JHHS SMH EOC Rounds Tracer

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

ENVIRONMENT OF CARE

• Any broken equipment or furniture stored on the unit? • Check for broken/inoperable/no longer in use equipment; look for need repair tags; Check for chipped finishes on patient furniture (arms of chairs; dresser drawers; etc); • Check that protective coverings are intact no rips/tears (linen carts, EKG machines; etc)

  Yes

  No

  N/A

• Are EVS carts attended or locked when unattended? • Check EVS carts to ensure they are attended or locked when unattended

  Yes

  No

  N/A

• Are storage rooms with electrical or mechanical components are locked?<br><br> • Check that all protective boxes, enclosures, cabinets, etc. that house electrical or mechanical components are locked

  Yes

  No

  N/A

• Are refrigerator/freezer temperatures monitored and maintained on the unit/department?<br> • Ask how refrigerators for food/medication are monitored for temperature<br>• Review logs each day for temps-Food Storage (Refrigerator: 40F or below; Freezer: 0F or below)-check logs for daily check documentation<br>• Check for documentation supporting actions taken for out of range temps. (NOTE: 1. The Pyxis refrigerators are monitored by a temperature tracking software in the Pharmacy. 2. Fluid and Blanket warmers are controlled by micro-processors and should not exceed 104F and 130F respectively).

  Yes

  No

  N/A

• Extension cords are NOT used on the unit / department for medical equipment? • Look for power strips used for multiple medical devices

  Yes

  No

  N/A

• Are multi-plug power strip outlets, if seen, used ONLY on non-medical equipment (nurse’s station-computers, monitors, etc)

  Yes

  No

  N/A

• Are there shipping carton boxes in patient care areas? • Shipping carton boxes should not be on patient units

  Yes

  No

  N/A

• Is there evidence of preventative maintenance inspections on medical equipment? <br> • Check for up-to-date inspection stickers-can be 7 different colors to determine frequency<br>• Acceptable date is within one year from last check<br>• Check for cleanliness of medical equipment (dust, fluids)

  Yes

  No

  N/A

INFORMATION MANAGEMENT

• Was patient health information protected by good HIPAA practices? <br> • Computers/WOWs/COWs terminals signed off when not in use.<br>• Pt information is not discussed in public areas<br>• Labels with PHI are discarded in shredding bins<br>• No clipboards displayed as sign-in sheets with multiple patient names on the list<br>• If fax machine is in a public viewing area, patient information is quickly removed<br>• Cannot be overheard or seen by unauthorized persons

  Yes

  No

  N/A

LIFE SAFETY

• Are the storage of boxes & patient care items stored properly? • Not directly on the floor<br>• No more than 18 inches from the ceiling<br>• If on bottom shelf; ensure that the last shelf is solid (protection from getting soiled from mopping)

  Yes

  No

  N/A

• Are oxygen or other combustible gas cylinders stored properly?<br> • Secured in a floor stand/carrier, placed in a fire-rated cabinet or secured to the wall by a chain. (not laying on floor or against walls)<br>• Empty and full cylinders stored separately<br>• No combustible material (netting, cardboard) on or around the cylinders?

  Yes

  No

  N/A

• Are fire exits & hallways clear of clutter or obstruction?<br> • Exit corridors must have 8 ft clearance<br>• Equipment in corridors must be actively in use (cleaning carts)<br>• The only exceptions are Code Carts and Isolation Carts

  Yes

  No

  N/A

• Are fire alarm pull stations, fire extinguishers & medical gas zone panels free of obstruction?

  Yes

  No

  N/A

• Are all employee on the unit wearing ID badges appropriately? • ID badges worn above the waist<br>• ID badges display name <br>• ID badge photos are clear

  Yes

  No

  N/A

PATIENT SAFETY / NATIONAL PATIENT SAFETY GOALS

• Staff attentive to alarms or alert systems in a timely manner? • Call lights<br>• Monitors

  Yes

  No

  N/A

PERFORMANCE IMPROVEMENT

• Is quality improvement data posted in unit? • Compliance with Hand Hygiene; Hospital Acquired Infection rates; Falls; etc

  Yes

  No

  N/A

INFECTION PREVENTION

• Was food & drink stored in designated areas?<br> • No food/ drink at the nursing workstations<br>• No employee food in patient refrigerator <br>• No expired food/ drink in patient refrigerator <br>• No food/drink in laboratory specimen, hazardous storage, window seal

  Yes

  No

  N/A

• OBSERVATION: Was PPE being used correctly? <br> • Staff don PPE appropriately when patient on isolation precautions

  Yes

  No

  N/A

• Was there seperation of clean vs. dirty supplies & equipment?<br> • Look for green tags and coverings for clean items<br>• In small spaces, look for lines separating clean vs. dirty side of room

  Yes

  No

  N/A

• All patient care supplies clean, undamaged, and within expiration date? Look for any expired, damaged or soiled patient care supplies?<br> • Look for expiration dates on labels (syringes, IV fluids, cannulas, tubing, bandages, lab specimen tubes)

  Yes

  No

  N/A

MEDICATION MANAGEMENT

• Are medication rooms clean and uncluttered?

  Yes

  No

  N/A

• Are all medication carts & storage locked for safety or under constant surveillance?<br> • Med carts/rooms are locked<br>• No unsecured medications found on unit <br>• Check pneumatic tube areas, emergency drug boxes, crash carts, patient care areas for insulin pens; unidentified liquids; ointments

  Yes

  No

  N/A

• Code Carts meets the following:<br> • Earliest expiration date on cart is current<br>• Locked & marked with the first drug to expire?<br>• Checked daily and documented on log sheet?<br>• Include defibrillator check?<br>• O2 tank > ¾ full<br>• Cart is clean?

  Yes

  No

  N/A

WAIVED TESTING / POINT OF CARE TESTING

• Are expiration dates on materials used for point of care testing (blood glucose monitoring) within date and appropriately labeled? <br> Check expiration dates based on date opened: 1) test strip 180 days (6 months); 2) Quality Control (QC) test solution 90 days (3 months); NOTE: Strips & QC solution should be stored between 15-30 C (59-86 F) degrees to match the stringent storage criteria for the glucose monitor

  Yes

  No

  N/A

• Are quality checks and room temperature log completed? Check for Logs: 1) QC check & 2) room temperature

  Yes

  No

  N/A

UNITS RESPONSE TO AUDITOR ARRIVAL

• Was the team greeted with smiles and introductions?

  Yes

  No

  N/A

• Was a space designated for the team to conduct interviews and file reviews?

  Yes

  No

  N/A

• Did staff promptly answer questions or deliver materials required for review to the tracer team?

  Yes

  No

  N/A