• Document No.

  • Jack Hughston Memorial Hospital Environmental Tours Survey

  • Department:

  • Conducted on

  • Prepared by

Safe Environment

Cabinetry / Counters

  • Are cabinets and countertops in overall good condition?

  • Are doors, hinges, drawers and handles in good condition?


  • Are doors in overall good condition?

  • Does door hardware function properly? (Handles, Hinges, Latches)

Floors / Hallways / Tile / Carpet

  • Is flooring in good condition?

  • Is flooring clean and dry?

  • Is flooring free of trip / fall hazards? (No areas unleveled by more than 1/2 in)

  • Are wet floors signs being used in the area?


  • Are walls in overall good condition?

  • Is paint in overall good condition?

  • Are wall plates present and in good condition?


  • Is the ceiling in good condition?

  • Are ceiling tiles in place and undameged?

  • Is ceiling grid / track in good condition?

Infection Control


  • Are shipping boxes present in the area? (patient care areas only)

  • Is staff food / drink present in patient care areas?

  • Are areas under the sink free of patient contact items?

  • Are all cardboard boxes off the floor?

  • Is personal protective equipment available and in good condition?

  • Are soap and paper towels properly stocked at handwashing sinks?

  • Are hand sanitizer dispensers properly stocked?


  • Is soiled linen stored properly?

  • Is clean linen properly covered?

  • Are clean and soiled linens properly seperated?


  • Are refrigerators labeled properly? ("Meds Only", "Patient Only", "Staff Only", etc.)

  • Do refrigerators have current temperature logs, where applicable?

  • Are temperature alarms set at the proper parameters? (can be found on temp logs)

  • Are items properly stored? (No food and meds in same refrigerator)

  • Are refrigerators clean and organized?

  • Is food in refrigerator properly dated? ("Patient Only" & Kitchen refrigerators)

Bloodborne Pathogen

  • Are sharps containers free of items being stored on top on container?

  • Are sharps properly stored and secured?

  • Are personal protective precautions evident? (Gloves, Masks, Gowns, etc.)

  • Are sharps properly disposed of in sharps containers ONLY?

  • Are sharps containers les than 75% full?



  • Are corridors kept clear to allow ambulation of patients and visitors?

  • Are corridors kept clear to allow carts, wheelchairs and beds to pass?

  • Are corridors clean and free of obstructions?

Egress / Exit Doors

  • Are doors clearly and correctly marked?

  • Are exit signs working properly?

  • Are doors clear of debris and eqipment?

Fire / Smoke / Stairwell Doors

  • Are doors free of being propped / wedged open?

  • Are doorways clear to close? (Nothing in the path of the door)

  • Do fire and stairwell doors latch firmly and maintain closure?

  • Do door closers / interrupters work properly? Fir

Fire Extinguishers

  • Are all fire extinguisher locations clearly marked and unobstructed?

  • Do all fire extinguishers have current inspection tags?

  • Are safety seals present on all extingushers?

Fire Alarm Pull Stations

  • Are pull stations free from obstruction? (Carts, Furniture, Equipment, etc.)

  • Are pull stations in good condition?

Combustibles (Paper, Trash, Linen, Cardboard, etc.)

  • Are items stored at least 18" from ceiling?

  • Are items kept in a safe, designated location?

  • Do privacy curtains have atleast 18" net at the top?

  • Is non-approved equipment present? (heaters, toasters, candles, etc.)

  • Are there any idications of smoking in the area?HAZARDOUS MATERIAL

  • Are items kept at minimum for daily use?


Hazardous Chemicals

  • Are chemicals labeled correctly?

  • Are chemicals stored correctly? (Flammable, Corrosive, Hazardous Areas)

  • Are spill kits available? (If Applicable)

Medical Waste

  • Is medical waste in red bags and in proper containers?

  • Is medical waste properly seperated and segregated?

  • Is medical was properly disposed of?


Bio-Med and Digital Imaging Equipment

  • Are inspection tags current on all medical equipment?

  • Is equipment clean and properly stored?

  • Is broken equipment properly tagged and out of service?


Electrical Safety

  • Are breaker panels kept locked?

  • Are electrical cords in good condition?

  • Are electrical boxes, switches and outlets in tact and in good condition?

Emergency Power

  • Are emegency power sources clearly marked with red outlets, switches, or labels?

  • Are emergency outlets only being used for critical equipment?

Medical Gases

  • Are medical gas valves clealry marked with gas identity and location served?

  • Are area medical gas valves accessible and not obstructed? (Carts, Equipment etc.)

  • Are compressed gas cylinders properly labeled and segregated?

  • Are compressed gas cylinders properly stored and secured?

  • Is less than 300 cu ft of O2 stored in an area? (12E tanks)


Patient and Staff Safety

  • Are staff, vendor and contractors wearing ID badges in plain view?

  • Are medications being secured properly?


Emergency Operations Plan

  • Is a current copy of the EOP available in the area?

  • Is there a mechanism in place noting emergency staff response for area?


  • Does staff know what number to call in case of an emergency?

  • Does staff know what CODE RED is?

  • Can staff explain what R.A.C.E stands for?

  • Can staff explain the P.A.S.S. technique for extinguisher use?

  • Can staff demonstrate how to look up a MSDS or SDS?

  • Can staff explain what information is included in a MSDS or SDS sheet?

  • Does staff know the two locations that keep a hardcopy of MSDS or SDS sheets?

  • Does staff understand who shuts off medical gases valves in a fire emergency in the area?

  • Can staff explain their role in a CODE PINK?

  • Can staff explain if medical equipment inspections are current?

  • Can staff explain how to get help in a secuirty emergency?

  • Does staff know what the Emergency Kardex is and it's location in the area?

  • Department Director / Manager:

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.