Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
ENVIRONMENT OF CARE
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No items stored under sinks?
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Equipment / Furniture:<br> * No broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips or repairs needed.
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Hazardous chemicals and flammable agents are labeled and stored properly.
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Eyewash stations: not expired.
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Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)
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Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.
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Fluid warmers: Set to maintain temp of 104. Necessary logs completed including actions taken to out of range temperature readings.
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Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.
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No outer shipping carton boxes in patient care areas.
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No expired items.
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Preventative Maintenance:<br> * Equipment checked with up to date bio-med sticker.
EMERGENCY PREPAREDNESS
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Can staff locate medical gas zone shutoff valves.
INFORMATION MANAGEMENT
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Confidential Patient Information:<br>Cannot be overheard or seen by unauthorized persons:<br> * Computer terminals signed off when not in use.<br> * Patient information is not discussed in public areas.<br> * Labels and PHI are obliterated before discarding in the trash.
LIFE SAFETY
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Appropriate storage of boxes and pt care items:<br> * Not directly on floor.<br> * 18" clearance from sprinkler head.<br> * Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping.<br> * Volume of combustible material is not stored in large quantity as to create a fire hazard.
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Oxygen or other combustible compressed gas cylinders are stored properly:<br> * Secured in floor stand, carrier or secured to the wall by a mount. (not laying on the floor or against wall)<br> * Limited to 12 E-cylinders per smoke compartment.<br> * Limited to 4 large cylinders.
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Fire exits and hallways are cleared:<br> * Egress corridors must have 8ft clearance.<br> * Equipment in corridors must be actively accessed to be in use.
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Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.
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Fire extinguishers have been inspected monthly.
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Fire doors are not blocked or propped and when closed there is positive latching.
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Exit signs are illuminated.
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Evacuation route posted & current.
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Everyone has ID badges and worn appropriately:<br> * Staff and Visitors
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Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.
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Floors, ceilings, walls, and other surfaces intact and free from holes.
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Nurse call lights working (if applicable).
STANDARD PERFORMANCE IMPROVEMENT
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Are units quality improvement dashboards posted on unit.
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Is unit's PI project data posted.
PROVISION OF CARE TREATMENT AND SERVICES
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Are there any alarms sounding that staff is not attending to in a timely manner.
INFECTION PREVENTION
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Food and drink in designated areas:<br> * None in patient care areas or procedure areas.
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Hand Hygiene Products:<br> * No empty alcohol gel bottles<br> * No empty soap or paper towels<br> * No unapproved lotions
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PPE:<br> * Readily available<br> * Clearly marked<br> * Worn correctly<br>
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Patient food & drinks: No expired items.
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Biohazard Waste:<br> * Discard in Red Bags with a biohazard symbol<br> * Not overfilled<br> <br>
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Soiled Linen: Properly stored and not overfilled.
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Separation of clean vs. dirty supplies & equipment.
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Patient care supplies:<br> * Not expired, damaged, soiled.
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Linen and Linen Carts: Covered and carts have solid bottoms.
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Sharps Waste:<br> * Placed in puncture resistant sharps container.<br> * Disposed of when 3/4 full or "full" indicator<br> * Mounted appropriately
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General Cleanliness:<br> * Observe surfaces for high dust & residue -floors, med prep areas, pt rooms & bathrooms<br> * No blood or bodily fluids
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Air vents: Clean
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All items in PT care area that are not disposable are able to be wiped down.
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Curtains, drapes clean.
MEDICATION MANAGEMENT
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Medication areas are clean and uncluttered.
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Area free of distractions.
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Medication is appropriately labeled.<br> * Expiration dates, directions, etc..
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All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.
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Controlled substances stored to prevent diversion.
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Medications & solutions not beyond expiration date.
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Opened multi-dose vials dated with today's date and initialed. Exceptions: vaccinations, PPD, and insulin.
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Code Carts:<br> * Locked and marked with then first drug to expire.<br> * Checked per policy.<br> * Include defibrillator check.<br> * Cart is clean.<br> * O2 tank is >1/2 full
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Syringes are labeled when in use.
WAIVED TESTING / POINT OF CARE TESTING
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Point of Care testing control solution labeled & dated.
DESCRIBE THE UNITS RESPONSE TO YOUR ARRIVAL
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Greet the team with smiles and introductions.
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Promptly deliver materials required for review to the tracer team.
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Any additional comments regarding positive or suboptimal issues observed during the tracer.
