No

  N/A

• Stocked medical supplies, food, and medications are not outdated

  Yes

  No

  N/A

• Areas are clean, sanitary, and clean from reoccurring offensive odors. This includes lights, vents, horizontal surfaces, ceiling tiles, walls, and equipment.

  Yes

  No

  N/A

• Can staff explain how a patient is placed in isolation?

  Yes

  No

  N/A

• Staff are able to properly describe the dwell times for our cleaning wipes<br> Graytop- 3 Minutes<br> Clorox Wipes- 30 seconds- 3 Minutes

  Yes

  No

  N/A

• Can staff state the number one way to help prevent the spread of infection? (Wash in/ Wash out)

  Yes

  No

  N/A

FIRE SAFETY MANAGEMENT

• Hallways are free from all obstructions. This does NOT include crash carts, isolation carts, and equipment in use (this means accessed at least every 30 minutes or often) (LS.02.01.20 EP13)

  Yes

  No

  N/A

• Stored items are more than 18" from the bottom of the ceiling in any room (LS.02.01.35 EP6)

  Yes

  No

  N/A

• Sprinklers and smoke detectors look free from dust (LS.02.01.35 EP5)

  Yes

  No

  N/A

• Fire extinguishers and pull stations are not blocked at all times (LS.02.01.35 EP8)

  Yes

  No

  N/A

• Fire extinguishers have been inspected this month (Look at the backside of the tag) (EC.02.03.05 EP15)

  Yes

  No

  N/A

• Emergency Exit signs are clearly visible and working properly (evenly illuminated) (LS.02.01.20 EP13)

  Yes

  No

  N/A

• Emergency Evacuation Signage/ Maps are posted and reflect the proper evacuation routes

  Yes

  No

  N/A

• Fire doors are not blocked from shutting and latching properly (LS.02.01.30 EP11)

  Yes

  No

  N/A

• Doors are not wedged open (LS.03.01.20 EP8)

  Yes

  No

  N/A

• Medical gas shutoff valves are labeled and clear of obstructions (EC.02.05.9 EP3)

  Yes

  No

  N/A

• Flammable decorations like natural Christmas trees are not present in the hospital at any time (LS.02.01.70 EP1)

  Yes

  No

  N/A

• Space heaters are not present at anytime in patient sleeping areas and only radiant heat panels are allowed in all other areas<br>If any heaters other than radiant heat panels are found during rounding, remove them immediately

  Yes

  No

  N/A

• Staff can describe the proper process for responding to a fire (RACE) and using a fire extinguisher (PASS)<br>RACE: <br> Rescue anyone in immediate danger<br> Activate the alarm pull station/ call 9-911<br> Contain the fire by clearing hallways of obstructions and closing doors and windows<br> Extinguish the fire if able and if appropriate evacuate <br><br>PASS:<br> Pull the pin<br> Aim the nozzle at the base of the fire<br> Squeeze the levers together<br> Sweep the nozzle at the base of the fire SLOWLY<br><br>

  Yes

  No

  N/A

• Oxygen tanks are stored properly (no more than 12 tanks (full or empty) stored in an approved location. The storage racks are labeled correctly

  Yes

  No

  N/A

UTILITY SYSTEMS MANAGEMENT

• Sinks, showers, toilets, and water lines are in good repair (not leaking and working appropriately) (EC.02.06.01 EP1)

  Yes

  No

  N/A

• Extension cords are not used in the department (EC.02.03.01 EP1)

  Yes

  No

  N/A

• Electrical outlets are not damaged or loose and have covers. This also includes switches, and network connections (EC.02.03.01 EP1)

  Yes

  No

  N/A

• Electrical panels are labeled as such and locked (locked in public areas) (EC.02.05.01 EP8)

  Yes

  No

  N/A

• Internal walls, doors, ceilings, cabinetry, and floors are in good condition

  Yes

  No

  N/A

ABOVE THE CEILING

• Penetrations are filled with fire approved chalking

  Yes

  No

  N/A

• Sprinkler lines do not have anything hung from, draped over, or tied too them or their support brackets

  Yes

  No

  N/A

• Electrical junction boxes have covers on them

  Yes

  No

  N/A

• Nothing is stored above the ceiling (basins, covers, debris)

  Yes

  No

  N/A

OUTDOOR SAFETY ROUNDING

• Outdoor signage is visible and evenly illuminated

  Yes

  No

  N/A

• Outdoor lighting is working properly and illuminating appropriate areas

  Yes

  No

  N/A

• ADA accessible ramps are clear from obstructions

  Yes

  No

  N/A

• Parking lots are in good repair (no potholes, large cracks, visible lines, curbs are intact)

  Yes

  No

  N/A

• During winter months parking lots, sidewalks, steps, and curbs are free from snow and ice

  Yes

  No

  N/A

• Emergency Exits are free from any external hazards (snow/ice (falling), shrubs, rocks)

  Yes

  No

  N/A

• Fire Department Connections (FDC) are visible and not blocked by shrubs, vehicles, or snow/ice

  Yes

  No

  N/A

• External walls, doors, windows, etc. are in good condition

  Yes

  No

  N/A

NURSING SECTION (TO ONLY BE COMPLETED BY A NURSE ON THE ROUNDING TEAM)

• Can staff state any one of the National Patient Safety Goals?

  Yes

  No

  N/A

• Can staff give an example of a “never event”? (Surgery wrong body part, Infant discharge to wrong person, Patient death with med. error)

  Yes

  No

  N/A

• Staff knows patient identifiers used when taking blood samples, giving medications or blood products?

  Yes

  No

  N/A

• Staff labels blood and other specimens in the presence of the patient?

  Yes

  No

  N/A

• Staff knows the process for scanning medications? (Scans patient ID Band then Meds with bar code scanner prior to giving meds)

  Yes

  No

  N/A

• Staff knows how long glucometer solution is good after opening? (90 days, labeled with exp. date)

  Yes

  No

  N/A

• Does staff know that patients at risk for suicide require continuous 1:1 observation until physician orders otherwise?

  Yes

  No

  N/A

• If restraints were used, is the patient being monitored appropriately according to the type of restraint used? ( Review doc flow sheet in the patient's chart)

  Yes

  No

  N/A

• Staff knows the proper way to receive verbal or phone orders?<br>( Enter into the patient's chart and read back)

  Yes

  No

  N/A

• Does staff know how to adjust the temperature in the refrigerator/warmer?

  Yes

  No

  N/A

• Was the consent to treat signed by the patient or representative?

  Yes

  No

  N/A

• Can the nurse identify the patients’ primary language?

  Yes

  No

  N/A

• Does the nurse know if the patient has an advanced directive?

  Yes

  No

  N/A

• Staff completes the pre procedure checklist in the patient's chart for all patients undergoing an invasive procedure?

  Yes

  No

  N/A

• Does the nursing care plan contain all required elements based on the initial assessment? (pain/abuse/skin/VTE/smoking/falls, etc.)

  Yes

  No

  N/A

• Staff knows the process used to communicate with other caregivers when providing the status of a patient or transfer of care? (SBAR)

  Yes

  No

  N/A

• Does staff know how long they must remain at the bedside immediately after the administration of a blood transfusion? (15 minutes)

  Yes

  No

  N/A

• Does staff know where to find a list of patients’ rights and responsibilities?

  Yes

  No

  N/A

• Does staff know what programs or methods are available for patients and families to report concerns related to care, treatment, services, and patient safety issues? (Patient Advocate, Nursing Managers/Charge nurse, and follow chain-of command, CMS & TJC Hotlines)

  Yes

  No

  N/A

• Does staff know what programs or methods are available for staff to report concerns related to care, treatment, services, and patient safety issues? (Follow chain of command)

  Yes

  No

  N/A

• Does the staff know what interpretive services we offer and what the process is to provide on off hours?

  Yes

  No

  N/A

• Is the current month Defib Log the ONLY log in the book? (current log in book only)

  Yes

  No

  N/A

• The monthly log is free from any missing checks? (All required signatures are present on the log)

  Yes

  No

  N/A

• Can the nurse identify how each patient is assessed for learning needs?

  Yes

  No

  N/A

• Can the nurse state the goals for their patient?

  Yes

  No

  N/A

PHARMACY SECTION (TO ONLY BE COMPLETED BY A PHARMACY REPRESENTATIVE ON THE ROUNDING TEAM)

• Does staff know the proper procedure for checking the crash cart?

  Yes

  No

  N/A

• All medications are secured (MM.03.01.01 EP3)

  Yes

  No

  N/A

• Are insulin & multi-dose vials labeled with the expiration date?

  Yes

  No

  N/A

• Are fluids in refrigerator/warmer labeled with the expiration date?

  Yes

  No

  N/A

• Is the record free from unacceptable abbreviations?

  Yes

  No

  N/A

• Do all PRN medication orders include indications?

  Yes

  No

  N/A

• Is the record free of any therapeutic duplication of PRN orders?

  Yes

  No

  N/A

• Does the staff know the process for informing a patient of the med. reconciliation upon discharge?

  Yes

  No

  N/A

• Can staff identify high alert drugs or look alike/sound alike drugs?

  Yes

  No

  N/A

• Does staff know how to report medication errors?

  Yes

  No

  N/A

• Can staff identify sources of drug information?

  Yes

  No

  N/A

• Does staff know what safeguards are in place when treating a patient on anticoagulants?

  Yes

  No

  N/A

• What is the current process if a physician allows a patient to take their own medication from home? (3 requirements: medication is non-formulary, the pharmacy has confirmed the medication and affixed a supplemental label to it, and the patient’s own medication should be stored in the medication room.)

  Yes

  No

  N/A

• Does staff know who educates patients on Warfarin and dietary interactions? (Dieticians and Nurses)

  Yes

  No

  N/A

• Does staff know what lab value is followed for a patient on Warfarin? (PT/INR)

  Yes

  No

  N/A

• Can the staff describe the process for labeling medications on and off a sterile field?

  Yes

  No

  N/A

• Are opened irrigation bottles labeled with an expiration date?

  Yes

  No

  N/A

• Is the medication prep area including the pill crusher/splitter clean and clutter free?

  Yes

  No

  N/A

• Does staff know what medications require double check? (Heparin, Infusion, Insulin, PCA pump, Chemo)

  Yes

  No

  N/A

• Does staff know the requirements of the double check? (Visibly verify order, Dose, Product, Pump programming with another nurse)

  Yes

  No

  N/A

• Can staff properly explain what meds need to be disposed of in the blue/black pharmacy containers?

  Yes

  No

  N/A

EMERGENCY MANAGEMENT

• Does staff know where to access emergency management policies? (IDA and Safety Manual)?

  Yes

  No

  N/A

• Does staff know what to do during severe weather (thunderstorm/ tornado)?

  Yes

  No

  N/A

• Does staff know what to do during a Code Pink (infant/ child abduction)?

  Yes

  No

  N/A

• Does staff know what to do during a Code Yellow (bomb threat)?

  Yes

  No

  N/A

• Does staff know what to do when they discover a patient is missing?

  Yes

  No

  N/A

• Does staff know what to do during a Code Silver (active shooter)? RUN HIDE FIGHT

  Yes

  No

  N/A

• Does HOSPITAL staff know the universal number to call to activate a code? (ext. 7000)

  Yes

  No

  N/A

MISCELLANEOUS

• Can staff describe hospital’s Mission and Vision Statements?

  Yes

  No

  N/A

• Can staff describe the proper process to dispose of Protected Health Information (PHI)

  Yes

  No

  N/A

• Any other concerns for your unit or area of inspection?

• Please add and additional photos during this audit that are of a concern but do not fit into any of the above categories.

  Media

END OF SURVEY

• Department Manager or Designee Representative

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• Environmental Services Department Representative

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• Nursing Representative

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• Pharmacy Representative

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• Plant Engineering Representative

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• Safety Department Representative

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