Bluestone - Suicide Risk

• Site conducted

  Select

• Conducted on

  Date

• Site name

• Prepared by

• Inspected by

• Location
  Address

Entry

• Entry doors are locked and in working condition?

  Yes

  No

  N/A

• Entry areas are free from suicide or self-harm risks?

  Yes

  No

  N/A

• Lobby areas are free from suicide or self-harm risks?

  Yes

  No

  N/A

• Hallways leading to patient areas are free from suicide or self-harm risks?

  Yes

  No

  N/A

• Postings related to accreditation, required notices, and licensure are present and current?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues related to entry and lobby areas?

  Yes

  No

  N/A

Exam Room

• Exam room is clean, safe and in good condition?

  Yes

  No

  N/A

• Furniture in the exam room is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Items stored in the exam room are stored under safe conditions preventing risks to patients?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues related to the exam room?

  Yes

  No

  N/A

Seclusion and Restraint

• Doors are free from suicide or self-harm risks?

  Yes

  No

  N/A

• Rooms are free from suicide or self-harm risks?

  Yes

  No

  N/A

• Beds stored in S/R room are free from suicide or self-harm risks?

  Yes

  No

  N/A

• The bathroom in the S/R area is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Area adjacent to S/R rooms is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues related to S/R area?

  Yes

  No

  N/A

Clean Linen Room

• Area is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues?

  Yes

  No

  N/A

Dirty Linen Room

• Area is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues?

  Yes

  No

  N/A

Secondary/Ambulance Entry

• Area is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues?

  Yes

  No

  N/A

Nursing Station

• Area is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues?

  Yes

  No

  N/A

Common Areas, Patient Care

• Furniture in patient common areas is clean, safe, free from suicide or self-harm risks, and in good condition?

  Yes

  No

  N/A

• Common areas appear clean?

  Yes

  No

  N/A

• Common area is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Posting in common areas are present, including patient rights and unit schedule? There are cues to alert clients of date and time?

  Yes

  No

  N/A

• Sound reducing ceiling fixtures are free from damage?

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness in common areas?

  Yes

  No

  N/A

Servery

• Servery is locked?

  Yes

  No

  N/A

• Servery is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Are there boxed gloves available?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to servery?

Laundry

• Laundry Room is locked at time of inspection?

  Yes

  No

  N/A

• Laundry area is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to laundry room?

  Yes

  No

  N/A
Group Rooms

• Group room number

• Furniture is in good condition and free from suicide or self-harm risks?

  Yes

  No

  N/A

• Group room is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness in group room?

  Yes

  No

  N/A
Patient Rooms

• Room Number

• Furniture is in good condition and free from suicide or self-harm risks?

  Yes

  No

  N/A

• Overall the room is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Bathroom in client room is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to patient room?

  Yes

  No

  N/A
Common Bathrooms

• Room number of bathroom

• Bathrooms are clean and free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to patient bathroom areas?

  Yes

  No

  N/A
Patient Outdoor Areas

• Identify Wing

• Area is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Free from holes/hives/nests or other damage related to pests?

  Yes

  No

  N/A

• Entry ways are free from tripping hazards and maintained according to season?

  Yes

  No

  N/A

• Fences/retaining walls are in good condition and free from suicide or self-harm risks?

  Yes

  No

  N/A

• Gutters and downspouts are in good condition and free from suicide or self-harm risks?

  Yes

  No

  N/A

• Locks present and in good condition and free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional issues related to compliance, safety, security, or cleanliness?

  Yes

  No

  N/A

Consult Room

• Furniture is in good condition and free from suicide or self-harm risks?

  Yes

  No

  N/A

• Overall the room is free from suicide or self-harm risks?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns?

  Yes

  No

  N/A

Additional Areas

• Areas deemed as "secure" are locked upon inspection? (Examples: Medication closets, bathrooms, utility closets, janitor closets, etc.)

  Yes

  No

  N/A

• Entry and exits are clear at time of inspection? If no, note what is blocking area and where it's located.

  Yes

  No

  N/A

• Exit signs are in working order?

  Yes

  No

  N/A

• Stairwells are clear of all items, nothing is stored within stairwell or under stairs? If no, detail what is being stored under stairwell.

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness issues related to the general areas?

  Yes

  No

  N/A