Engineering issues
Lighting is in good condition
In Working Order
Work Order needed
Not Applicable
Light Pull Chord in working condition
In Working Order
Work Order needed
Not Applicable
Plumbing in working condition
In Working Order
Work Order needed
Not Applicable
Ceiling tiles and tbar are clean with no stains, cracks, or missing
In Working Order
Work Order needed
Not Applicable
Paint is in good condition
In Working Order
Work Order needed
Not Applicable
Doors are in working condition including all hinges
In Working Order
Work Order needed
Not Applicable
Bathroom door in working order
In Working Order
Work Order needed
Not Applicable
Shower door in working order
In Working Order
Work Order needed
Not Applicable
Patient Room door in working order
In Working Order
Work Order needed
Not Applicable
All outlets in working order
In Working Order
Work Order needed
Not Applicable
Vents are in working order and are clean of debris and dust
In Working Order
Work Order needed
Not Applicable
Nurse Call working properly?
In Working Order
Work Order needed
Not Applicable
TV working properly in correlation to the Nurse Call System?
In Working Order
Work Order needed
Not Applicable
Are there any holes in the walls?
In Working Order
Work Order needed
Not Applicable
No Penetrations in the corridors or stairwell
In Working Order
Work Order needed
Not Applicable
All fire doors latch and close properly
In Working Order
Work Order needed
Not Applicable
All exit signs are properly working
In Working Order
Work Order needed
Not Applicable
All stairwell passage lights are working properly?
In Working Order
Work Order needed
Not Applicable
Are all means of egress free of obstruction both internal and external?
In Working Order
Work Order needed
Not Applicable
Is flooring in good condition?
In Working Order
Work Order needed
Not Applicable
Housekeeping Issues
Floor dust/dirt free corners/edges
In Working Order
Work Order needed
Not Applicable
Floor under furniture dust/dirt free
In Working Order
Work Order needed
Not Applicable
Walls dust/dirt free including corners
In Working Order
Work Order needed
Not Applicable
Window ledges dust/dirt free
In Working Order
Work Order needed
Not Applicable
Overbed light dust/dirt free
In Working Order
Work Order needed
Not Applicable
Closets are dust/dirt free
In Working Order
Work Order needed
Not Applicable
Call light control dust/dirt free
In Working Order
Work Order needed
Not Applicable
Patient bed rails cleaned
In Working Order
Work Order needed
Not Applicable
TV set dust/dirt free
In Working Order
Work Order needed
Not Applicable
Bedside cabinet clean
In Working Order
Work Order needed
Not Applicable
Over bed table clean
In Working Order
Work Order needed
Not Applicable
Cubicle curtain clean
In Working Order
Work Order needed
Not Applicable
Air vents clean
In Working Order
Work Order needed
Not Applicable
Waste containers clean
In Working Order
Work Order needed
Not Applicable
Room is odor free
In Working Order
Work Order needed
Not Applicable
Restroom floor corners/edges clean
In Working Order
Work Order needed
Not Applicable
Restroom walls dust/dirt free
In Working Order
Work Order needed
Not Applicable
Toilet cleaned including around and on the bottom
In Working Order
Work Order needed
Not Applicable
Sink cleaned including bottom
In Working Order
Work Order needed
Not Applicable
Paper towel dispenser supplied
In Working Order
Work Order needed
Not Applicable
Soap dispenser supplied
In Working Order
Work Order needed
Not Applicable
Toilet paper dispenser filled
In Working Order
Work Order needed
Not Applicable
Hand Sanitizer is in working order and filled
In Working Order
Work Order needed
Not Applicable
Sharp Container is less than 3/4 full and clean
In Working Order
Work Order needed
Not Applicable
Approval of these rounds are accepted by:
Clinical Unit Director/CSM
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Engineering Representative:
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EVS Representative:
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Calvin Fakkema
Clinical rounds - Engineering /EVS
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