Title Page

  • Location

  • Conducted on

  • Prepared by

Life Safety

  • Are exit doors. corridors, and stairwells clear?

  • Are fire doors closed and not able to be propped open?

  • Are pull stations, fire extinguishers, and fire doors unobstructed?

  • Corridor sprinkler heads clean and not missing escutcheons or have gaps around escutcheons?

  • Are eyewash stations and showers inspections documented weekly?

Clean Utility/Medication Room/Equipment Storage

  • All clean supplies stored off of the floor. No outside cardboard. Nothing stored under sinks

  • Does the equipment's cleanliness, paint, wiring, and covers appear satisfactory?

  • No equipment or beds stored in hallway?

  • Are supplies within expiration dates. Check drawers for improperly stored items. Glucometer supplies dated with expiration?

  • Crash Cart Checks are completed daily? No expired supplies, oxygen tank has >1500 psi, no dust, plugged into red outlet?

  • Is there 18 inches or more of open space maintained below the sprinkler deflector to the top of storage?

  • Is clean linen covered? No product stored on top of linen cart?

  • Clean utility rooms contain only clean/sterile items? Clean equipment is clean and bagged appropriately?

  • 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.

  • Are chemicals stored separately from patient contact or other clean items?

  • Medications are secured

Clean Space

  • Ceilings, walls, lighting is clean and intact? No bugs/debris in overhead lights? All light bulbs are functioning?

  • Are walls free from paint or repair needs? All ceiling tiles are clean, no stains or cracks?

  • Countertops, Flooring, Trim, and Handrails are clean and undamaged?

Patient Care

  • Is "Per Shift Staff Assignments Binder/clipboard" up to date?

  • Are nurse call pull cords proper length - 2 to 6 inches from floor, not tied to grab bars, etc?

  • Are sharps containers securely mounted and not overfilled?

Nourishment Rooms

  • Are patient food refrigerator logs maintained and up-to-date? Are temperatures within range?

  • Ice machine is clean?

  • No outside food stored in refrigerator? All patient food is labeled with patient name and date to discard?

Positive/Negative Air

  • Positive Air Pressure for sterile storage, medication rooms, and other clean/sterile areas.

  • Negative Air Pressure for soiled utility, trash, hazardous waste, and other dirty rooms.


  • Are all employees wearing their ID badges in plain view?

  • Confidential patient information is secure and HIPAA practices are followed

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.