Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • 551 Hill Country Drive Kerrville, Texas 78028
  • Auditor


  • Are exit doors and stairwells unobstructed ( Main corridors, hallways, passageways, and stairwell exits). Exits cannot be blocked at anytime. (Rating 1)

  • Do exit doors and exit areas have illuminated exit signs clearly depicting direction of exit? ( Rating 2)

  • Do fire doors latch properly? ( Close double fire doors to see if they latch properly ( gap between doors must be less than 1/8 of an inch).

  • Are pull stations and fire extinguishers unobstructed—access to pull stations and fire extinguishers must be clear.

  • Are fire doors to supply, storage rooms etc propped or held open? Fire doors are not to be propped or held open. If Staff member is in the area working open door is ok but must be closed once the Staff member leaves the area.

  • Are all materials stored no less than 18 inches from sprinkler deflectors?

  • Are storage rooms and equipment rooms free of clutter and unsafe conditions? This is a judgement call—want to ensure items are not overstocked and falling off shelves etc...

  • Is there any evidence of smoking?

  • Is there unauthorized heat producing equipment in the area ( heaters , toasters w/ out three pronged plug to ground the equipment.

  • If applicable, is Eye Wash Station inspected weekly? Is inspection documented?

  • Are floors and hallways in good condition?

  • Are walls in need of repair or paint?

  • Are cables and wires exposed in work areas?

  • Are ceiling tiles clean, stain free and in good condition.?

  • Are there any expired medications?

  • Are there any expired medical supplies?

  • Are heavy items stored at low levels or mid level—want to ensure heavy items are stored at mid and low levels.

  • Are general areas clean and free of clutter?

  • Are Medical Gas valves unobstructed?

  • Are compressed gases stored properly? Are compressed gases secure in a holder? Compressed gases must be in a holder or chained to the wall or on a cart—free standing cylinders are not allowed.

  • Is monthly Safety Training being conducted and recorded? Check documentation of Safety Training.

  • Are gloves, gowns, eye ware and masks readily available?

  • Are there separation of clean and dirty items

  • Are single use item left out for re-use

  • Are supplies stored in bathrooms or soiled utility rooms?

  • Are supplies stored on the floor?

  • Are supplies stored no less than 6 inches from the floor.?

  • Is high level dusting performed?

  • Are sinks clean.

  • Is clean linen covered?

  • Is clean linen kept separate from dirty linen disposal?

  • Are refrigerator ( patient and medication) logs maintained and up to date ? <br><br>Temps for meds and specimens 36-46 degrees. Ensure there are separate refrigerators for medications, specimens and food/ drink.

  • Are medications and food kept in separate refrigerators?

  • Are sharps RMW containers under 2/3rds full.

  • Are employees eating or drinking in designated areas? Staff should not have food/drink in patient care areas.

  • Are cleaning supply’s the only supplies under the sinks? Cleaning supplies are the only type supplies authorized under sinks.


  • Are RMW and other Hazardous Waste Containers covered?

  • Are secondary chemical containers labeled with product name and hazard label? Document any chemical that is in a container other than the original container.

  • Are waste containers clean, operational—in good condition?

  • Are chemicals stored separate from food and other clean items.

  • Does the department have the SDS available—SDS is available on Peterson Health Intranet and in back-up copy in the departments SDS Inventory Binder.


  • Are Staff personal items properly secured? ( Check for purses, billfolds, money, keys etc.)

  • Are all employees wearing ID Badges in plain view?

  • Are all mechanical, electrical, EVS and communications rooms locked? If not document which are not secure.

  • Are medications kept in secure (locked) cabinet/s, rooms etc...


  • Is Crash Cart current—daily check documented?

  • Is there exposed wires coming from medical equipment or plug outlet area?

  • Are all tags current for medical equipment? ( This is checking for PM’s , calibration etc.)

  • Is equipment clean?


  • Do staff know MRI emergency procedures? Do they know how to perform them?

  • Are there procedures to restrict access to the MRI control room and magnet area (Zone IV)?<br><br>Do staff know procedures ?

  • Are MRI safety procedures in place? ( Patient in-take process, history, screening forms, hearing protection available)

  • Does Radiology Department have MRI training documentation?

  • Is Staff wearing dosimeters?

  • When are dosimeters checked for exposure limits to staff?

  • How is ALARA ( As Low As Reasonably Achievable)assessed?

  • Does Radiology Technologist know how to determine if medical imaging equipment is functioning properly?

  • Who checks medical imaging equipment? How is it checked? When or how often is it checked?

  • What is the process to measure /verify CT radiation output?

  • Do we use patient exam formulas for CT protocols?

  • Who performs verification of CT radiation does index? How often is the measurement and verification performed?

  • What is the process for testing CT, NM, and MRI image acquisition monitors? Who does this and how often is it done?


  • Does Staff know what to do for utility failures? Ensure they know to contact FM and where to find the Work Order system.

  • Are there any two pronged extension cords in the area? ( These are household type extension cords. These must be removed on the spot.)

  • Are telephone cords a fall or trip hazard? Are the cords out of the way from foot traffic that would generate wear and tear and possible cause a cord to be pulled out of the wall?

  • Are all mechanical, electrical, EVS and communications rooms clean and free of storage items?


  • Staff know Plain Language for Emergencies?

  • Staff know what a Code Blue is?

  • Staff member can describe the EOC Committee? Staff know Peterson Health has an EOC Committee?

  • Do Staff members know how to report defective equipment—medical or utility?

  • Are Staff knowledgeable on who is authorized to turn off Oxygen cut off valves? The Charge Nurse or Nurse Supervisor is authorized to turn off Oxygen valves.

  • Do staff know where the oxygen cut off valves are located?

  • Do Staff members know how to get SDS via the intranet? Do Staff know where SDS back-up book is?

  • Were there any other Safety issues found?

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