Title Page

  • Environment of Care Rounds

  • Campus:

  • Conducted on

  • Prepared by

  • Building

  • Floor

  • Personnel


  • Employees were observed using safe lifting techniques and good body mechanics.

  • Ergonomic hazards identified and corrected

  • Flashlights and batteries available.

  • Emergency #s are readily available.

  • Gurneys and wheel chairs in good repair.

  • Wheeled equipment in hallway on one side.

  • Supervisor confirmed eye-wash/shower stations are tested weekly and documented.

  • Halls are free of uneven surfaces, cracks, loose tiles, water and other slip, trip, and fall hazards.


  • No personal property at Nurses station.

  • Staff was observed wearing identification badges appropriately.

  • Vendors were observed wearing contractor badges.

  • Doors are secured.

  • Locks functioning as appropriate.

  • Staff personal property secured.

Electrical Safety

  • Electric panels have 3 feet clearance.

  • Medical shut-off panels have 3 feet clearance.

  • Surge protector utilized for office equipment only.

  • No plugging of one surge protector into another (piggyback).

  • Electrical cords in good condition (not frayed, etc.).

Fire Safety

  • Fire Alarms not blocked.

  • Fire extinguishers are not blocked.

  • Fire extinguisher seals are in place.

  • 18" storage clearance from top of ceilings.

  • (3') Three feet clearance in corridors and exits clear.

  • Exits are clear from obstruction.

  • Exit signs lit and functioning properly.

  • Fire doors latch properly and completely.

Infection Control

  • Are gloves, gowns, eyewear, and masks readily available?

  • Is clean linen covered?

  • Is clean linen/supplies kept separate from the dirty linen/supply disposal?

  • Are refrigerator logs maintained and up to date in medicine and patient refrigerators?

  • Are medicines and food kept in separate refrigerator?

  • Are needle boxes under 2/3 full or below full line?

  • Were employees eating or drinking in designated areas only? Staff should not have food/drink in patient care areas.

  • Are cleaning products the only things located under sinks? These are the only items allowed under the sinks.

  • Can staff verbalize the proper cleaning/disinfecting procedures for medical equipment in their department (include high level or sterilization processes, if applicable)?

  • Dated medical supplies or dedications are not expired?

  • Patient use furniture in good condition - surface material intact.

  • Is dirty utility room door closed/secured and labeled with appropriate signage?

  • Is staff performing Hand Hygiene appropriately?

  • Are isolation signs posted appropriately and precautions observed?

  • Staff can verbalize PPE requirements for various isolation?

Hazardous Materials / Waste

  • Staff is able to obtain SDS when requested.

  • Oxygen and other gas tanks stored upright in designated holding areas and in approved containers/canisters.

  • Combustibles stored in proper containers and storage kept to a minimum.

  • Hazardous chemicals properly labeled and stored.

  • Bio-hazardous wastes are appropriately labeled.

  • All cleaning solutions are labeled.

Questionnaire / Employee Interview

  • Staff able to answer: What response plan is implemented for Code Red?

  • Staff able to answer: What does the acronym PASS stand for?

  • Staff able to answer: What is the clearance requirement from the ceiling while storing.

  • Staff able to answer: What do you do if you see suspicious person(s) or activity?

Ergonomic Questionnaire

  • Does employee/staff know or demonstrate the proper technique of lifting patients?

  • Is the employee/staff able to articulate some of the safe ergonomic practices?

  • Does employee/staff know whom to notify in an event of an employee injury?

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.