Title Page
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Conducted on
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Prepared by
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Location
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Handrails free of damage
- Yes
- No
- N/A
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Light fixtures clean, fire of trash, dust, rust
- Yes
- No
- N/A
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Room Graphics free of damage
- Yes
- No
- N/A
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Lamps in light fixtures in working order
- Yes
- No
- N/A
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All exit lights in working order
- Yes
- No
- N/A
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Sinks free of leaks, rust and damage
- Yes
- No
- N/A
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Toilets free of leaks, rust and damage
- Yes
- No
- N/A
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Tubs and showers are free of leaks, rust and damage
- Yes
- No
- N/A
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Wall are free of damage
- Yes
- No
- N/A
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Walls are free of unused picture hooks and screws
- Yes
- No
- N/A
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Pictures and frames are free of damage and do not have glass covers
- Yes
- No
- N/A
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Patient Room Foot Walls have protection up to 4 ft to prevent bed, cart and cart damage
- Yes
- No
- N/A
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Furniture is free of damage
- Yes
- No
- N/A
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Cabinets, closets, countertops are free of damage, cracks, chips
- Yes
- No
- N/A
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Flooring is free of damage
- Yes
- No
- N/A
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Baseboard is free of damage
- Yes
- No
- N/A
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Door hardware latches and is free of damage
- Yes
- No
- N/A
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Doors are free of damage
- Yes
- No
- N/A
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HVAC grills are free of damage, water and rust
- Yes
- No
- N/A
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Electrical device cover plates are free of damage
- Yes
- No
- N/A
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Electrical cover plates match the device color
- Yes
- No
- N/A
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Electrical outlets are Hospital grade (green dot identifier)
- Yes
- No
- N/A
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Electrical outlets at sink are GCFI
- Yes
- No
- N/A
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Ice machine is plugged into a GFCI receptacle
- Yes
- No
- N/A
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Electrical Panels are locked (except in Operating Rooms)
- Yes
- No
- N/A
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All plug strips are UL1363A
- Yes
- No
- N/A
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All UL1363A strips are secured to the wall
- Yes
- No
- N/A
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UL1363A strips are not daisy chained
- Yes
- No
- N/A
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Electrical Panels are not blocked
- Yes
- No
- N/A
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Med Gas panels are not blocked
- Yes
- No
- N/A
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Nurse Call pull cords are no more than 5’ from floor
- Yes
- No
- N/A
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Smoke doors are not blocked
- Yes
- No
- N/A
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Fire Alarm devices are not blocked
- Yes
- No
- N/A
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Fire Extinguishers are not blocked
- Yes
- No
- N/A
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Fire Extinguishers are inspected in current month (every 30 days)
- Yes
- No
- N/A
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Fire Extinguishers have 3D signage
- Yes
- No
- N/A
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Fire Extinguishers are free of glass covers (must be plastic)
- Yes
- No
- N/A
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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
- Yes
- No
- N/A
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Smoke detectors are seated to ceiling tile with no more than 1/8” gap
- Yes
- No
- N/A
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Smoke doors are labeled and latch freely
- Yes
- No
- N/A
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EVS closet is locked
- Yes
- No
- N/A
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EVS closet is negative pressure
- Yes
- No
- N/A
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EVS closet is free of hand written door code on wall
- Yes
- No
- N/A
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Clean Supply and Soiled Utility Room doors are labeled and latch freely
- Yes
- No
- N/A
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Clean Supply room pressure is positive
- Yes
- No
- N/A
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Soiled Utility room is negative pressure
- Yes
- No
- N/A
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Electrical, Mechanical, IT, supply, utility and storage rooms are free of non-rated wood
- Yes
- No
- N/A
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Electrical, Mechanical, IT, supply, utility and storage rooms are free of Cardboard on floor
- Yes
- No
- N/A
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Electrical, Mechanical, IT, supply, utility and storage rooms are free of Wood pallets
- Yes
- No
- N/A
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Ceiling tiles are tightly fitted to ceiling grid - no more than 1/8” gap
- Yes
- No
- N/A
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Ceiling tiles are tightly fitted to all ceiling devices - no more than 1/8” gap
- Yes
- No
- N/A
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Ceiling tiles are free of damage, cracks, chips, stains
- Yes
- No
- N/A
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Beds have a current inspection sticker on bed frame
- Yes
- No
- N/A
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Beds are free of damage
- Yes
- No
- N/A
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Windows are “locked”
- Yes
- No
- N/A
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Window lock keys are at the nurse station or Pyxis station
- Yes
- No
- N/A
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Windows are free of damage, cracks, water
- Yes
- No
- N/A
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Windows blinds are free of damage
- Yes
- No
- N/A
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Medication refrigerator is locked
- Yes
- No
- N/A
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Eye Wash station is inspected weekly
- Yes
- No
- N/A
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Eye Wash station is free of damage
- Yes
- No
- N/A
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