Title Page

  • Conducted on

  • Prepared by

Department:

Safety Management

  • - Compressed gas cylinders properly secured, categorized full vs empty, and do not exceed q’ty limits

  • - Flammable liquids properly stored

  • Flooring/Ceiling Surfaces are intact, undamaged, and free of stains

  • - Chemicals labeled and properly stored

  • - Walking surfaces in good repair

  • - Tripping hazards are not present

  • - Adequate precautions taken during remodeling or construction

  • - Radiation, laser, biological hazards clearly identified

  • Pt care and medication refrigerators are labeled, clean, and logs current

  • Pt foods are dated and within expiration ranges

  • Cabinets under sinks are clean and not used for storage

  • Proper hand hygiene is followed

Fire Safety Management

  • - Fire doors, pull stations, and egress routes are clear

  • Trash/Linen Chutes are secured and properly close & latch

  • - Storage at least 18” below sprinkler heads

  • Stored supplies are elevated off the floor with solid shelving

  • - Fire extinguishers inspected monthly

  • Fire Extinguishers are mounted properly and at within appropriate heights

  • Sprinkler heads are clean and unobstructed

  • Fire doors latch and close properly w/ < 1/8” gap

  • - Patient rooms doors close and latch properly

  • - Satisfactory housekeeping/sanitation

  • - Exhaust ventilation system functioning

  • - Stairway, ramps, handrails in good condition, free of obstacles and storage

  • - No flammable decorations

  • - No doors propped open

  • - Electrical panels are closed, latched, and unobstructed

  • Hand foam canisters are within expiration date

Security

  • - Personal belongings secure

  • - Medication room secure

  • - Co-workers wearing identification badges

  • Staff can explain security process for forensic patients

  • Access control properly functions

  • Staff can explain their role in an infant abduction

Hazmat & Waste

  • Staff can demonstrate SDS

  • Hazardous waste is properly stored

  • Janitors closets are secured

  • Eyewash station is current on logs

  • There is appropriate PPE in area

Infection Control

  • - Soiled linen covered and not overflowing

  • Medical equipment is clean (sticker free) and in good repair

  • - Sharps containers not overfilled

  • Clean utility is segregated from dirty

  • Proper Air pressure is maintained

Utilities Management

  • - Lights in good working order

  • - Extension cords not in use for permanent power

  • - Multistrip outlets are hospital-grade

  • - Air supply and returns clean

  • - Medical gas zone valves in good condition, properly labeled, clean, and unobstructed

  • - Emergency lighting for exit signs operable and arrows pointed correctly

  • - Air pressure relationships are correct (clean rooms are positively pressured, dirty rooms are negative)

HIPPA Concerns

  • - Inappropriate staff discussion of PHI overheard in area

  • - Documents containing PHI concealed from public access and view

  • - Pt info boards include minimum pt information

Water Management Optional

  • Water Sample Location 1

  • Temperature

  • Water Sample Location 2

  • Temperature

  • Water Sample Location 3

  • Temperature

  • Water Sample Location 4

  • Temperature

  • Water Sample Location 5

  • Temperature

Other Deficiencies Noted

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