Cannon Memorial Hospital Safety Inspection

• Department/ Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• QSF-SAF-INS-0001 Rev 1

1.0 - Previous inspection

• 1.1 - Has the last inspection been reviewed?

  Yes

  No

  N/A

• 1.2 - Are there no outstanding actions?

  Yes

  No

  N/A

2.0 - Fire Prevention

• 2.1 - Doors not wedged or propped open?

  Yes

  No

  N/A

• 2.2 - Fire doors are not blocked by carts, equipment, or materials?

  Yes

  No

  N/A

• 2.3 - Extinguishers is not missing damaged, or discharged?

  Yes

  No

  N/A

• 2.3a - Is chalk present for marking doors?

  Yes

  No

  N/A

• Notify Engineering of Deficiency

• 2.4 - Extinguishers has current inspection documentation?

  Yes

  No

  N/A

• 2.5 - Extinguishers clear of obstructions?

  Yes

  No

  N/A

• 2.6 - Sprinkler Heads/Smoke Detectors are clean & intact?

  Yes

  No

  N/A

• 2.7 - Indicator Lights are not obstructed?

  Yes

  No

  N/A

• 2.8 - Fire Exit signs are illuminating and working properly?

  Yes

  No

  N/A

• Notify Engineering

• 2.9 - Fire Doors close and latch properly?

  Yes

  No

  N/A

• 2.10 - Storage is less than 18" from ceiling?

  Yes

  No

  N/A

• 2.11 - Doors to Soiled/Clean/Hazardous Materials Rooms closed?

  Yes

  No

  N/A

• 2.12 - Emergency Exit Corridors / Doors are clear?

  Yes

  No

  N/A

• 2.14 - Flammables, stored appropriately?

  Yes

  No

  N/A

• 2.15 - Penetrations to Walls / Ceilings / Floors, not present?

  Yes

  No

  N/A

• 2.16 - No unauthorized space heaters present?

  Yes

  No

  N/A

• 2.17 - No unauthorized heat producing equipment (toasters, hot plates, etc).

  Yes

  No

  N/A

• 2.18 - Are evacuation routes properly posted (location indicated, oriented properly, etc)?

  Yes

  No

  N/A

• 2.19 Can staff identify the closest fire extinguisher?

  Yes

  No

  N/A

• 2.10 Can staff explain the types of fire extinguishers and their purposes?

  Yes

  No

  N/A

• 2.11 Are emergency evacuation illustrations posted in every room?

  Yes

  No

  N/A

3.0 - Electrical Safety

• 3.1 - Electrical outlets are not damaged or loose?

  Yes

  No

  N/A

• 3.2 - Critical equipment is plugged into Red Outlet?

  Yes

  No

  N/A

• 3.3 - All extension cords are equipped with a ground prong?

  Yes

  No

  N/A

• 3.4 - All switches, receptacles and computer boxes have covers or plates?

  Yes

  No

  N/A

• 3.5 - Electrical panels are accessible - 36" clearance around panels.

  Yes

  No

  N/A

• 3.6 Are electrical appliance inspection stickers up-to-date?

  Yes

  No

  N/A

• Yes

  No

  N/A

• 3.7- Only terminal strips are utilized. No extension cords

  Yes

  No

  N/A

• 3.8 are vapor or explosion proof switches and covers utilized where necessary?

  Yes

  No

  N/A

4.0 - General Safety

• 4.1 - Handrails are attached firmly to the walls?

  Yes

  No

  N/A

• 4.2 - All wheelchairs are in good repair and with both footrest?

  Yes

  No

  N/A

• 4.3 - Storage is at least 6" from the floor. No boxes on the floor?

  Yes

  No

  N/A

• 4.4 - Floors - tiles, carpet in good repair - no trip hazards?

  Yes

  No

  N/A

• 4.5 - Stairwell lights working?

  Yes

  No

  N/A

• 4.6 - Storage Rooms clean and orderly?

  Yes

  No

  N/A

• 4.7 - Are the areas under sinks empty?

  Yes

  No

  N/A

• 4.8 - Step ladders available to reach high places are in good shape?

  Yes

  No

  N/A

• 4.9 - No electrical cords, telephone and computer wires in area that might entangle feet?

  Yes

  No

  N/A

• 4.10 - Desk, chairs, furniture in safe condition?

  Yes

  No

  N/A

• 4.11 - Patient Room furniture in safe condition?

  Yes

  No

  N/A

• 4.12 - No evidence of food, drinks or eating occurring around computers or nurse station?

  Yes

  No

  N/A

• 4.13 - Are documents posted in areas other than bulletin boards laminated?

  Yes

  No

  N/A

• 4.14 - Are refrigerators, coffee makers, and/or microwave ovens properly labeled?

  Yes

  No

  N/A

• 4.14a - Is the Engineering inspection label up-to-date?

  Yes

  No

  N/A

• 4.15 - Are HVAC vents clean?

  Yes

  No

  N/A

• Notify Housekeeping

• 4.16 Can staff explain the definition of a Sentinel Event?

  Yes

  No

  N/A

• A Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury

• 4.17 Do staff know the location of the decon shower?

  Yes

  No

  N/A

• 4.18 Do employees know the location of emergency eyewashes?

  Yes

  No

  N/A

• 4.19 Can staff explain the procedure for cleaning up a blood spill when Environmental Services staff are not available?

  Yes

  No

  N/A

• 4.20 Is a copy of the Emergency Alert Codes posted in an easily accessible location?

  Yes

  No

  N/A

5.0 - Hazardous Material

• 5.1 - Eye wash station inspected weekly and documented?

  Yes

  No

  N/A

• 5.2 - High level disinfectant policy being followed - QC, documentation, etc?

  Yes

  No

  N/A

• 5.3 - Medical gas cylinders are stored where full and empties are separated?

  Yes

  No

  N/A

• 5.4 - Medical gas cylinders are properly secured?

  Yes

  No

  N/A

• 5.5 - Biohazard containers are stored properly?

  Yes

  No

  N/A

• 5.6 - Sharps boxes are no more than 3/4 full; syringe disposed of properly?

  Yes

  No

  N/A

• 5.7 - Staff are able to obtain a MSDS?

  Yes

  No

  N/A

• Demonstrate MSDS Online on PC desktop.

• 5.8 - Secondary container are labeled properly?

  Yes

  No

  N/A

• 5.9 - Hazardous materials properly stored?

  Yes

  No

  N/A

• 5.10 - Are "Oxygen in Use" signs properly displayed?

  Yes

  No

  N/A

• 5.11 Biohazard containers are free of non-biohazard items?

  Yes

  No

  N/A

• 5.12 Can a staff member locate the online MSDS program?

  Yes

  No

  N/A

6.0 - Security Management

• 6.1 - Employee personal items are secured out of sight?

  Yes

  No

  N/A

• 6.2 - Employee I.D. Badges visible and worn properly?

  Yes

  No

  N/A

• 6.3 - Confidential Materal secured /protected?

  Yes

  No

  N/A

• 6.4 - High risk patient's, equipment areas, hazardous material area rooms are secure?

  Yes

  No

  N/A

• 6.5 - Medications secured?

  Yes

  No

  N/A

• 6.6 - Doors with security hardware operate properly?

  Yes

  No

  N/A

• 6.7 - Code carts locked and in view of staff?

  Yes

  No

  N/A

• 6.8 Can control desk personnel verbalize policies for visitor entrance after hours?

  Yes

  No

  N/A

7.0 - Utilities Management

• 7.1 - All lights are operational, no lights out?

  Yes

  No

  N/A

• 7.2 - Ceiling tiles, none discolored,/wet/damaged?

  Yes

  No

  N/A

• 7.3 - HVAC System - Air temperature within condor table range?

  Yes

  No

  N/A

• 7.4 - Plumbing, faucets,, toilets operational (no leaks)?

  Yes

  No

  N/A

• 7.5 - Ice machine clean and maintenance on schedule?

  Yes

  No

  N/A

• 7.6 - Are lights in nearest stairwell operational?

  Yes

  No

  N/A

Department/Area

• Clinical<br>

  Off

  On

• Can staff explain the procedure for taking verbal or telephone orders?

  Yes

  No

  N/A

• Document VORB or TORB for order readback

• Is there a Poison Control Center phone number posted prominently in each department?

  Yes

  No

  N/A

• Are function checks conducted on defibrillators?

  Yes

  No

  N/A

• Are function checks conducted weekly on suction equipment?

  Yes

  No

  N/A

• Are crash carts secured

  Yes

  No

  N/A

• Do wheelchairs have working locks?

  Yes

  No

  N/A

• Do floor scales have wheels? (They should not move when stood upon)

  Yes

  No

  N/A

• Are narcotics kept under dual locks?

  Yes

  No

  N/A

• Do staff utilize 2 forms of identifying patients?

  Yes

  No

  N/A

• Can staff demonstrate the location of PPE to include PAPRs?

  Yes

  No

  N/A

• Are soiled linens placed in leakproof containers and covered?

  Yes

  No

  N/A

• Are counter areas cleaned properly?

  Yes

  No

  N/A

• Operating Room<br>

  Off

  On

• Is traffic control of unauthorized personnel adequate?

  Yes

  No

  N/A

• Are only non-flammable germicides used for preoperative patient preparation?

  Yes

  No

  N/A

• Are table wheels locked?

  Yes

  No

  N/A

• Are dress requirements enforced?

  Yes

  No

  N/A

• Is OR locked when not in use?

  Yes

  No

  N/A

• Is relative humidity maintained at 50% or greater?

  Yes

  No

  N/A

• Can staff explain if a patient with signs/symptoms of TB is scheduled for surgery?

  Yes

  No

  N/A

• If elective, consult surgeon about postponing until TB ruled out.

• Are heated instruments spark restricted in the presence of flammable anesthetics?

  Yes

  No

  N/A

• Laboratory

  Off

  On

• Is there adequate documentation of checks of the laminar flow hood?

  Yes

  No

  N/A

• Is decon shower inspected monthly?

  Yes

  No

  N/A

• Are staff aware of the Chemical Hygiene plan?

  Yes

  No

  N/A

• Are counters cleaned per policy?

  Yes

  No

  N/A

• Is the Decontamination shower inspected monthly and tested annually?

  Yes

  No

  N/A

• Is the shower handle/cord accessible to the shortest staff member in the area?

  Yes

  No

  N/A

• Are specimens contained in leakproof, biohazard labeled containers?

  Yes

  No

  N/A

• Are discarded specimens contained in a leakproof red bag?

  Yes

  No

  N/A

• Radiology

  Off

  On

• Are gloves worn for all patients who are to be administered IV contrast or when patient is to have barium enema?

  Yes

  No

  N/A

• Are women of childbearing age screened for pregnancy?

  Yes

  No

  N/A

• Are med cabinets in Nuclear Medicine locked when unattended?

  Yes

  No

  N/A

• Are rooms with radiation sources properly secured?

  Yes

  No

  N/A

• Are controls arranged to prevent external energizing?

  Yes

  No

  N/A

• Are radiation exposure badges worn by all persons exposed to radiation?

  Yes

  No

  N/A

• Are lead aprons, gowns, or shields worn when necessary?

  Yes

  No

  N/A

• Do nuclear med and x-ray machines maintain a secondary radiation cone and filters?

  Yes

  No

  N/A

• Nuclear Medicine: Are face shields worn when opening and administering medications?

  Yes

  No

  N/A

• Nuclear Medicine: Is there a suitable container to store contaminated items?

  Yes

  No

  N/A

• Is there an emergency code box in close proximity?

  Yes

  No

  N/A

• Are the oxygen and suction analyzed daily and working?

  Yes

  No

  N/A

• Pharmacy

  Off

  On

• Is an antidote list available for easy reference?

  Yes

  No

  N/A

• Are standard reference materials immediately available?

  Yes

  No

  N/A

• Are look-alike/sound-alike medications segregated by label or location?

  Yes

  No

  N/A

• Does the pharmacy remained locked when unattended?

  Yes

  No

  N/A

• Emergency Department

  Off

  On

• Is the Poison Control Antidote Chart visible?

  Yes

  No

  N/A

• Are pediatric crash cart supplies immediately accessible?

  Yes

  No

  N/A

• Can staff demonstrate the use of the security intercom?

  Yes

  No

  N/A

• Critical Care Unit

  Off

  On

• Cardiopulmonary

  Off

  On

• Can staff demonstrate one-handed scoop method for recapping after drawing ABG?

  Yes

  No

  N/A

• Can staff locate the Nitroglycerin tablets in the Stress lab? Are the tablets in date?

  Yes

  No

  N/A

• Non-Clinical

  Off

  On

• Plant Engineering

  Off

  On

• Can staff explain when eye protection is required and where it is stored?

  Yes

  No

  N/A

• Are safe methods used when changing light bulbs and tubes?

  Yes

  No

  N/A

• Are all electrical cords, switches and plugs in good working order?

  Yes

  No

  N/A

• Are flammable liquids stored in safety cans?

  Yes

  No

  N/A

• Are electrical appliances brought in by staff tagged appropriately?

  Yes

  No

  N/A

• Are gas cylinders kept clear of heat sources?

  Yes

  No

  N/A

• Are ladders in good working condition?

  Yes

  No

  N/A

• Environmental Services

  Off

  On

• Is ladder in good working condition?

  Yes

  No

  N/A

• Is clean linen maintained in a covered container?

  Yes

  No

  N/A

• Are patient care areas cleaned according to policy (top to bottom, clean to dirty)?

  Yes

  No

  N/A

• Food Services

  Off

  On

• Are food carts in good working order?

  Yes

  No

  N/A

• Is there physical separation of food from non-food items?

  Yes

  No

  N/A

• Are food prep areas separate from cleaning/sanitizing areas and are they adequate?

  Yes

  No

  N/A

• Is food protected from contamination and spoilage?

  Yes

  No

  N/A

• Are gloves and head coverings worn as appropriate?

  Yes

  No

  N/A

• Are staff members eating or drinking in food prep areas?

  Yes

  No

  N/A

• Are food refrigerator temperatures checked daily?

  Yes

  No

  N/A

• Are scoops with handles properly used and stored?

  Yes

  No

  N/A

• Are acceptable temperature parameters posted?

  Yes

  No

  N/A

• Can staff explain how to test sanitizing chemical concentration?

  Yes

  No

  N/A

• Are cutting boards clean, rinsed, and sanitized prior to use?

  Yes

  No

  N/A

• Are cutting boards constructed of hard maple or other non-toxic material?

  Yes

  No

  N/A

• Are all vent hood filters clean?

  Yes

  No

  N/A

• Control Desk

  Off

  On

• Can staff verbalize visitor policies (after hours)?

  Yes

  No

  N/A

Comments

• Additional Comments

• Surveyor's Signature

  Sign