• Conducted on

  • Prepared by

  • Personnel Conducting inspection

  • Clinical unit performed on:


Engineering issues

  • Lighting is in good condition

  • Light Pull Chord in working condition

  • Plumbing in working condition

  • Ceiling tiles and tbar are clean with no stains, cracks, or missing

  • Paint is in good condition

  • Doors are in working condition including all hinges

  • Bathroom door in working order

  • Shower door in working order

  • Patient Room door in working order

  • All outlets in working order

  • Vents are in working order and are clean of debris and dust

  • Nurse Call working properly?

  • TV working properly in correlation to the Nurse Call System?

  • Are there any holes in the walls?

  • No Penetrations in the corridors or stairwell

  • All fire doors latch and close properly

  • All exit signs are properly working

  • All stairwell passage lights are working properly?

  • Are all means of egress free of obstruction both internal and external?

  • Is flooring in good condition?


Housekeeping Issues

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • Overbed light dust/dirt free

  • Closets are dust/dirt free

  • Call light control dust/dirt free

  • Patient bed rails cleaned

  • TV set dust/dirt free

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean


  • Approval of these rounds are accepted by:

  • Clinical Unit Director/CSM

  • Engineering Representative:

  • EVS Representative:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.