Title Page

  • Site conducted

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

SURVEILLANCE ROUNDS

  • LOCATION/UNIT:

  • WHICH SHIFT

  • DEPT MANAGER/LEADER:

  • INSPECTOR(S):

  • DATE:

SECURITY MANAGEMENT

  • Associates are wearing DHHS identification badges

  • Patient Information is kept private/confidential

  • Are medications properly secured in the Medication Room

SAFETY MANAGEMENT

  • Floor surfaces are uncompromised (not wet, no cracks/gaps or trip hazards)

  • Corridors unobstructed (equipment "IN USE" stored on one side only)

  • Emergency Exits are unobstructed (not blocked, clear of obstacles)

  • Exit signs are posted and lit

  • Storage areas appropriately utilized

  • Patient refrigerator / freezer temperature monitoring log compliant

  • Items are not stored directly on the floor (at least 6" off the floor)

  • There were no expired supplies found in supplies and medication room

  • Emergency eye wash station are inspected weekly In Triage

  • Emergency eye wash station are inspected weekly In ER

  • No broken, defective or nonfunctional equipment/furniture found

  • Emergency Lighting is operational.

Crash Cart

  • Portable suction present x2 on each crash cart

  • Crash Cart Log Daily checks are documented, defibrillator is tested

  • Cardiac Monitors have all attachments

Review of ER Proper

  • Associates know where to find eye wash station and how to operate it

  • Hand Hygiene compliance observed

  • Portable oxygen tanks are clearly marked and segregated EMPTY or FULL

  • Containers/spray bottles are labeled accordingly (i.e. legible, expiration date)

  • Sharps containers are not over filled, needles are below the full line

  • Nurse call button, code button operational. Test conducted

  • Dinamap fully functional (Triage )

  • Nursing station clean and free of clutter

Cubicles Review

  • Each cubicle had alaris pump

  • All Cardiac Monitors are functional with all attachments

  • Each Cubicle has Pediatric facemask (2)

  • Each Cubicle has Pediatric NC (2)

  • Each Cubicle has Pediatric Nebulizer

  • Each Cubicle has Adult Facemask

  • Each Cubicle has an Adult NRFM

  • Each Cubicle has an Adult NC

  • Each Cubicle has Disposable gowns, sheets, blue pads

  • Cubicle 6 have vaginal speculum(s)

  • Each cubicle has a suction device setup

  • Each cubicle has sterile gloves 2 pairs in each size

Urinary Catheter Observations

  • Is the catheter properly secured to the patient?

  • Is there unobstructed flow from the catheter into the bag?

  • Is the collection bag below the level of the bladder?

  • Are the bag and tubing off of the floor?

Falls Risk Observation

  • Is Fall risk arm band on patient

  • is the patient bed in lowest position

  • is the stretcher locked

  • Is the Side rails in upright position

  • Is the patient Call bell within reach

  • Fall risk assessment completed

  • Evidence of Purposeful rounding for 4 P's (Pain, Position, Personal Space, Potty)

HAPI/CAPI Risk Observation

  • Braden Assessment completed

  • Photos taken on admission

  • Frequent diaper checks done

  • If a CAPI is present, are family members updated and documented?

Restraints Observation

  • Physican order present in Meditech system

  • Order contains type of restrains to be used

  • Behaviour/reason for restraint is documented

  • Date and time restraints initiated documented

  • Who applied the restraint(s) is documented

  • Location of restraints is documented

  • Restraints status is documented every two hours

  • Sign of injury is documented

  • Can two finger breath fit under the restraints

  • Is restraints secured on the immovable part of the stretcher

  • Restraint flow sheet documented

  • Evidence of Q30 minutes documentation of patient observations

  • Explanation for restraints documented

OVERALL SCORE:

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.