Environmental Rounds

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Physical Environment

• Are ceiling tiles free of damage?

  Yes

  No

  N/A

• Is the area free of slip, trip, or fall hazards?

  Yes

  No

  N/A

• Are extension cords being used?<br>

  Yes

  No

  N/A

• Are electrical panels (in public access) closed and locked?

  Yes

  No

  N/A

• Are electrical outlets free of damaged?

  Yes

  No

  N/A

• Are appliances clean?

  Yes

  No

  N/A

• Is the area free of exposed electrical wires?

  Yes

  No

  N/A

• Are visitor waiting areas free of damage (chairs, tables, etc)?

  Yes

  No

  N/A

• Are electrical appliances and/or cords located away from water sources?

  Yes

  No

  N/A

• Comments:

Fire Safety & Egress

• Are fire extinguishers unobstructed?

  Yes

  No

  N/A

• Are pull stations unobstructed?

  Yes

  No

  N/A

• Is the area free from portable heaters?

  Yes

  No

  N/A

• Do fire doors operate correctly?

  Yes

  No

  N/A

• Are sprinklers heads free from damage?

  Yes

  No

  N/A

• Are exit signs illuminated?

  Yes

  No

  N/A

• Are hallways clear of clutter? Allowable carts include: crash, chemo, isolation

  Yes

  No

  N/A

• Do exit doors open in the path of egress?

  Yes

  No

  N/A

• Are evacuation routes accurate?

  Yes

  No

  N/A

• Are stairs free from hazards? (railings secured, moisture free)

  Yes

  No

  N/A

• Are exits free from obstructions?

  Yes

  No

  N/A

• Are storage areas compliant with the 18" rule? (except against walls- can go to ceiling but not within 4" of sprinkler head)

  Yes

  No

  N/A

• Are storage areas accessible and orderly?

  Yes

  No

  N/A

• Are supplies stored off the floor to facilitate cleaning?

  Yes

  No

  N/A

• Comments:

Patient Safety

• Does medical equipment have an accurate TriMedx sticker?

  Yes

  No

  N/A

• Are oxygen cylinders stored in a clean, dry location, separate from other flammable or combustible chemicals/materials?

  Yes

  No

  N/A

• Are oxygen cylinders transported in a manner to prevent them from falling?

  Yes

  No

  N/A

• Are medical gas shut off valves properly labeled? (label on pipe or behind pipe on wall, not on outside cover or wall)

  Yes

  No

  N/A

• Are medical gas valves accessible?

  Yes

  No

  N/A

• Are sharps containers less than full capacity?

  Yes

  No

  N/A

• Are hazardous containers appropriately labeled?

  Yes

  No

  N/A

• Are hazardous rooms, employee only rooms, etc, labeled so patients or visitors do not enter?

  Yes

  No

  N/A

• Are dirty and clean linens stored properly?

  Yes

  No

  N/A

• Comments:

Team Member Questions

• Do staff members know how to access MSDS

  Yes

  No

  N/A

• Do staff members know evacuation routes?

  Yes

  No

  N/A

• Do staff members know how to report occupational injuries?

  Yes

  No

  N/A

• Do staff members know how to report adverse events?

  Yes

  No

  N/A

• Do staff members know reporting procedures for broken or malfunctioning equipment?

  Yes

  No

  N/A

• Do staff members know their role during a Code Red?

  Yes

  No

  N/A

• Do staff members know their role during a Code Black?

  Yes

  No

  N/A

• Do staff members know their role during a Code Green and Code Silver?

  Yes

  No

  N/A