Title Page

  • Conducted on

  • Prepared by

  • Location

  • Handrails free of damage

  • Light fixtures clean, fire of trash, dust, rust

  • Room Graphics free of damage

  • Lamps in light fixtures in working order

  • All exit lights in working order

  • Sinks free of leaks, rust and damage

  • Toilets free of leaks, rust and damage

  • Tubs and showers are free of leaks, rust and damage

  • Wall are free of damage

  • Walls are free of unused picture hooks and screws

  • Pictures and frames are free of damage and do not have glass covers

  • Patient Room Foot Walls have protection up to 4 ft to prevent bed, cart and cart damage

  • Furniture is free of damage

  • Cabinets, closets, countertops are free of damage, cracks, chips

  • Flooring is free of damage

  • Baseboard is free of damage

  • Door hardware latches and is free of damage

  • Doors are free of damage

  • HVAC grills are free of damage, water and rust

  • Electrical device cover plates are free of damage

  • Electrical cover plates match the device color

  • Electrical outlets are Hospital grade (green dot identifier)

  • Electrical outlets at sink are GCFI

  • Ice machine is plugged into a GFCI receptacle

  • Electrical Panels are locked (except in Operating Rooms)

  • All plug strips are UL1363A

  • All UL1363A strips are secured to the wall

  • UL1363A strips are not daisy chained

  • Electrical Panels are not blocked

  • Med Gas panels are not blocked

  • Nurse Call pull cords are no more than 5’ from floor

  • Smoke doors are not blocked

  • Fire Alarm devices are not blocked

  • Fire Extinguishers are not blocked

  • Fire Extinguishers are inspected in current month (every 30 days)

  • Fire Extinguishers have 3D signage

  • Fire Extinguishers are free of glass covers (must be plastic)

  • Alcohol Based Hand Rub (ABHR) Gel is not over an electrical outlet, within 6” horizontal of an electrical outlet or within 4 ft. Of another ABHR dispenser

  • Smoke detectors are seated to ceiling tile with no more than 1/8” gap

  • Smoke doors are labeled and latch freely

  • EVS closet is locked

  • EVS closet is negative pressure

  • EVS closet is free of hand written door code on wall

  • Clean Supply and Soiled Utility Room doors are labeled and latch freely

  • Clean Supply room pressure is positive

  • Soiled Utility room is negative pressure

  • Electrical, Mechanical, IT, supply, utility and storage rooms are free of non-rated wood

  • Electrical, Mechanical, IT, supply, utility and storage rooms are free of Cardboard on floor

  • Electrical, Mechanical, IT, supply, utility and storage rooms are free of Wood pallets

  • Ceiling tiles are tightly fitted to ceiling grid - no more than 1/8” gap

  • Ceiling tiles are tightly fitted to all ceiling devices - no more than 1/8” gap

  • Ceiling tiles are free of damage, cracks, chips, stains

  • Beds have a current inspection sticker on bed frame

  • Beds are free of damage

  • Windows are “locked”

  • Window lock keys are at the nurse station or Pyxis station

  • Windows are free of damage, cracks, water

  • Windows blinds are free of damage

  • Medication refrigerator is locked

  • Eye Wash station is inspected weekly

  • Eye Wash station is free of damage

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.