Information
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Safety
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Physical hazards that would cause slip/trip/fall/puncture/cuts
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Look at stair treads, floor tiles, carpeting, sink areas, ice machine areas, wall fixtures, etc.
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Furnishings in good repair?
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Furniture, wheelchairs, mattresses cannot have holes or tears. Tape not allowed
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Clean items not stored in "Dirty" areas.
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Dirty items not stored in "Clean" areas.
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Grab bars and handrails securely mounted.
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Place a work order to address if an issue is observed.
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Equipment is clean.
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Free of dust, dirt.
Patient Safety
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Dirty linen not overfilled
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Clean linen stored covered
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Appliances for patient food clean. Temp checked. Safety label on toasters, microwaves, refrigerator.
Hazardous Material/Waste
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Hazardous material secure?
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Covers closed on all containers. Dirty utility door locked.
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ESD closets locked at all times. Carts never left unattended.
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Chemicals are stored in ESD closets and on carts. These items should be secured at all times. Carts should not be brought into patient rooms.
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Needle boxes available/secure/not overfilled
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Free standing containers must have cover closed when not in use.
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No evidence of mixed waste streams. Regular trash, Regulated Medical Waste, Sharps should all be in proper receptacles.
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Regular trash in wastebaskets. Regulated Medical Waste in red bags or bins. Sharps (including syringes without needles) once used are immediately disposed of into sharps containers.
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Eye wash stations/showers unobstructed with weekly inspection records.
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Able to easily walk up to or under without having to move anything. Weekly test for 5 seconds or until clear.
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Gas cylinders secured-chained or in holders. No more then 6 full and 6 empty cylinders on one smoke compartment.
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Each nursing unit is its own smoke compartment. Consider other patient care areas as one smoke compartment. O2 tanks with >500 psi in clean utility and <500 in dirty utility.
Fire Safety
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Egress passages and exits are free of obstructions.
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No carts, furniture, etc. are positioned so as to " narrow" the width of a doorway or easy passage through a hallway. "In Use" carts must be moved within 30 minutes.
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Exit signs are illuminated.
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Pull Stations are accessible.
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Nothing on the floor directly in front of pull station.
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Fire Extinguishers accessible and inspection tags up to date.
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Medical Gas Valves and alarm panels labeled and accessible.
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Sprinkler heads not obstructed. 18" (minimum) clearance.
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Escutcheon plates in place. Tight to ceiling with no gaps.
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No gaps or missing plates. No broken ceiling tiles around the plates.
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Doors not propped open.
Biomedical/Electrical Safety
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All medical patient care equipment is labeled and not out of date.
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Does the equipment have a current Bio-Med sticker with a current date? If out of date the PCE must be removed by Bio-Med
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Portable PCE is plugged in to maintain charge.
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Code cart equipment (i.e. defibrillators) are plugged into red electrical outlets when not in use.
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Code cart is checked each day the department is open.
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Ensure supplies are not expired and equipment is working correctly.
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All appliances in patient care areas have initial safety inspection label.
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Electrical panels are locked and unobstructed.
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No extension cords are being used for permanently place equipment.
Security
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All employees are wearing badges and hospital emergency codes. A review is completed with staff.
Infection Control
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No eating or drinking in patient care areas.
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Eating and drinking is only allowed in cafeterias, break rooms, private offices.
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Storage areas are clean and uncluttered.
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No storage on the floor. No supplies overstocked.
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No outdated supplies.
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Check if the department has a system for rotating supplies.
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No storage close around the tops of the sinks. Under sink cabinets contain only cleaning supplies.
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Only cleaning supplies can be stored under sinks. No storage allowed within the slash range of the sink.
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No storage on the floor. (N/A for offices)
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All corrugated shipping cartons are removed from the clean utility/supply room.
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Supplies should be removed from original shipping corrugated container.
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No storage near windows or windowsills. (N/A for offices)
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Hand hygiene product available.
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Hand hygiene dispensers in working condition.
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PPE available as needed.
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Ensure face shields are readily available.
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Isolation rooms appropriate.
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Appropriate signage in place. If airborne precautions, door is closed with negative pressure on and working.
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Disinfection/sterilization handled properly.
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Medication not left out unsupervised.
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Water and/or saline labeled with expiration date.
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No evidence of holes in walls or ceilings.
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Ceiling tiles are intact without evidence of mold, staining, cracks, etc.
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HVAC vents are clean.
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Comments.