Environmental Rounds Checklist - Surgical Areas

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

PATIENT SAFETY

• Are egress corridors kept clear. And passageways

  Yes

  No

  N/A

• In suites managed to allow adequate save for:

  Yes

  No

  N/A

• Patients and staff to walk safely?

  Yes

  No

  N/A

• Are floors clear and slip resistant finishes in place?

  Yes

  No

  N/A

• Carts, wheelchairs, equipment and beds to pass with adequate clearance?

  Yes

  No

  N/A

Are medications and sharps secured and locked?

• Are medications and sharps secured and locked?

  Yes

  No

  N/A

• Are medication rooms and anesthesia carts locked when unattended?

  Yes

  No

  N/A

• Are needles and syringes locked when not attended?

  Yes

  No

  N/A

FIRE SAFETY

Are the means of egress corridors/exit doors:

• Clearly and correctly marked for EXIT, including when fire doors are closed?

  Yes

  No

  N/A

• Are exit signs functional

  Yes

  No

  N/A

• Are egress corridors and exits clear of any obstructions/equipment?

  Safe

  At Risk

  N/A

• In secure units, locked doors in the means of egress can be readily unlocked by staff at all times (e.g. Keys carried by staff, pin code or badge access

  Yes

  No

  N/A

Are fire extinguishers:

• Clearly marked for identification and installed at correct height (maximum of sixty inches)?

  Yes

  No

  N/A

• Are CO2 fire extinguishers in place for use in operating rooms?

  Yes

  No

  N/A

• Inspection tags current and safety seals in place?

  Yes

  No

  N/A

• Accessible with three foot clearances in all direction?

  Yes

  No

  N/A

• Within seventy five feet in any direction in the area?

  Yes

  No

  N/A

Are the fire pull stations:

• Accessible, with three foot clearance in all directions?

  Yes

  No

  N/A

• In good condition, free from tampering and glass bar in place where applicable?

  Yes

  No

  N/A

Are combustible materials:

• Stored in proper containers (32 gallons or less)

  Yes

  No

  N/A

• Kept to a minimum for daily use in department?

  Yes

  No

  N/A

• Properly labeled and identified?

  Yes

  No

  N/A

• Are alcohol-based hand rubs properly mounted from electrical devices?

  Yes

  No

  N/A

Compressed gases and trash/linen chutes:

• Are there less than12 E- tanks (300 cu. ft. Oxygen) stored in the smoke compartment?

  Yes

  No

  N/A

• Where compressed gas storage exceeds 300 cu. ft., is there a designated, protected storage room?

  Yes

  No

  N/A

• Full and empty O2 cylinders in storage are segregated and labeled?

  Yes

  No

  N/A

• Are all permanently out of service dumb waiters sealed?

  Yes

  No

  N/A

• Are all dumbwaiters that are in use kept locked at all times?

  Yes

  No

  N/A

• Are all linen/trash chutes kept locked at all times?

  Yes

  No

  N/A

• Are all linen/trash chutes sprinkled?

  Yes

  No

  N/A

• Transferring of liquid oxygen prohibited?

  Yes

  No

  N/A

• Are vertical shafts (HVAC, dumb waiter, linen, trash), properly rated and maintained?

  Yes

  No

  N/A

Fire Building Systems, components and Safety Practices

• Are all doors free from being propped, wedged or held open in any way?

  Yes

  No

  N/A

• Are all doorways clear to close properly?

  Yes

  No

  N/A

• Are fire doors labeled properly and free of paint?

  Yes

  No

  N/A

• Do fire and stairwell doors latch positively and maintain closure?

  Yes

  No

  N/A

• Are stairwells free of storage and penetrations?

  Yes

  No

  N/A

• Do door coordinators function properly where installed?

  Yes

  No

  N/A

• Are all doors physically in good condition to prevent the spread of smoke or fire?

  Yes

  No

  N/A

• Are rooms used as patient/resident sleeping rooms free of deadbolt locks?

  Yes

  No

  N/A

• Is there at least 18" clearance between storage and sprinkler heads?

  Yes

  No

  N/A

• Are escutcheons in place on sprinkler heads and are they clean and free of debris?

  Yes

  No

  N/A

• Do patient privacy curtains haven't least an 18" mesh top?

  Yes

  No

  N/A

• Is the area free from portable heaters and heating devices?<br><br><br>

  Yes

  No

  N/A

• Are furnishing and decorations fire rated?

  Yes

  No

  N/A

• Is the area free from any evidence of smoking in the area?

  Yes

  No

  N/A

• Facility to inspect several fire/smoke walls to ensure walls are maintained in accordance with Life Safety<br>.

  Yes

  No

  N/A

SAFE ENVIRONMENT

Are the floors in hallways:

• In good physical condition?

  Yes

  No

  N/A

• Clean and dry?

  Yes

  No

  N/A

• Free from trip/fall hazards?

  Yes

  No

  N/A

• Wet floor signs used properly?

  Yes

  No

  N/A

• Carpet free of wrinkles or tears?

  Yes

  No

  N/A

• Free from obstruction (wires/cords etc)?

  Yes

  No

  N/A

• Is the flooring in operating/procedure rooms free of tears, nicks, or gouges that may prevent proper disinfecting of the floor?

  Yes

  No

  N/A

Are the walls:

• Painted and in good physical condition? (Free of holes or water damage)

  Yes

  No

  N/A

• Clean and free of splatters and stains?

  Yes

  No

  N/A

• Free from exposed wiring of any kind?

  Yes

  No

  N/A

• Are electrical covers/plates in place and in good condition?

  Yes

  No

  N/A

• Door frames and walls free from chipped paint that may prevent proper disinfecting?

  Yes

  No

  N/A

• Ceramic tile walls free of broken and chipped tiles?

  Yes

  No

  N/A

Are ceiling tiles:

• In place and in good condition?

  Yes

  No

  N/A

• Free of dirt, mold, dust, and stains?

  Yes

  No

  N/A

• Free from evidence of water stains?

  Yes

  No

  N/A

• Intact, no broken, pieced tiles?

  Yes

  No

  N/A

Infection Control Practices

• Are all sharps containers less than 2/3 full?

  Yes

  No

  N/A

• Is clean linen covered?

  Yes

  No

  N/A

• Is the clean linen physically and clearly separated from dirty linen?

  Yes

  No

  N/A

• Are all medications dated and labeled?

  Yes

  No

  N/A

• Any outdated medications /supplies found?

  Yes

  No

  N/A

• Are refrigerators labeled to identify "Patient", "staff" and "medication" use?

  Yes

  No

  N/A

• Are all foods dated and labeled?

  Yes

  No

  N/A

• Are current temperature logs in place and readily available?

  Yes

  No

  N/A

• Are cardboard boxes off the floor, with no corrugated shipping containers present?

  Yes

  No

  N/A

• Is ther evidence of bloodborne pathogen precaution procedures in place? ( gloves, mask, gowns, separation of waste, etc.)

  Yes

  No

  N/A

• Is personal protective equipment readily available for use!

  Yes

  No

  N/A

• Are the cabinets under the sinks free of storage and clean supplies/equipment?

  Yes

  No

  N/A

• Are all sharps storage areas kept locked at all times?

  Yes

  No

  N/A

• Have all product recalls been corrected by department?

  Yes

  No

  N/A

• Are floors, fixtures, and equipment in clean condition?

  Yes

  No

  N/A

• Are patient rooms and bathrooms clean and suitable for patient care?

  Yes

  No

  N/A

• Are emergency showers and eye washes tested?

  Yes

  No

  N/A

HAZARDOUS MATERIAL AND WASTE

• Are janitor closets and other rooms with chemicals secured and stored correctly? (flammables, corrosives, etc)<br><br>

  Yes

  No

  N/A

• Labeled correctly?<br>

  Yes

  No

  N/A

• Disposed of correctly? (Are there procedures for disposal?)

  Yes

  No

  N/A

Material Safety Data Sheets

• Can staff explain how obtain MSDS information?<br>

  Yes

  No

  N/A

• Can staff describe what information is listed on an MSDS sheet?<br>

  Yes

  No

  N/A

• Is there a chemical inventory available?<br>

  Yes

  No

  N/A

• Have the MSDS and inventory been updated within the past 12 months?

  Yes

  No

  N/A

• Does staff know where the master MSDS is located<br>

  Yes

  No

  N/A

Medical waste:

• Stored in properly labeled bags and containers?

  Yes

  No

  N/A

• Properly stored and disposed of?

  Yes

  No

  N/A

• Stored and segregated appropriately?

  Yes

  No

  N/A

• Are bio-hazardous waste bulk storage areas secured, except o essential personnel?<br>

  Yes

  No

  N/A

MEDICAL EQUIPMENT

• Are the inspection tags current with date of next inspection?

  Yes

  No

  N/A

• Can staff describe how they know if equipment is safe for use?

  Yes

  No

  N/A

• Is clean equipment identified and stored properly?

  Yes

  No

  N/A

• Can staff describe training requirements for equipment?

  Yes

  No

  N/A

• Can staff explain emergency procedures for life-support equipment?

  Yes

  No

  N/A

• Are crash cart logs documented consistently?

  Yes

  No

  N/A

• Are medical equipment consumables (defib pads, etc. ) within expiration dates?

  Yes

  No

  N/A

• Are temperatures within range for blanket warmers(<130)?

  Yes

  No

  N/A

• Are temperatures within range for fluid warmers (<110)

  Yes

  No

  N/A

• Are sterilizer records on file for each load?<br>

  Yes

  No

  N/A

• Are Daily Air Removal Tests (DART) performed on sterilizers and do records show compliant test results?

  Yes

  No

  N/A

• Are daily biological tests performed on sterilizers and do records show compliant test results?

  Yes

  No

  N/A

• Are integrator tests on file for each flash load, and do records show compliant test results?

  Yes

  No

  N/A

• Are PM records for sterilizers current and is equipment in good condition?

  Yes

  No

  N/A

• List two (2) equipment inventory tag numbers and verify that equipment information is correct and inspections are currentl?

  Yes

  No

  N/A

UTILITY SYSTEMS

• Clearly Marked by red covers and outlets?

  Yes

  No

  N/A

• Being used for critical equipment only?

  Yes

  No

  N/A

Electrical panels and devices;

• Are breakers in distribution panels labeled?

  Yes

  No

  N/A

• Are mechanical/electrical rooms or exposed distribution panels kept locked, except to essential personnel?

  Yes

  No

  N/A

• Are all covers free from damage and securely in place?

  Yes

  No

  N/A

• Are waiting rooms provided with tamper-resistant outlets?

  Yes

  No

  N/A

• Is the area free of extension cords and multi plug-in outlet strips?

  Yes

  No

  N/A

Are medical gas zone and main valves:

• Marked to identify the area served?

  Yes

  No

  N/A

• Are the valves accessible for immediate access?

  Yes

  No

  N/A

• Can staff describe who is authorized to shut off medical gases in the event of an emergency?

  Yes

  No

  N/A

Are plumbing systems:

• Drains capped? (cysto)

  Yes

  No

  N/A

• Autoclaves free of leaks from supply, drain, or splashing?

  Yes

  No

  N/A

Temperature and humidity

• Is temperature and humidity monitored in each OR and areas where anesthetic gases are administered?

  Yes

  No

  N/A

• Are temperatures maintained between 68 and 73 degrees?

  Yes

  No

  N/A

• Are relative humidity levels maintained between 35 and 60 percent?

  Yes

  No

  N/A

• Have appropriate actions documented when readings are outside of parameters?

  Yes

  No

  N/A

SECURITY

• Are all employees wearing identification badges in plain view?

  Yes

  No

  N/A

• Can staff explain the procedure to get help in the event of a security emergency?

  Yes

  No

  N/A

• Are security measures in place for the OR and can staff explain their role in providing security for patients?

  Yes

  No

  N/A

• Can staff explain their role in a CODE ADAM?

  Yes

  No

  N/A

• Are all roof accesses locked except to essential personnel?

  Yes

  No

  N/A

• Is the OR locked after normal business hours?

  Yes

  No

  N/A

EMERGENCY MANAGEMENT

• Is there a current copy of the EOC/Safety manual available?

  Yes

  No

  N/A

• Can staff explain their role in the various emergency management operations?

  Yes

  No

  N/A

• Is there a copy of the Emergency Operations Plan available?

  Yes

  No

  N/A

HAZARDOUS AREAS - (LS 19.3.5.4)

Are Mechanical Rooms:

• Secure, neat, and orderly?

  Yes

  No

  N/A

• Free of storage?

  Yes

  No

  N/A

• Do all doors have closures?

  Yes

  No

  N/A

• Do all doors positively latch?

  Yes

  No

  N/A

Soiled Utility Rooms and Storage Rooms >50 Square Feet

• Clean, neat, and orderly?

  Yes

  No

  N/A

• items stored greater and 18 inches from fire sprinklers, unless fixed shelving against the wall?

  Yes

  No

  N/A

• Rooms are constructed as hazardous areas (i.e. 1 hour fire rated or smoke resistive and sprinklered)?

  Yes

  No

  N/A

• Do doors to Hazardous Areas have automatic closers?

  Yes

  No

  N/A

• Do doors to corridors and rated rooms positively latch?

  Yes

  No

  N/A

OTHER SAFTEY ISSUES IDENTIFIED?