Title Page
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Location
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Conducted on
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Prepared by
Life Safety
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Are exit doors. corridors, and stairwells clear?
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Are fire doors closed and not able to be propped open?
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Are pull stations, fire extinguishers, and fire doors unobstructed?
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Corridor sprinkler heads clean and not missing escutcheons or have gaps around escutcheons?
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Are eyewash stations and showers inspections documented weekly?
Clean Utility/Medication Room/Equipment Storage
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All clean supplies stored off of the floor. No outside cardboard. Nothing stored under sinks
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Does the equipment's cleanliness, paint, wiring, and covers appear satisfactory?
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No equipment or beds stored in hallway?
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Are supplies within expiration dates. Check drawers for improperly stored items. Glucometer supplies dated with expiration?
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Crash Cart Checks are completed daily? No expired supplies, oxygen tank has >1500 psi, no dust, plugged into red outlet?
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Is there 18 inches or more of open space maintained below the sprinkler deflector to the top of storage?
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Is clean linen covered? No product stored on top of linen cart?
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Clean utility rooms contain only clean/sterile items? Clean equipment is clean and bagged appropriately?
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Are oxygen cylinders stored correctly? Empty and full containers physically separated and labeled? Open cylinders not stored with full? No more than 12 cylinders in a room.
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Are chemicals stored separately from patient contact or other clean items?
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Medications are secured
Clean Space
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Ceilings, walls, lighting is clean and intact? No bugs/debris in overhead lights? All light bulbs are functioning?
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Are walls free from paint or repair needs? All ceiling tiles are clean, no stains or cracks?
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Countertops, Flooring, Trim, and Handrails are clean and undamaged?
Patient Care
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Is "Per Shift Staff Assignments Binder/clipboard" up to date?
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Are nurse call pull cords proper length - 2 to 6 inches from floor, not tied to grab bars, etc?
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Are sharps containers securely mounted and not overfilled?
Nourishment Rooms
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Are patient food refrigerator logs maintained and up-to-date? Are temperatures within range?
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Ice machine is clean?
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No outside food stored in refrigerator? All patient food is labeled with patient name and date to discard?
Positive/Negative Air
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Positive Air Pressure for sterile storage, medication rooms, and other clean/sterile areas.
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Negative Air Pressure for soiled utility, trash, hazardous waste, and other dirty rooms.
Security
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Are all employees wearing their ID badges in plain view?
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Confidential patient information is secure and HIPAA practices are followed
