Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Mat-Su Regional Medical Center

  • Physical Environment & Infection Control Rounds - Clinical Areas

  • EC.04.01.01.14.a

  • Select date

  • Department being surveyed:

  • Surveyed By:

  • Surveyed By:

PATIENT SAFETY MANAGEMENT

  • Are corridors kept clear to allow adequate space for:

  • A) Patients, visitors and staff to walk safely?

  • B) Carts, wheelchairs, equipment and beds to pass with

  • C) Are floors clear and slip-resistant finishes in place?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

FIRE SAFETY MANAGEMENT

  • Are the means of egress corridors/exit doors:

  • A) Clearly and correctly marked for EXIT, including when fire doors are closed?

  • B) Are lights in exit signs functional?

  • C) Clear of any obstructions/equipment?

  • D) Are exterior patios, if in the exit passageway marked & EXIT & and free of obstructions?

  • E) In secured units, locked doors in the means of egress can readily be unlocked by staff at all times (e.g. keys carried by staff, pin-code or badge access)?

  • F) Are there CO2 fire extinguisher in place for use in Cath-Lab?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are all fire extinguishers:

  • A) Clearly marked for identification and installed at correct height (maximum of sixty inches)?

  • B) Inspection tags current? (monthly and annual)

  • C) Safety seals intact and in place?

  • D) Accessible, with three foot clearance in all directions?

  • E) Within seventy five feet in any direction in the area? (main corridors only)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are the fire alarm pull stations:

  • A) Accessible, with three foot clearance in all directions?

  • B) In good condition, free from tampering and glass bar in place where applicable?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are combustible materials: cardboard, boxes, paper, linen, wastes)

  • A) Stored in proper containers? (32 gallons or less)

  • B) Kept to a minimum for daily use in department? (no over flowing containers)

  • C) Properly labeled and identified?

  • D) Are alcohol-based hand rubs properly mounted from electrical devices? (6 inch's from the center)

  • E) Kept in a safe and acceptable location?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Compressed gases and trash/linen chutes:

  • A) Are there less than 12 E-tanks (300 cu ft., oxygen) stored in the smoke compartment in storage?

  • B) Where compressed gas storage exceeds 300 cu ft., is there a designated, protected storage room?

  • C) Full and empty O2 cylinders in storage are segregated? (full and empty)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Fire Building Systems, components and Safety Practices:

  • A) Are all doors free from being propped, wedged or held open in any way?

  • B) Are all doorways clear to close properly?

  • C) Do patient/resident room doors latch when closed?

  • D) Do fire and stairwell doors latch positively and maintain closure?

  • E) Are all doors physically in good condition to prevent the spread of smoke or fire?

  • F) Is the area free from portable heaters and heating devices? (No heaters in the hospital per CHS)

  • G) Are rooms used as patient sleeping rooms free of deadbolt locks?

  • H) Is the area free from any evidence of smoking in the area?

  • I) Are furnishing and decorations fire-rated?

  • J) Is there at least 18 inchs; clearance between storage and sprinkler heads?

  • K) Are escutcheons in place on sprinkler heads and are they clean and free of debris?

  • L) Do patient privacy curtains have at least an 18 inch's; mesh top?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

SAFETY MANAGEMENT

  • Are the floors in hallways:

  • A) In good physical condition?

  • B) Clean and dry?

  • C) Free from trip/fall hazards?

  • D) Wet floor signs used properly?

  • E) Carpet free of wrinkles or tears?

  • F) Free from obstruction? ( wires/cords etc.)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are the walls:

  • A) Painted and in good physical condition? (Free of holes or water damage)

  • B) Free from exposed wiring of any kind?

  • C) Are electrical covers/plates in place and in good condition?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are ceiling tiles:

  • A) In place and in good condition?

  • B) Free of dirt, mold, dust and stains?

  • C) Free from evidence of water stains?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

INFECTION CONTROL & RISK MANAGEMENT

  • Infection Control Practices:

  • A) Are all sharps containers less than 2/3 full?

  • B) Is clean linen kept covered?

  • C) Is the clean linen physically separated from the dirty linen?

  • D) Are all medications dated and labeled?

  • E) Any outdated medication/supplies found?

  • F) Are refrigerators labeled to identify - Patient; Staff; Medication; use?

  • G) Are all patient foods dated and labeled?

  • H) Are current refrigerator temperature logs in place and readily available?

  • I) Are cardboard boxes off the floor, with no corrugated shipping containers present?

  • J) Is there evidence of BLOOD BORNE PATHOGEN PRECAUTION procedures in place? (gloves, masks, gowns, separation of waste, etc.)

  • K) Is personal protective equipment readily available for use?

  • L) Are the cabinets under the sinks free from storage of clean supplies/equipment?

  • M) Are all sharps storage areas kept locked at all times?

  • N) Have all product recalls been corrected by department?

  • O) Are floors, fixtures and equipment in clean condition?

  • P) Are patient rooms and bathrooms clean and suitable for patient care?

  • Q) Are emergency showers and eye washes tested?

  • R) Are current temperature logs in place; readily available on all blanket warmers? Are temperatures within range for blanket warmers (?130) and fluid warmers (?110)?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

HAZARDOUS MATERIAL AND WASTE MANAGEMENT

  • Hazardous chemicals used in the area:

  • A) Are janitor closets and other rooms with chemicals secured and stored correctly? (flammables, corrosives, etc.)

  • B) Labeled correctly?

  • C) Disposed of correctly? (Are there procedures for disposal?)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • MSDS Manual in the Area:

  • A) Are the department inventory (online) & updated within the past 12 months?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Medical Waste:

  • A) Stored in properly labeled bags and containers?

  • B) Properly stored and disposed of?

  • C) Stored and segregated appropriately?

  • D) Are bio-hazardous waste bulk storage areas secured, except to essential personnel?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

MEDICAL EQUIPMENT MANAGEMENT

  • A) Are the inspection tags current with date of next inspection?

  • B) Is clean equipment identified and stored properly?

  • C) Are crash carts or carts with sharps and meds locked?

  • E) Are crash cart logs documented consistently?

  • F) Are medical equipment consumables (defib, pads, etc.) within expiration dates?

  • G) List two (2) equipment inventory tag numbers and verify that equipment information is correct and inspections are current.

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

UTILITY MANAGEMENT

  • Are emergency power outlets:

  • A) Clearly marked by red covers and outlets?

  • B) Being used for critical equipment only?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Electrical panels and devices:

  • A) Are breakers in distribution panels labeled?

  • B) Are mechanical/electrical rooms or exposed distribution panels kept locked, except to essential personnel?

  • C) Are all covers free from damage and securely in place?

  • D) Are waiting rooms provided with tamper-resistant outlets?

  • E) In the area free of extension cords and multi plug-in outlet strips? (Patient care area only)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Are medical gas zone and main valves:

  • A) Marked to identify the area served?

  • B) Are the valves accessible for immediate access? And not blocked?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

SECURITY MANAGEMENT

  • SECURITY

  • A) Are all employees wearing identification badges in plain view?

  • B) Are all computer rooms locked?

  • C) Are all computers that re not in use - logged out?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

EMERGENCY MANAGEMENT

  • EOP

  • A) Is the department emergency lighting box locked? (Clinical areas only)

  • B) Are the Emergency Procedures flip charts easily accessible? (Red Flip charts)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

HAZARDOUS AREAS - (LS 19.3.5.4)

  • Soiled Utility Rooms and Storage Rooms > than 50 Square Feet

  • A) Clean, neat and orderly?

  • B) Items stored greater than 18 inches from fire sprinklers, unless fixed shelving against the wall?

  • C) Rooms are constructed as hazardous areas (i.e. 1 hour fire rated or smoke resistive and sprinklered)?

  • D) Do doors to Hazardous Areas have automatic closers?

  • E) Do doors to corridors and rated rooms positively latch?

  • Deficiency

  • Responsible Person for Addressing Deficiency:

STAFF QUESTIONS: 1 (Must Interview a minimum of one staff member)

  • Staff Member Job Title:

  • FIRE SAFETY MANAGEMENT

  • A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate)

  • B) How do you alert everyone that there is a fire? (Dial 6999 and have the operator announce "Code Red" and the location - or Pull a fire alarm box)

  • C) If a building evacuation is announced, what would you do? (Should know their departments staging area. (Nursing Department s Only)

  • SAFETY MANAGEMENT

  • A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)

  • B) What equipment should employees wear while caring for T.B. patients? (N95 Mask or Orange Duck Bill)

  • C) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. Examples like PPE)

  • D) Do you know where to find a current copy of the EOC/Safety manual online? ( On the Intranet Home page. Click on the EOC/Safety Manual Link)<br> EOC Safety Manual link

  • HAZARDOUS MATERIALS & WASTE:

  • A) What is a MSDS for? (Safety Precautions, hazards, and PPE to be used)

  • B) Can staff explain how to obtain MSDS information? (MSDS Sheets link on the Intranet Home Page)

  • D) Can staff explain what the Code is for a large HazMat spill? (Code Orange)

  • MEDICAL EQUIPMENT:

  • A) If a piece of medical equipment fails on a patient, you should? (Clinical Departments only) (Call your supervisor, remove it from service, keep all items like disposables, place a out of service slip on it, submit an event report to Risk Management if failed on a patient and send to Biomed)

  • B) Can staff describe how they know if equipment if safe for use? ( Look at the Biomed service sticker and note the date.)

  • C) Can staff explain emergency procedures for life-support equipment? (Describe what they should do for various life support equipment failures.)

  • UTILITIES:

  • A) Can staff describe who is authorized to shut off medical gases in the event of an emergency? (Resp. Therapy & Charge Nurse)

  • SECURITY:

  • A) Can staff explain the procedure to get help in the event of a security emergency (Code Silver)? (Dial 6999 & Code Silver called with a location)

  • B) Can staff explain their role to get help with an uncontrollable person? (Dial 6999 & call a Code Strong)

  • C) Can staff explain where to go and what to do when a Code Pink is called? ( Should know what exit their department is assigned to cover during a Code Pink. )

  • EMERGENCY MANAGEMENT:

  • A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)

  • B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

STAFF QUESTIONS: 2 (Must Interview a minimum of one staff member)

  • Staff Member Job Title:

  • FIRE SAFETY MANAGEMENT

  • A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate)

  • B) How do you alert everyone that there is a fire? (Dial 6999 and have the operator announce "Code Red" and the location - or Pull a fire alarm box)

  • C) If a building evacuation is announced, what would you do? (Should know their departments staging area. (Nursing Department s Only)

  • SAFETY MANAGEMENT

  • A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)

  • B) What equipment should employees wear while caring for T.B. patients? (N95 Mask or Orange Duck Bill)

  • C) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. Examples like PPE)

  • D) Do you know where to find a current copy of the EOC/Safety manual online? ( On the Intranet Home page. Click on the EOC/Safety Manual Link)<br> EOC Safety Manual link

  • HAZARDOUS MATERIALS & WASTE:

  • A) What is a MSDS for? (Safety Precautions, hazards, and PPE to be used)

  • B) Can staff explain how to obtain MSDS information? (MSDS Sheets link on the Intranet Home Page)

  • D) Can staff explain what the Code is for a large HazMat spill? (Code Orange)

  • MEDICAL EQUIPMENT:

  • A) If a piece of medical equipment fails on a patient, you should? (Clinical Departments only) (Call your supervisor, remove it from service, keep all items like disposables, place a out of service slip on it, submit an event report to Risk Management if failed on a patient and send to Biomed)

  • B) Can staff describe how they know if equipment if safe for use? ( Look at the Biomed service sticker and note the date.)

  • C) Can staff explain emergency procedures for life-support equipment? (Describe what they should do for various life support equipment failures.)

  • UTILITIES:

  • A) Can staff describe who is authorized to shut off medical gases in the event of an emergency? (Resp. Therapy & Charge Nurse)

  • SECURITY:

  • A) Can staff explain the procedure to get help in the event of a security emergency (Code Silver)? (Dial 6999 & Code Silver called with a location)

  • B) Can staff explain their role to get help with an uncontrollable person? (Dial 6999 & call a Code Strong)

  • C) Can staff explain where to go and what to do when a Code Pink is called? ( Should know what exit their department is assigned to cover during a Code Pink. )

  • EMERGENCY MANAGEMENT:

  • A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)

  • B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)

  • Deficiency

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

  • Comments/Observations

  • Responsible Person for Addressing Deficiency:

  • Date Corrected:

SIGN OFF

  • Department Director or Representative:

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  • Lead Surveyor:

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