Audit

Mat-Su Regional Medical Center

Physical Environment & Infection Control Rounds - Clinical Areas

EC.04.01.01.14.a

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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)
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)
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

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Date Corrected:

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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.