Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

RESULTS

  • Total Number of Findings

  • Total number of Facilities/Engineering work orders

  • Total number of EVS work orders

  • Total number of educational opportunities

1. PREVIOUS AUDITS

  • 1.1 Has the last audit been reviewed?

  • 1.2 Are there any outstanding concerns?

A. SAFETY/GENERAL SAFETY

  • A1. Warning signs or barricades are placed when work creates a hazard (wet floor, maintenance work in ceiling)?

  • A2. Medication cart is locked, neat and tidy, without expired medicines/products?

  • A3. Clean linen is covered with nothing on top of cart?

  • A4. All furniture and equipment is in sound condition? (no chipped or torn surfaces- no leaky faucets)

  • A5. This area is free from sharp objects?

  • A6. All wall-mounted devices (lights, TV’s, pictures, signs, containers, handrails, etc.) are secure and not loose?

  • A7. Cleaning chemicals are properly labeled and are not accessible by residents and visitors?

  • A8. Quality Control logs for Refrigerators/Freezers, freezers, and warmers are complete and corrective actions documented as appropriate?

  • A9. Boxes of patient care items/supplies are not stored directly on the floor? (must be elevated 6")

  • A10. Items are not stored under sink(s)? (If items found - list in comment section.)

B. ELECTRICAL SAFETY

  • B1. Items are not stored within 30” of an electrical panel?

  • B2. Electrical cords, plugs, plates and switches are in good repair?

  • B3. Extension cords only used temporarily but not on a permanent everyday basis?

  • B4. The underside of beds and counters are free of electrical “wire nests” where feet could be entangled?

C. MEDICATION/MEDICAL SUPPLIES

  • C1. Medications/medical supplies - have not passed expiration dates?

  • C2. All syringes, basins, cups, containing medication or solutions are labeled with the name of the contents?

  • C3. Med Carts/Med Rooms are secured at all times?

D. INFECTION PREVENTION

  • D1. Staff food is not stored in patient refrigerators?

  • D2. Refrigerators/Freezers are clean, frost free, and labeled for type of storage with only those items present (no food and medication in the same refrigerator).

  • D3. Refrigerators/Freezers contain thermometers and the refrigerator graphs are up-to-date? (thermometer should be located in the back)

  • D4. No open or expired patient nourishment containers in refrigerator?

  • D5. Ice machines are clean, no signs of deposits in tray or dispensing mechanism?

  • D6. Anti-microbial soap and paper towels are available for hand washing?

  • D7. Containers used for regulated or infectious waste are covered, leak proof, and clearly labeled as a biohazard?

  • D8. Disposed sharps are in an approved container?

  • D9. Sharps containers are secured in their holders, not accessible to residents and not more than three-fourths full?

  • D10. Staff (including contracting physicians) perform hand hygiene when entering room?

  • D11. Staff (including contracting physicians) perform hand hygiene while providing care.

  • D12. Staff (including contracting physicians) perform hand hygiene when exiting the patient room.

E. ENVIRONMENTAL

  • E1. Floors free of dirt, dust and litter?

  • E2. Ledges, walls and air vents free of dust?

  • E3. Toilets and sinks secure?

  • E4. Privacy curtains clean and unsoiled?

F. HAZARDOUS MATERIALS

  • F1. ** How can you access Material Safety Data Sheets (MSDS)?

  • F2. ** Do you know where your PPE is located?

  • F3. Material Safety Data Sheets available for all chemicals in this unit?

G. FIRE PREVENTION/ LIFE SAFETY

  • G1. ** Can you explain when you would implement R.A.C.E. and what does it stand for?

  • G2. ** Can you explain P.A.S.S. and what does it stand for?

  • G3. ** Where are the fire extinguishers and pull stations located in your department?

  • G4. Two exit signs visible from each corridor?

  • G5. Halls/Corridors uncluttered and accessible?

  • G6. Wheeled items such as the WOW’s are stored in corridor less then 30 minutes at a time?

  • G7. Are ceiling tiles in place, not stained and not broken?

  • G8. Are the sprinkler heads free of dust?

  • G9. Fire extinguisher (s) recently serviced? (monthly)

  • G10. Automatic fire doors free from obstacles and positively latch when activated? (Doorways should not be blocked or wedged.)

  • G11. Eighteen-inch clearance from sprinkler head ensuring no obstruction?

  • G12. Are compressed gases stored in designated areas only?

  • G13. Are full and empty cylinders stored separately according to sign/labels?

  • G14. All lights are working properly?

  • G15. Flammable and hazardous materials properly stored and labeled?

  • G16. Fire extinguishers and pull stations clear of obstructions?

  • G17. Placement of Hand Sanitizer is not adjacent(with-in 6”) to a potential ignition source?

  • G18. Exits clear of obstructions?

H. EMERGENCY MANAGEMENT PROCEDURES

  • H1. ** Can you tell me the number you would dial to initiate an emergency response?

  • H2. ** Where are your IT Downtime Forms? Do you have an IT Downtime Box? Are the forms current?

I. SECURITY MANAGEMENT

  • I1. ** How do you notify Security in a non-emergency?

  • I2. Employees, volunteers, students, contracted staff, physicians, contractors and venders wearing ID badges @ eye level?

  • I3. Are valuables properly stored in department?

J. EQUIPMENT MANAGEMENT

  • J1. ** What are the procedures if a device/equipment does not work properly OR if the device is involved in a resident related incident?

  • J2. All medical equipment/devices has a current Bio-Medical sticker?

K. UTILITY MANAGEMENT

  • K1. ** Where are your emergency backup procedures located for a loss of utility services?

  • K2. ** In case of a fire on the unit, who is authorized to shut off medical gases?

L. RISK MANAGEMENT

  • L2. Patient Health Information is not visible(computer screens protected, hard copies covered, patient charts closed)

M. RESIDENT SAFETY

  • M1. ** Name two patient identifiers?

  • M2. ** Describe the Falls Prevention efforts in your department.

N. BRALY UNIT

  • N1. FREE OF PERVASIVE ODORS?

COMMENTS/OBSERVATIONS

SIGN OFF

  • Department/Unit Representative

  • Auditor

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