Env. Safety Inspection - Surgery West

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Corridors

• Are corridors free of stored items?

  Yes

  No

  N/A

• Are corridors free of flammable materials?

  Yes

  No

  N/A

• Are evacuation plans current?

  Yes

  No

  N/A

• Are Exit signs properly lit?

  Yes

  No

  N/A

• Do battery-operated emergency lights work properly (if applicable)?

  Yes

  No

  N/A

Stairwells

• Are stairwell doors clear of blocking materials?

  Yes

  No

  N/A

• Is stairwell lighting working properly?

  Yes

  No

  N/A

• Are all stair treads in tact?

  Yes

  No

  N/A

• Is proper exiting signage posted in stairwell?

  Yes

  No

  N/A

• Are stairwells free of storage?

  Yes

  No

  N/A

Anesthesia Work Room

• Are life safety conditions met in this space?

  Yes

  No

  N/A

Equipment Storage/Storage Rooms

• Do items on the floor meet appropriate storage requirements?

  Yes

  No

  N/A

• Are stored items below the 18" ceiling sprinkler plane?

  Yes

  No

  N/A

• Storeroom doors are not held or wedged open?

  Yes

  No

  N/A

• Is the door to the room kept locked when unoccupied?

  Yes

  No

  N/A

• Are sprinkler heads unobstructed?

  Yes

  No

  N/A

PACU

• Are life safety conditions met in these spaces?

  Yes

  No

  N/A

POCU

• Are life safety conditions met in these spaces?

  Yes

  No

  N/A

EVS

• Are EVS carts being left in the corridors?

  Yes

  No

  N/A

• Are EVS closets kept locked?

  Yes

  No

  N/A

• Is EVS equipment stored in appropriate places?

  Yes

  No

  N/A

Fire/Smoke Doors

• Do fire/smoke doors close properly?

  Yes

  No

  N/A

• Are fire/smoke doors free of blocking items on both sides of the doors?

  Yes

  No

  N/A

Electrical/Telephone Rooms

• Is the door to the room locked when not in use?

  Yes

  No

  N/A

• Rooms do not contain inappropriate storage items?

  Yes

  No

  N/A

Medical Gases

• Are the medical gas shutoff valves labeled clearly?

  Yes

  No

  N/A

• Is staff aware of responsibility for shutting off medical gases during an emergency and where gas shutoff valves are located?

  Yes

  No

  N/A

• Are gas shutoff panels clearly accessible?

  Yes

  No

  N/A

• Are all oxygen tanks secured properly?

  Yes

  No

  N/A

Fire Safety

• Do staff know where fire alarm pull stations are located?

  Yes

  No

  N/A

• Are all fire pull stations accessible and do they appear to be in working order?

  Yes

  No

  N/A

• Have fire extinguishers been checked, and the tag marked properly?

  Yes

  No

  N/A

• Are fire sprinkler escutcheon plates all properly in place?

  Yes

  No

  N/A

Surgical Suites

• All flooring is in good condition?

  Yes

  No

  N/A

• Does surgical suite door positively latch?

  Yes

  No

  N/A

• Do electrical outlets appear to be in good condition?

  Yes

  No

  N/A

• Do all room lights work properly?

  Yes

  No

  N/A

Sub-Sterile Alcove

• Is flooring in alcove in good condition?

  Yes

  No

  N/A

Signage

• Are all rooms clearly labeled to assist emergency response personnel?

  Yes

  No

  N/A

Linen/Utility Rooms

• Linens and pillows are not on the floor?

  Yes

  No

  N/A

• Are items stored on the floor appropriately?

  Yes

  No

  N/A

• Is room storage below the 18" ceiling sprinkler restriction?

  Yes

  No

  N/A

• Is the door to the room kept closed appropriately?

  Yes

  No

  N/A

• Are doors to utility rooms unblocked?

  Yes

  No

  N/A

Male Locker Room

• Are life safety conditions met in this space?

  Yes

  No

  N/A

Female Locker Room

• Are life safety conditions met in this space?

  Yes

  No

  N/A

Miscellaneous

• Extension cords are not in use?

  Yes

  No

  N/A

• No paper signs are posted in the area?

  Yes

  No

  N/A

• All cabling is dressed appropriately under work surfaces?

  Yes

  No

  N/A

General Comments

• Are life safety conditions1 met?

  Yes

  No

  N/A

• Are life safety conditions2 met?

  Yes

  No

  N/A

• Are life safety conditions3 met?

  Yes

  No

  N/A

• Are life safety conditions4 met?

  Yes

  No

  N/A

• Are life safety conditions5 met?

  Yes

  No

  N/A

• Are life safety conditions6 met?

  Yes

  No

  N/A

• Are life safety conditions7 met?

  Yes

  No

  N/A

• Are life safety conditions8 met?

  Yes

  No

  N/A