Title Page

  • Site conducted

  • Site conducted

  • Conducted on

  • Prepared by

  • Location





  • DATE:


  • Associates are wearing DHHS identification badges

  • Contractors are wearing appropriate identification

  • Patient Information is kept private/confidential

  • If installed, panic alarms are operational

  • Emergency door alarms are operational

  • Telephone in elevator rings at the communications desk

  • Rooms containing medications are properly secured


  • Floor surfaces are uncompromised (not wet, no cracks/gaps or trip hazards)

  • Corridors unobstructed (equipment "IN USE" stored on one side only)

  • Emergency Exits are unobstructed (not blocked, clear of obstacles)

  • Exit signs are posted and lit

  • Storage areas appropriately utilized

  • Patient refrigerator / freezer temperature monitoring log compliant

  • Items are not stored directly on the floor (at least 6" off the floor)

  • Crash Cart Log Daily checks are documented, defibrillator is tested

  • There were no expired goods/supplies found

  • Medications are secured (medications that should be kept locked are not found in public areas)

  • Emergency eye wash station are inspected weekly

  • No broken, defective or nonfunctional equipment/furniture found

  • Emergency Lighting is operational. Test this by pressing the button

  • Receptacles and light switches are covered. There are no lights out

  • Approved power cords are not piggybacked

  • Doors positive latch and are not propped open with unapproved devices


  • Portable fire extinguishers checked monthly (Refer to the yellow tags)

  • Fire equipment unobstructed and easily accessible

  • Evacuation routes posted and are current

  • Fire sprinkler heads are free of dust and unobstructed. No penetrations or gaps around the sprinkler head

  • Associates familiar with fire response: what number to dial to report a fire, RACE, and PASS

  • No storage within 18" of the ceiling sprinkler head clearance maintained

  • Evacuation routes unobstructed. Nothing blocking evacuation routes leading to emergency exit doors

  • Associates are able to locate nearest fire alarm pull station

  • Associates are able to locate oxygen shut off valves. Know who is authorized to shut off valves

  • Portable oxygen tanks are secured in trolley or attached to the crash cart

  • Portable oxygen tanks secured with chain in medical gas room

  • Portable oxygen tanks are clearly marked and segregated EMPTY or FULL


  • Safety Data Sheet folder/binder is available

  • Safety Data Sheets are current and relevant

  • Any hazardous materials on hand is easily identified/labeled

  • Hazardous Materials are properly stored and segregated

  • Storage of Hazardous Materials are in compliance with approved quantities

  • Containers/spray bottles are labeled accordingly (i.e. legible, expiration date)

  • Appropriate spill kit available for hazardous material(s) on hand

  • Associates knowledgeable of accidental spill response. Ask questions on how to clean up a spill using supplies in spill kit

  • Biomedical Waste is properly discarded. Red bags and red bins are appropriately labeled and utilized

  • Trash cans are not overfilled and are appropriately sized for the amount of waste generated

  • Associates know where to find eye wash station and how to operate it


  • There are no corrugated boxes in sterile / clean areas.

  • Hand Hygiene compliance observed

  • Sharps containers are not over filled, needles are below the full line

  • PPE is available and used appropriately

  • Dry wall and doors are free of cracks and penetrations

  • Ceiling tiles are in good condition free of stains, water intrusions, cracks

  • Isolation Rooms negative pressure daily monitoring log compliant

  • Soiled Linen hampers not overfilled

  • Clean linen storage carts are covered

  • Portable fans are free of dust

  • Associate food is not stored with patient food

  • No open food / drinks, cosmetics, etc. at the nurse's station

  • Associates know when to wash hands with soap and water vs hand saniter


  • Equipment has asset tags with a visible identification number

  • Preventative Maintenance sticker affixed and PMs are on schedule

  • Nurse call buttoncode button operational. Test conducted

  • Electrical panels are unobstructed (3 feet clearance)

  • Electrical panels are covered and locked


  • Associates able to articulate area's evacuation procedure. Create a scenario and ask what they would do, nearest exit, where to evacuate

  • Associates know emergency codes. Ask to give at least 3 codes and their meaning. Note: Allowed to read from signage posted


  • Policies and Procedures are readily available. Ask associate to show you where policies are located. Can be hard copy or electronic

  • Associates know how to find/use policies and procedures. Give them a policy title/subject and ask them to locate

  • Associates able to articulate International Patient Safety Goals. Ask them to give at least 2 IPSG and how we meet these goals

  • Associates able to articulate DHHS Mission statement (can use ID badge)

  • Associates able to articulate the DHHS Vision statement (can use ID badge)

  • Associates able to articulate performance improvement initiative for their area

  • Additional Comments:

Central Lines Observations

  • Is dressing adhesive intact over the catheter insertion site? (Includes chlorhexidine gluconate (CHG) and any other dressings)

  • Is any drainage at the insertion site contained?

  • Is the dressing dated and timed according to facility policy?

  • Is the catheter secured to reduce movement or tension?

  • Are the administration tubing sets labeled with the start date and time?

  • If the tubing set is labeled, is it within the specified date and time range for use?

  • Are all inactive ports capped according to facility policy?

Urinary Catheter Observations

  • Is the catheter properly secured to the patient?

  • Is there unobstructed flow from the catheter into the bag?

  • Is the collection bag below the level of the bladder?

  • Are the bag and tubing off of the floor?

Ventilator Observations

  • Is the head of the bed elevated >30 degrees?

  • Is the ventilator tubing free of excessive condensation?

  • Are supplies needed for oral care readily available?

Falls Risk Observation

  • Fall risk sign on the patient door

  • Is Fall risk arm band on patient

  • is the patient bed in lowest position

  • is the bed locked

  • Is the Side rails in upright position

  • Is the patient Call bell within reach

  • Is a patient sitter at the bedside

  • Fall Risk Assessment Completed on admission

  • Fall risk assessment completed per shift

  • Evidence of Purposeful rounding for 5 P's

  • Fall risk Care plan activated in Meditech

HAPI/CAPI Risk Observation

  • Braden Assessment completed on admission

  • Braden Assessment completed per shift

  • Photos taken on admission

  • Photos take on discharge

  • Patient seen by wound care within 24 hours post admission

  • Patient seen by wound care daily

  • Risk Connect completed for braden <15

  • Partial Bath /perineal care done q4h

  • Catheter care done Q4hrs

  • Foot care done daily

  • Patient seen by dietician

  • Patient seen by Rehabilitation Team

  • Airflow mattress in place

  • Frequent diaper checks done

  • Position change every 2 hours

  • Pressure care provided every 2 hours

  • 30 degree foam wedge in use

  • Evidence of patient and family education

Restraints Observation

  • Physican order present in Meditech system

  • Order contains type of restrains to be used

  • Behaviour/reason for restraint is documented

  • Date and time restraints initiated documented

  • Who applied the restraint(s) is documented

  • Location of restraints is documented

  • Restraints status is documented every two hours

  • Sign of injury is documented

  • Can two finger breath fit under the restraints

  • Is restraints secured on the immovable part of the bed

  • Restraint flow sheet documented

  • Evidence of Q30 minutes documentation of patient observations

  • Explanation for restraints documented

  • Plan of care documented

  • Justification for restraints documented every two hours

  • Date and time restraints discontinued documented

  • Reason for discontinuation of restraints documented


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.