Life Safety (Departments are responsible for corrective actions.)

Fire exits are clear from obstructions.

Hallways are clear.

Fire alarm pull stations are not blocked.

Fire extinguishers are not blocked.

Electrical panels are not blocked. (Nothing within the yellow taped areas)

Sprinklers have 18 inch clearance.

Toasters are not located near combustibles.

Multi-outlet strips are not plugged into other multi-outlet strips.

Extension cords are not used. (unless approve by Facilities) (this excludes multi-outlet strips)

Safety (Departments are responsible for corrective actions.)

Gas cylinders are stored in proper holders. (Single dollies are for in-use cylinders)

Floors are free of boxes and articles being stored.

Ladders & stools are solid & equipped w/ non-skid feet.

Emergency pull cords are free hanging and accessible. (Within 4 inches of the floor)

Cords & tubings are not obstructing walkways.

Hazardous Materials and Waste (Departments are responsible for corrective actions.)

Hazardous substance containers are properly labeled.

Medical waste is bagged appropriately at point of origin & at point of collection.

Sharps containers are secured, contain only sharps waste, emptied when 3/4 full. (No recapped needles)

Flammable materials are properly stored.

Waste is disposed in the appropriate containers.

Staff Knowledge (Departments are responsible for corrective actions.)

Location of manuals (Disaster, Safety, Infection Control) known by staff.

Location of MSDS known by staff.

Location of flashlights known by staff.

Staff know how to unlock Pt. bathroom doors.

Infection Control - (Departments are responsible for corrective actions.)

Linen carts (primary and secondary carts) and supplies are appropriately covered. The bottom shelves are solid

Storage areas are clean and uncluttered. Sterile/supplies should be 12 inches from the floor. Storage supplies are covered, as appropriate to area.

Sterile supplies/medications are current (not outdated) upon random survey.

Syringes and needles are secured (locked).

Use of needle-less and sharps protective devices are used appropriately.

IV tubing dated and changed every 96 hours.

Head of Bed (HOB) up signs are posted above beds of patients with tube feedings. HOB up to 30 degrees for patients with ventilator or tube feedings.

Appropriate isolation precaution signs are posted.

Staff are observed using appropriate infection control measures/techniques. (Hand washing, PPE, spill clean up)

There is no staff/physician food or drink in nurses station, where specimens are placed, or patient care areas.

Food brought in for patients by others is covered, labeled, and dated.

Nourishment refrigerator or freezer temperatures are checked daily and logged. Interventions are noted when out of range.

Nourishment refrigerator?s freezers are regularly defrosted.

Medications are not stored in patient nourishment refrigerators.

Medication refrigerator or freezer temperatures are checked daily and logged. Interventions are noted when out of range.

Medications are secured or locked with access by unauthorized persons prohibited.

Multi-dose vials will be discarded 28 days from date of opening or per product manufacturer recommendation for discarding, if less than 28 days.

Graduates/sanipans are labeled with the patient?s name.

Personal hand lotions are not observed in the work areas.

Patient Rooms: Under sink storage is free from hazardous materials and clean/sterile items.

Additional Comments / Findings (Departments are responsible for corrective actions.)

Dept. Notes:

Facilities (Items in this section will be corrected by the Facilities dept.)

Doors latch properly & smoke seal is in good condition.

Exit signs are illuminated.

Fire escutcheons are in place & fit properly.

Fire extinguishers have current inspection date.

Linen & trash chute doors latch & fire links are in place.

Ceilings are in good repair, free of loose tiles.

Lighting - corridors & work areas are properly illuminated.

Walls free of damage. Fire walls free of penetrations.

Floors are in good repair (No loose tiles or carpet damage).

Cords, Plugs & Switches in good repair.

Toasters & microwaves have attended while in-use signs.

Construction areas have ILSM (Interim Life Safety Measures) in place.

Equipment PM labels are current. (Next due date can be determined)

Equipment & appliances in patient care vicinity (6 foot radius) are double insulated or are equipped with a grounded plug.

Facilities Dept: Additional Comments / Findings

Environmental Services (Items in this section will be corrected by the Environmental Services dept.)

Bio-medical waste containers are labeled on all sides

Trash cans are not overflowing.

Lights & vents are free of dust.

Ledges & walls are clean & free of dust.

Floors & kick plates are clean & unsoiled.

Furniture is clean & orderly.

Ice machines are clean.

Blinds & Privacy curtains are clean & work properly

Sinks areas are clean.

Bathrooms are clean & odor free.

Adequate paper supplies are available.

EVS Dept: Additional Comments / Findings

Attendee Signature (if available)
Auditor Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.