Environment of Care Rounds

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Life Safety

• EXIT SIGN CEARLY VISIBLE AND WELL LIT

  Yes

  No

  N/A

• CORRIDORS CLEAR OF DEBRIS, CLUTTER & EQUIPMENT

  Yes

  No

  N/A

• DO PATIENT PRIVACY CURTAINS HAVE 18" NET AT TOP ?

  Yes

  No

  N/A

• No presence of portable heaters

  Yes

  No

  N/A

• FIRE EXTINGUISHERS HAVE CURRENT INSPECTION TAGS

  Yes

  No

  N/A

• FIRE EXTINGUISHERS HAVE SAFETY SEALS IN PLACE

  Yes

  No

  N/A

• FURE EXTINGUISHERS ARE FULLY CHARGED

  Yes

  No

  N/A

• FIRE EXTINGUISHERS ACCESSIBLE WITH 3 FT OF CLEARANCE

  Yes

  No

  N/A

• FIRE DOORS FREE OF BEING PROPPED/ HELD OR WEDGED OPEN

  Yes

  No

  N/A

• FIRE DOORS HAVE 5' OF CLEARANCE

  Yes

  No

  N/A

• DOOR FIRE AND STAIRWELL DOORS LATCH FIRMLY

  Yes

  No

  N/A

• ARE DOOR COORDINATORS WORKING

  Yes

  No

  N/A

• STAIRS IN STAIRWELLS FREE OF STORAGE

  Yes

  No

  N/A

• ARE ITEMS STORED ATLEAST 18" BELOW BOTTOM OF SPRINKLER HEAD

  Yes

  No

  N/A

• IS THERE ANY INDICATION OF SMOKING IN THE AREA

  Yes

  No

  N/A

• ARE HAZARDOUS CHEMICALS LABELED CORRECTLY

  Yes

  No

  N/A

• NO PAPER SIGNS IN CORRIDOR

  Yes

  No

  N/A

• ARE MEDICAL GAS VALVES MARKED WITH IDENTITY AND LOCATION SERVED

  Yes

  No

  N/A

• MEDICAL GAS VALVE IS ACCESSIBLE AND NOT BLOCKED

  Yes

  No

  N/A

• ARE HAZARDOUS MATERIALS (CHEMICALS) STORED PROPERLY

  Yes

  No

  N/A

• ARE GAS CYLINDERS SECURED AND STORED PROPERLY

  Yes

  No

  N/A

• IS THERE LESS THAN 300 cu ft OXYGEN STORED IN A SMOKE COMPARTMENT (12 E-cylinders)

  Yes

  No

  N/A

• IF FORMILIN USED IN UNIT, IS CORRECT SPILL KIT AND NEUTRALIZER AVAILABLE

  Yes

  No

  N/A

• ARE UNIVERSAL WASTE BUKETS DATED PROPERLY

  Yes

  No

  N/A

• ARE UNIVERSAL WASTE BUCKETS OVERFLOWING

  Yes

  No

  N/A

• RCRA RECEPTACLES PRESENT AND BEING USED ACCORDING TO POLICY

  Yes

  No

  N/A

• EYEWASHES ACCESSIBLE, MAINTAINED AND INSPECTED

  Yes

  No

  N/A

• EMERGENCY RECEPTACLES MARKED WITH RED COVERS

  Yes

  No

  N/A

• EMERGENCY RECEPTACLES BEING USED FOR CRITICAL EQUIPMENT

  Yes

  No

  N/A

• ARE ELECTRICAL CIRCUITS LABELED

  Yes

  No

  N/A

• ARE MULTIPLE STRIP OUTLETS HOSPITAL GRADE IN PATIENT AREAS

  Yes

  No

  N/A

• IS EQUIPMENT GROUNDED AS NECESSARY

  Yes

  No

  N/A

• ARE THREE PRONG EXTENSION CORDS BEING USED

  Yes

  No

  N/A

• ARE ALL EMPLOYEES WEARING ID BADGES AND IN PLAIN VIEW

  Yes

  No

  N/A

• ARE PROTECTIVE MEASURES IN SENSITIVE AREAS ACTIVE ( ie access control)

  Yes

  No

  N/A

• COMBINATION CODES TO SECURED AREAS NOT READILY VISIBLE

  Yes

  No

  N/A

• ELECTRICAL BOXES, OUTLET COVERS, DAMAGED OR MISSING

  Yes

  No

  N/A

• 100% AGGREGATE WALL,SPACE NOT BEING USED

  Yes

  No

  N/A

INFECTION CONTROL AND CLINICAL SAFETY

• STRETCHERS WITHOUT SLASHES AND TAPE

  Yes

  No

  N/A

• HAND SANITIZERS NOT MOUNTED OVER AN ELECTRICAL DEVICE

  Yes

  No

  N/A

• MEDICATIONS SECURED AND LOCKED

  Yes

  No

  N/A

• MEDICATION CARTS AND ROOMS LOCKED WHEN NOT ATTENDED TO

  Yes

  No

  N/A

• SYRINGES STORED IN SECURE LOCATION

  Yes

  No

  N/A

• MULTIPLE DOSE VIALS ARE PROPERLY DATED

  Yes

  No

  N/A

• CRASH CARTS SECURED AND LOGS COMPLETED PER POLICY

  Yes

  No

  N/A

• ARE SAFE AND PROPER INFECTION CONTROL PRACTICES IN USE

  Yes

  No

  N/A

• HAND SANITIZERS FILLED

  Yes

  No

  N/A

• SUPPLIES BEING USED WITHIN EXPIRATION DATES

  Yes

  No

  N/A

• ARE NEEDLE BOXES LESS THAN 3/4 FULL

  Yes

  No

  N/A

• ARE NEEDLE BOXES AND SHARPS CONTAINERS COVERED

  Yes

  No

  N/A

• IS CLEAN LINEN COVERED

  Yes

  No

  N/A

• IS THE CLEAN LINEN KEPT SEPARATE FROM DIRTY

  Yes

  No

  N/A

• IS MEDICATION LABELED AND DATED ( no outdated medications)

  Yes

  No

  N/A

• IS THE MEDICATION REFRIGERATOR FREE FROM FOOD

  Yes

  No

  N/A

• DO THE REFRIGERATORS HAVE CURRENT TEMPERATURE LOGS

  Yes

  No

  N/A

• ARE BLOODBORNE PATHOGENS PRECAUTIONS IN EVEIDENCE

  Yes

  No

  N/A

• IS PERSONAL PROTECTIVE EQUIPMENT READILY AVAILABALE

  Yes

  No

  N/A

• ARE CLEAN AND SOILED ITEMS STORED SEPARATELY

  Yes

  No

  N/A

• ARE RED BIOHAZARD BAGS LABELED

  Yes

  No

  N/A

• ARE RED BIOHAZARD CONTAINERS PROPERLY STORED

  Yes

  No

  N/A

• ARE RED BIO HAZARD BAGS AND CONTAINERS SEPARATED AND SEGREGATED

  Yes

  No

  N/A

• CHECK BIOHAZARD RECEPTACLES, ONLY RED BIOHAZARD BAGS ARE IN USE

  Yes

  No

  N/A

• SOILED UTILITY ROOMS SECURED AND LOCKED

  Yes

  No

  N/A

• ARE BIOHAZARD SIGNS ON DOORS WHERE BIOHAZARDS ARE STORED

  Yes

  No

  N/A

• ARE CORRECT BIOHAZARD STICKERS PLACED ON TRASH CANS USED TO STORE BIOHAZARDS

  Yes

  No

  N/A

• NURSES STATION FREE FROM FOOD OR DRINK

  Yes

  No

  N/A

• ARE PATIENT ROOMS NEAT AND PERSONAL ITEMS STORED

  Yes

  No

  N/A

• IS PATIENT PRIVACY AND DIGNITY MAINTAINED

  Yes

  No

  N/A

ENVIRONMENT SAFETY

• FLOORS IN GOOD CONDITION

  Yes

  No

  N/A

• FLOORA CLEAN AND DRY

  Yes

  No

  N/A

• FLOORS FREE FROM TRIPPING, SLIP,RESISTANT AND FREE OF FALL HAZARDS

  Yes

  No

  N/A

• WET FLOOR SIGNS IN USE

  Yes

  No

  N/A

• CARPET LYING FLAT ON FLOOR

  Yes

  No

  N/A

• FLOORS FREE OF WIRES, CABLES AND PHINE CORDS

  Yes

  No

  N/A

• WALLS IN GOOD CONDITION(undamaged, free of holes or water damage)

  Yes

  No

  N/A

• WALLS FREE OF ELECTRICAL HAZARDS

  Yes

  No

  N/A

• RESTROOM CLEAN AND NO ODORS PRESENT

  Yes

  No

  N/A

• RESTROOMS FREE OF MILDEW AND MOLD

  Yes

  No

  N/A

• RESTROOMS FREE OF RUST

  Yes

  No

  N/A

• RESTROOMS FREE OF LEAKING FAUCETS

  Yes

  No

  N/A

• CEILING TILES IN PALCE AND IN GOOD CONDITION

  Yes

  No

  N/A

• CEILINGS FREE OF DIRT, MOLD OR MILDEW

  Yes

  No

  N/A

• LIGHTING IN AREA PROPERLY WORKING

  Yes

  No

  N/A

• CEILING FREE OF EVIDENCE OF WATER STAINS

  Yes

  No

  N/A

• MEDICAL EQUIPMENT HAS CURRENT INSPECTION STICKER

  Yes

  No

  N/A

• MEDICAL EQUIPMENT IS CLEAN AND STORED PROPERLY

  Yes

  No

  N/A

• PORTABLE EQUIPMENT IS IN GOOD CONDITION

  Yes

  No

  N/A

• PORTABLE EQUIPMENT IS CLEAN AND DRY

  Yes

  No

  N/A

• CEILING VENTS CLEAN

  Yes

  No

  N/A

• WINDOWS CLEAN

  Yes

  No

  N/A

• BLINDS AND DRAPES CLEAN

  Yes

  No

  N/A

• HIPPA PRECAUTIONARY MEASURES IN PLACE

  Yes

  No

  N/A

STAFF AWARENESS

• RED

  Yes

  No

  N/A

• BLUE

  Yes

  No

  N/A

• YELLOW

  Yes

  No

  N/A

• TRIAGE

  Yes

  No

  N/A

• GREY

  Yes

  No

  N/A

• AMBER

  Yes

  No

  N/A

• WHITE

  Yes

  No

  N/A

• GREEN

  Yes

  No

  N/A

• ECHO

  Yes

  No

  N/A

• ORANGE

  Yes

  No

  N/A

• CODE 45

  Yes

  No

  N/A

• CAN YOU SHOW ME YOUR DEPARTMENTS EMERGENCY PREPAREDNESS GUIDE

  Yes

  No

  N/A

• WHO SHOULD YOU CONTACT IF THERE IS NO WATER

  Yes

  No

  N/A

• CAN STAFF EXPLAIN OR SHOW HOW TO FIND AN MSDS SHEET

  Yes

  No

  N/A

• CAN STAFF EXPLAIN WHAT IS IN A MSDS SHEET

  Yes

  No

  N/A

• WHO DO YOU REPORT UNSAFE ENVIRONMENTAL CONDITIONS

  Yes

  No

  N/A

• HOW AND WHOM DO YOU REPORT AN INJURY, ILLNESS OR ACCIDENT

  Yes

  No

  N/A

• HOW DO YOU CLEAN UP BLOOD SPILLS

  Yes

  No

  N/A

• CAN YOU ARTICULATE P.A.S.S.

  Yes

  No

  N/A

• CAN YOU ARTICULATE R.A.C.E.

  Yes

  No

  N/A

• WHO CAN SHUT OFF AN OXYGEN VALVE

  Yes

  No

  N/A

• WHO DOES STAFF REPORT TO WHEN CALLED IN FOR CODE TRIAGE

  Yes

  No

  N/A

• HOW DO YOU EVACUATE HORIZONTALLY ? VERTICALLY ?

  Yes

  No

  N/A

• WHAT IS THE MOST COMMON THPE OF FIRE EXTINGUISHER USED IN THE HOSPITAL

  Yes

  No

  N/A

• WHERE IS THE NEAREST FIRE EXTINGUISHER

  Yes

  No

  N/A

• WHERE IS THE NEAREST PULL STATION

  Yes

  No

  N/A

• WHAT NUMBER TO YOU CALL TO REPORT A CODE RED

  Yes

  No

  N/A

• WHERE ARE EVACUATION MAPS POSTED ? ( stairwells, exits and elevator lobbies)

  Yes

  No

  N/A

• WHAT IS A SMOKE COMPARTMENT

  Yes

  No

  N/A

• IN CASE OF FIRE SHOULD YOU USE THE ELEVATOR OR STAIRS

  Yes

  No

  N/A

• CAN STAFF EXPLAIN HOE TO GET HELP IN A SECURITY EMERGENCY

  Yes

  No

  N/A

• CAN STAFF EXPLAIN THEIR ROLE IN CODE AMBER

  Yes

  No

  N/A

• CAN THE EMPLOYEE ARTICULATE THE HOSPITAL SMOKING POLICY

  Yes

  No

  N/A

• CAN STAFF EXPLAIN IF EQUIPMENT IS CURRENT AND SAFE TO USE

  Yes

  No

  N/A

• CAN STAFF EXPLAIN TRAINING REQUIREMENTS FOR EQUIPMENT

  Yes

  No

  N/A

• CAN STAFF EXPLAIN EMERGENCY PROCEDURES FOR LIFE SUPPORT

  Yes

  No

  N/A

• CAN STAFF ARTICULATE GLOBAL HARMONIZED SYSTEM (GHS)

  Yes

  No

  N/A