Jack Hughston Memorial Hospital Environmental Tours Survey

• Document No.

• Jack Hughston Memorial Hospital Environmental Tours Survey

• Department:

• Conducted on

  Date

• Prepared by

Safe Environment

Cabinetry / Counters

• Are cabinets and countertops in overall good condition?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Doors

• Are doors in overall good condition?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Floors / Hallways / Tile / Carpet

• Is flooring in good condition?

  Yes

  No

  N/A

• Is flooring clean and dry?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are wet floors signs being used in the area?

  Yes

  No

  N/A

Walls

• Are walls in overall good condition?

  Yes

  No

  N/A

• Is paint in overall good condition?

  Yes

  No

  N/A

• Are wall plates present and in good condition?

  Yes

  No

  N/A

Ceilings

• Is the ceiling in good condition?

  Yes

  No

  N/A

• Are ceiling tiles in place and undameged?

  Yes

  No

  N/A

• Is ceiling grid / track in good condition?

  Yes

  No

  N/A

Infection Control

Environmental

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are all cardboard boxes off the floor?

  Yes

  No

  N/A

• Is personal protective equipment available and in good condition?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are hand sanitizer dispensers properly stocked?

  Yes

  No

  N/A

Linens

• Is soiled linen stored properly?

  Yes

  No

  N/A

• Is clean linen properly covered?

  Yes

  No

  N/A

• Are clean and soiled linens properly seperated?

  Yes

  No

  N/A

Refrigerators

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

  Yes

  No

  N/A

• Do refrigerators have current temperature logs, where applicable?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are refrigerators clean and organized?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Bloodborne Pathogen

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

  Yes

  No

  N/A

• Are sharps properly stored and secured?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are sharps properly disposed of in sharps containers ONLY?

  Yes

  No

  N/A

• Are sharps containers les than 75% full?

  Yes

  No

  N/A

FIRE / LIFE SAFETY

Corridors

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are corridors clean and free of obstructions?

  Yes

  No

  N/A

Egress / Exit Doors

• Are doors clearly and correctly marked?

  Yes

  No

  N/A

• Are exit signs working properly?

  Yes

  No

  N/A

• Are doors clear of debris and eqipment?

  Yes

  No

  N/A

Fire / Smoke / Stairwell Doors

• Are doors free of being propped / wedged open?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Do door closers / interrupters work properly? Fir

  Yes

  No

  N/A

Fire Extinguishers

• Are all fire extinguisher locations clearly marked and unobstructed?

  Yes

  No

  N/A

• Do all fire extinguishers have current inspection tags?

  Yes

  No

  N/A

• Are safety seals present on all extingushers?

  Yes

  No

  N/A

Fire Alarm Pull Stations

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

  Yes

  No

  N/A

• Are pull stations in good condition?

  Yes

  No

  N/A

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

• Are items stored at least 18" from ceiling?

  Yes

  No

  N/A

• Are items kept in a safe, designated location?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are items kept at minimum for daily use?

  Yes

  No

  N/A

HAZARDOUS MATERIALS & WASTE MANAGEMENT

Hazardous Chemicals

• Are chemicals labeled correctly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are spill kits available? (If Applicable)

  Yes

  No

  N/A

Medical Waste

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

  Yes

  No

  N/A

• Is medical waste properly seperated and segregated?

  Yes

  No

  N/A

• Is medical was properly disposed of?

  Yes

  No

  N/A

MEDICAL EQUIPMENT

Bio-Med and Digital Imaging Equipment

• Are inspection tags current on all medical equipment?

  Yes

  No

  N/A

• Is equipment clean and properly stored?

  Yes

  No

  N/A

• Is broken equipment properly tagged and out of service?

  Yes

  No

  N/A

UTILITY SYSTEMS

Electrical Safety

• Are breaker panels kept locked?

  Yes

  No

  N/A

• Are electrical cords in good condition?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Emergency Power

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

  Yes

  No

  N/A

• Are emergency outlets only being used for critical equipment?

  Yes

  No

  N/A

Medical Gases

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are compressed gas cylinders properly labeled and segregated?

  Yes

  No

  N/A

• Are compressed gas cylinders properly stored and secured?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

SECURITY

Patient and Staff Safety

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

  Yes

  No

  N/A

• Are medications being secured properly?

  Yes

  No

  N/A

EMERGENCY MANAGEMENT

Emergency Operations Plan

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

STAFF KNOWLEDGE

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

  Yes

  No

  N/A

• Does staff know what CODE RED is?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Can staff explain their role in a CODE PINK?

  Yes

  No

  N/A

• Can staff explain if medical equipment inspections are current?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Department Director / Manager:

  Sign