Title Page
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Client / Site
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Conducted on (Date and Time)
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Inspected by
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Location
Environmental Safety
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Spills cleaned up immediately
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Keep floors clutter/obstacle-free (with attention to the path between bed and bathroom/commode)
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Decrease shine on floors
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Level floors (no step up or down into shower, bathroom, no area rugs)
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Even colored floor
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Handrails are distinctly different color from walls
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Handrails and transfer poles are clear for use
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Secure lacks on beds, stretchers, and wheelchairs
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Furniture secured to the floor or moved so there is a clear path around it
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Chair/bench placed strategically in hallways to provide a rest area for person’s with limited endurance
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Remove excess equipment/supplies/furniture from room
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Secure excess electrical and telephone wires
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Secure safety around the bed environment (use of transfer poles, transfer assist rails)
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Place call light and frequently used objects within patient reach
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Assure adequate lighting, especially at night
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Bathrooms are large enough to bring in wheelchairs and walking aids
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Adaptive equipment in bathrooms (vertical, horizontal, diagonal grab bars near toilet and shower; raised toilet seat or commode; rubber-backed bath mat; shower seat; hand-held showerhead)
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Sink, toilet, soap and paper towel holder at low enough level to reach from wheelchair or standing
Patient Safety
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Orient patients to surroundings, including bathroom, use of bed, and location of call light
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Encourage patients/families to call for assistance when needed
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Use properly fining nonskid footwear
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Assure ambulation as ordered
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Evaluate the patient's ability to interpret information
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Evaluate potential medication side effects
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Keep assistive devices at bedside within reach
Assess and assist the patient in the following daily routine (schedule):
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Assess mobility and gait as necessary
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Assess mental status, cognition, and ability to perform activities of daily living (ADL)
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Assess medications daily
Completion
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Inspector's Full Name and Signature
