Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

ENVIRONMENT OF CARE

  • No items stored under sinks?

  • No broken/damaged/unused equipment or furniture on the patient care units.<br>

  • Items are secured by person or lock: medications, needles, chemicals, and/or biohazardous materials.

  • Hazardous chemicals and flammable agents are labeled and stored properly.

  • Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient/employee food)

  • Refrigerators: If manually monitored, logs are complete. Documentation is present for actions taken to correct out of range temps.

  • No storage on top of refrigerator.

  • Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition. Wires neat and controlled, no trip hazard.

  • No outer shipping carton boxes (have shipping label). Empty and remove as soon as possible.

  • No expired chemicals or supplies.

  • Preventative Maintenance:<br> * Equipment checked with up to date bio-med sticker. (inspected and calibrated as required by manufacturer's recommendations)<br>

EMERGENCY PREPAREDNESS

  • Staff is able to locate the Disaster, MSDS, and policy manuals.<br> * all manuals contain current information

INFORMATION MANAGEMENT

  • Confidential Patient Information:<br>Cannot be overheard or seen by unauthorized persons:<br> * Computer terminals signed off when not in use.<br> * Patient information is not discussed in public areas.<br> * Labels and PHI are obliterated before discarding in the trash.<br> * No patient information visible to unauthorized persons

  • No clipboards displayed as sign-in sheets when multiple patient names on the list.

  • If fax machine is in public area, patient information is quickly removed.

LIFE SAFETY

  • Appropriate storage of boxes and patient care items:<br> * Not directly on floor.<br> * 18" clearance from sprinkler head.<br> * Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping (6 inches).<br> * Volume of combustible material is not stored in large quantity as to create a fire hazard.

  • Oxygen or other combustible compressed gas cylinders are stored properly:<br> * Secured in floor stand, carrier or secured to the wall by a mount. (not laying on the floor or against wall)<br> * Limited to 12 E-cylinders per smoke compartment. (does not include those tanks in use)<br> * Labeled and separated, full from empty

  • Fire exits and hallways are cleared:<br> * Egress corridors must have 8ft clearance.<br> * Equipment in corridors must be in use within 30 minutes to remain in corridor.

  • Fire alarm pull stations, fire extinguishers, medical gas shutoff valves, and electrical panels are not blocked.

  • Fire extinguishers have been inspected monthly.

  • Maximum of 2-32 gallon trash cans in a 10x10 room. (unless fire rated)

  • Fire doors are not blocked or propped and when closed there is positive latching.

  • Exit signs are illuminated.

  • Evacuation route posted & current.

  • Everyone has ID badges and worn appropriately.

  • Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.

  • Floors, ceilings, walls, and other surfaces intact and free from holes, damage, and soiling.

INFECTION PREVENTION

  • Food and drink in designated areas:<br> * No employee food or drinks in the public/patient areas, should be limited to private offices or break room.

  • Hand Hygiene Products:<br> * No empty alcohol gel bottles<br> * No empty soap or paper towels<br> * Hospital approved soap/hand gel/hand lotion readily available<br> * No unapproved products being used

  • PPE:<br> * Readily available<br> * Clearly marked<br> * Worn correctly<br>

  • Patient food & drinks: No expired items. Stored separately from employee food and drinks, no co-mingling.

  • Biohazard Waste:<br> * Discard in Red Bags with a biohazard symbol<br> * Not overfilled<br> * Covered containers<br> * Contains only biohazardous waste, no trash<br> * Stored in a secure area<br><br>

  • Soiled Linen: Properly stored in closed container and not overfilled.

  • Separation of clean vs. dirty supplies & equipment:<br> * Clearly marked<br> * No co-mingling of supplies, medications, waste, or food.

  • Patient care supplies:<br> * Not expired, damaged, or soiled.<br> * No open single use products. multi-use supplies labeled with expiration date according to manufacturer's recommendations for opened product.

  • Linen and Linen Carts: Covered and carts have solid bottoms. Pillows are cleaned and bagged for storage or considered dirty, to be cleaned prior to use. if dirty not stored with clean linens.

  • Sharps Waste:<br> * Placed in puncture resistant sharps container with lid.<br> * Disposed of when 3/4 full or "full" indicator<br> * Mounted appropriately<br> * Stored in secure location

  • General Cleanliness:<br> * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, lobby, exam rooms, bathrooms, equipment, decorative items, curtains, blinds, or drapes. <br> * No blood or bodily fluids<br> * Staff using hospital approved cleaning products according to manufacturer's recommendations

  • Air vents: Clean

  • All items that come in contact with patients, that are not disposable, are cleaned between each patient. Includes exam tables, stretchers, chairs, blood pressure cuffs, thermometers, etc.<br> * Follow manufacturer's recommendations for cleaning surfaces, equipment, and devices.<br> * Use only hospital approved products for cleaning and disinfection

  • All reprocessing of sterile instruments done through TRMC Sterile Processing Department. <br> * Documented staff training on decontamination and transport process.<br> * Separation of clean from dirty equipment during storage and transport.<br> * Appropriate processes observed for decontamination, storage, and transport before and after reprocessing.

  • Coverings are clean and intact on exam tables, phlebotomy chairs, chairs in waiting areas and exam rooms - no rips or repairs needed.<br> * Coverings can be cleaned/disinfected with hospital approved product.

MEDICATION MANAGEMENT

  • Medication rooms are clean, uncluttered, and free of distractions.

  • Medication is appropriately labeled.<br> * Samples labeled with expiration dates, directions, etc.. prior to dispensing to the patient<br> * Miultidose vials labeled when opened with expiration date<br>

  • Sample log contains current inventory and ability to track medications to patients. At minimum, log includes lot number, drug name and strength, patient identifier, date, and number dispensed.

  • All medications, needles and syringes are secured in locked cabinet, locked room, or under constant staff surveillance.

  • Controlled substances secured to prevent diversion.

  • Medications, formula, & solutions not expired. <br> * Expiration date of manufacture is applicable to unopened package <br> * Labeled with expiration date after opening (28 days unless no preservative present, then 24 hours)

  • Opened multi-dose vials dated with 28-day expiration date (or sooner by manufacturer's recommendation) and initialed. Not expired. No reuse of vials labeled for "single use"

  • Code Carts:<br> * Locked and marked with then first drug to expire.<br> * Checked per policy and log complete<br> * Includes defibrillator check while on battery power.<br> * Extra locks kept secured.<br> * All supplies & drugs that are on the inventory list are on the cart.<br> *. Cart is clean.<br> *. O2 tank is >1/2 full

  • Syringes are labeled per policy if multiple syringes present or one not immediately used (drawn up and taken directly to patient for administration, does not leave the hand of the nurse)

  • Medication refrigerators contain only TRMC medications (no patient prescriptions brought in from outside pharmacy except allergy injections).

WAIVED TESTING / POINT OF CARE TESTING

  • Point of Care testing lab controls documented and control solution labeled & dated.<br> *. Reagents, i Stat analyzes, glucometers, GEMS

  • Point of Care Testing Quality Control:<br> *. Consistently and correctly documented<br> *. Dates missing initials<br> *. Performed by qualified person<br> *. Out of range is followed<br> *. Logged numbers match bottle ID numbers<br>

  • Additional information?

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