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

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