Title Page
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Site conducted
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Site conducted
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Conducted on
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Prepared by
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Location
SURVEILLANCE ROUNDS
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LOCATION/UNIT:
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WHICH SHIFT
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DEPT MANAGER/LEADER:
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INSPECTOR(S):
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DATE:
SECURITY MANAGEMENT
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Associates are wearing DHHS identification badges
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Patient Information is kept private/confidential
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Are medications properly secured in the Medication Room
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SAFETY MANAGEMENT
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Floor surfaces are uncompromised (not wet, no cracks/gaps or trip hazards)
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Corridors unobstructed (equipment "IN USE" stored on one side only)
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Emergency Exits are unobstructed (not blocked, clear of obstacles)
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Exit signs are posted and lit
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Storage areas appropriately utilized
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Patient refrigerator / freezer temperature monitoring log compliant
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Items are not stored directly on the floor (at least 6" off the floor)
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There were no expired supplies found in supplies and medication room
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Emergency eye wash station are inspected weekly In Triage
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Emergency eye wash station are inspected weekly In ER
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No broken, defective or nonfunctional equipment/furniture found
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Emergency Lighting is operational.
Crash Cart
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Portable suction present x2 on each crash cart
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Crash Cart Log Daily checks are documented, defibrillator is tested
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Cardiac Monitors have all attachments
Review of ER Proper
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Associates know where to find eye wash station and how to operate it
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Hand Hygiene compliance observed
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Portable oxygen tanks are clearly marked and segregated EMPTY or FULL
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Containers/spray bottles are labeled accordingly (i.e. legible, expiration date)
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Sharps containers are not over filled, needles are below the full line
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Nurse call button, code button operational. Test conducted
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Dinamap fully functional (Triage )
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Nursing station clean and free of clutter
Cubicles Review
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Each cubicle had alaris pump
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All Cardiac Monitors are functional with all attachments
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Each Cubicle has Pediatric facemask (2)
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Each Cubicle has Pediatric NC (2)
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Each Cubicle has Pediatric Nebulizer
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Each Cubicle has Adult Facemask
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Each Cubicle has an Adult NRFM
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Each Cubicle has an Adult NC
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Each Cubicle has Disposable gowns, sheets, blue pads
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Cubicle 6 have vaginal speculum(s)
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Each cubicle has a suction device setup
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Each cubicle has sterile gloves 2 pairs in each size
Urinary Catheter Observations
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Is the catheter properly secured to the patient?
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Is there unobstructed flow from the catheter into the bag?
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Is the collection bag below the level of the bladder?
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Are the bag and tubing off of the floor?
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Falls Risk Observation
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Is Fall risk arm band on patient
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is the patient bed in lowest position
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is the stretcher locked
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Is the Side rails in upright position
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Is the patient Call bell within reach
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Fall risk assessment completed
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Evidence of Purposeful rounding for 4 P's (Pain, Position, Personal Space, Potty)
HAPI/CAPI Risk Observation
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Braden Assessment completed
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Photos taken on admission
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Frequent diaper checks done
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If a CAPI is present, are family members updated and documented?
Restraints Observation
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Physican order present in Meditech system
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Order contains type of restrains to be used
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Behaviour/reason for restraint is documented
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Date and time restraints initiated documented
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Who applied the restraint(s) is documented
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Location of restraints is documented
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Restraints status is documented every two hours
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Sign of injury is documented
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Can two finger breath fit under the restraints
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Is restraints secured on the immovable part of the stretcher
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Restraint flow sheet documented
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Evidence of Q30 minutes documentation of patient observations
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Explanation for restraints documented
