Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Corridors
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Egress routes are clear. There is no corridor clutter. Any items stored in hall are on one side.
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Carts or other wheeled equipment in corridor are in use.
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Area is clean and there is no visible dust, including vents.
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Bill of Rights is present and current.
Life Safety
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Sprinklers are free of dust.
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All electrical panels and medical gas panels are free from obstructions.<br>
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All electrical closets are locked.
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Fire doors are not propped open, no visible wedge or door prop is evident.
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All fire equipment including extinguishers, pull stations, and fire hoses are free from obstruction.
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Fire extinguishers have been inspected within the month.
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Power strips and cords are mounted on wall or side of desk at least 12 inches above floor.
Glucometers
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Glucometer is clean, no evidence of blood.
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Controls are labeled with open and expiration dates, and are not expired.
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Strips are labeled with open and expiration dates, and are not expired.
Crash Cart
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Emergency equipment logs are complete.
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Only current month's log is kept on cart. 12 months supply should be available to surveyors upon request.
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Crash cart and emergency equipment are locked with all lock numbers documented on emergency cart checklist.
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Defibrillator pads are unopened and not expired.
Warmers
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Blanket warmer is set with a range of 109.4 to 130 degrees F. No IV fluids are being warmed in the blanket warmer.
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Fluid warmer is set with a range of 96.8 to 104 degrees F. All IV fluids in the warmer are dated and timed not to exceed 14 days.
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Contrast warmer is set with a range of 86-89 degrees F. Contrast is labeled with a 30 day expiration date once placed in the warmer.
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A calibrated internal thermometer is present in the warming device, even if there is a mounted thermometer.
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Minimum, maximum, and actual temperatures are recorded daily. Minimum and maximum temperatures are recorded for any days that unit is closed.
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Any temperature recorded out of range is recorded on the log with a second validating temperature taken within 30 minutes. "Action taken" needs to filled out accordingly. Clinical Engineering should be contacted if temp remains out of range with second check.
Clean Utility
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Linens are covered.
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All carts/shelving/storage have a solid bottom.
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Area under sink is clear of any items.
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All patient care supplies are placed on palette or shelving, not directly on floor.
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Fluids are stored on the bottom shelf.
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Sprinklers are unobstructed, allowing 18 inches of clearance below the sprinkler head.
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No dirty supplies are stored in the clean utility room.
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Shipping boxes are not present.
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Sample of supplies are not expired.
Oxygen
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Oxygen tanks are stored in an appropriate handle with no more than 12 E cylinders in a rooms, or 1 H and 2 E cylinders.
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Full and partial cylinders are stored per protocol.
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Oxygen storage areas are labeled with precautionary signs indication oxidizing gas storage.
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All oxygen tanks outside of the normal storage area are secured correctly. Tanks should never be stored flat and they should be in a designated holder.
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Per policy, expiration tag (small white sticker on gas tank) is present and checked prior to use.
Nutrition Room
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If not Honeywelled, temperature logs are completed daily. Action is documented if out of range.
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All hospital issued food and open juice in the refrigerator are labeled and dated.
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Refrigerated food brought in by patient family is labeled with patient name, room number, and date. It expires in 48 hours, unless it is in an unexpired sealed manufacturer's container.
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Refrigerator is clean and in working order.
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No stored food items are expired (Ensure, formula, etc.)
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Area under sink is clear from any items.
Dirty Utility
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No clean items are stored in the dirty utility.
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No food or drink is stored in the dirty utility.
Medication Room
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Medications are not expired.
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Medications are in correct patient drawers.
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Supplies are not expired.
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Insulin is stored according to policy.
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Multidose vials are initialed and labeled to expire in 28 days, unless the manufacturer expiration date is sooner. This is indicated, if it is the case.
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Multidose vials and bottles are not brought into patient rooms. The syringe or cup is prepared in the med room, and a supplied bar code is placed on the cup or syringe.
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Pill cutters are without residue.
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Silent Knights are clean.
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Sharps container is not overflowing.
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Nothing is stored under the sink.
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Needles are kept secured unless storage area is monitored by licensed personnel, or area has high traffic.
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Those who have access to the medication room have received training on medication security.
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Patient own medications are stored per protocol.<br>Meds not for administration will be stored in the controlled substance room in pharmacy.<br>Meds for administration will be examined by the pharmacist, bar coded and placed in the unit pyxis. If the unit does not have a pyxis, meds will be stored in an appropriate secured location.
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Medication rooms and medications are secured, anesthesia and medication carts auto lock.
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Medication fridge is Honeywelled, or temps are monitored and logged, as required. Action is documented if out of range.
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The medication fridge is clean.
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Staff can speak to how they dispose of hazardous pharmaceutical waste.
Clean Patient Room
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Room is clean.
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Room is free of dust.
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Nothing remains from prior patient.
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Sharps container is not overflowing.
Eye wash Station
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Water is tepid.
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Only one step is required to operate the eye wash station.
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Eye wash is not blocked.
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Eye was log is complete.
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Eye wash log has only one month's checks present.
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Miscellaneous
EVC
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Carts are not left unattended.
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No food or drink is present in the cart.
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Secondary containers have been labeled with the name of the cleaning solution that they are holding.
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Bucket with wipes is closed.
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Hand hygiene practices are followed.
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Staff is able to verbalize the use of appropriate cleaning solutions.
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EVC staff is able to speak to contact time.
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Staff can speak to their cleaning process.
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Staff can speak to mop bucket and mop head procedures.
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Staff can verbalize what to do in the event of an eye splash.
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Staff can verbalize how to find information on chemicals (SDS sheets).
Infection Control
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Staff can speak to the process for cleaning/disinfecting equipment between patients.
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Clean, sterile, and dirty items are not stored together.
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Staff can speak to how clean items and equipment are stored versus dirty items and equipment.
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Isolation precautions are followed and PPE is available for isolation rooms.
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Isolation signage is present, as appropriate.
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Parents and visitors adhere to isolation precautions.
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3 observations of hand washing demonstrate compliance. Nurses with C. Diff patients use soap and water.
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Cotton balls and gauze pads are packaged, rather than open, in glucometers and supply carts.
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Cleaning wipe containers are closed.
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Staff can speak to contact time for cleaning products used on unit.
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Biohazard labels are present on items that contain bio-hazardous material, including specimen refrigerators.
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Biohazard bags are not used to store clean supplies.
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Tape residue is not present.
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Furniture/walls/ceiling tiles are in good repair.
Staff Interviews/Observations
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RN administers medication per policy. <br><br>5 rights (patient, medications, time, dose, route), 2 patient identifiers, and allergies are all verified and reviewed in addition to the bar coding process.<br>Orders are reviewed.<br>Medication retrieved from med room is kept in its original packaging. <br>Med expiration date is checked.<br>Multidose medications are prepared in the med room, and syringe or cup are labeled with bar code.<br>Meds are brought to the patient room.<br>Patient identity is confirmed using patient's first and last name and date of birth or medical record number,<br>The wrist band and med are scanned. This is done to supplement the original check, not to replace it.<br>The nurse checks the eMAR for allergies/warnings/alerts once the patient and med have been scanned.<br>Medication is given, if appropriate.
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Breast milk is stored, retrieved, and administered using the 5 rights and 2 patient identifiers.
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Staff can speak to PI and QI projects on unit.
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Staff member can access SDS sheets.
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Staff can speak to the process for broken equipment.
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Alarm response time is acceptable.
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Patient information is secured; computer screens are exited, report sheets are not visible.
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A staff member can access emergency and disaster references.
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Staff can demonstrate the process for checking the current license of the ordering provider.
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Staff can speak to the safety process for patients with same or similar names.
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For relevant units (L&D, Postpartum, NICU, peds), staff can speak to infant abduction drills and processes.
Miscellaneous
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Preventative maintenance tags are present and not expired on equipment.
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Staff are able to describe and show proof of lead apron inspection process.
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Miscellaneous
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Miscellaneous
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Miscellaneous
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Miscellaneous
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Miscellaneous
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Miscellaneous
