Memorial Hospital and Manor

• Memorial Hospital and Manor

  Select

• Department / Area Inspected

• Department Director Name and if they were present during the inspection.

• Conducted on

  Date

• Inspected By

• Are exit doors and stairwells clear? Main, corridor, and stairwell exits cannot be blocked.

  Yes

  No

  N/A

• Are exit doors clearly marked "exit" and illuminated? Check for burned out bulbs.

  Yes

  No

  N/A

• Do fire doors latch properly? Close fire doors to see if they latch properly and see that there is no gap <1/8 inch in the middle.

  Yes

  No

  N/A

• Are corridors and passageways free of obstruction? The corridor can have mobile items (wheels on them) that are emergency needed items that are in use.

  Yes

  No

  N/A

• Are pull stations or fire extinguishers unobstructed? There must be nothing to obstruct access.

  Yes

  No

  N/A

• Are fire doors propped open/held open? Doorstops or homemade hold open devices are not allowed is in the area. Tape is not allowed over any strike plates.

  Yes

  No

  N/A

• Are storage rooms and equipment rooms free of clutter and unsafe conditions? Make sure items are not falling down or overstocked.

  Yes

  No

  N/A

• If Applicable Are Emergency Back-Up Lights in Working Condition.

  Yes

  No

  N/A

• Are all materials stored a minimum of 18" from the bottom of the sprinkler head?

  Yes

  No

  N/A

• Are sprinkler heads painted, dirty or rusting?

  Yes

  No

  N/A

• Are ceiling tiles where applicable, properly placed in the frames provided. No missing, broken or unleveled tiles?

  Yes

  No

  N/A

• Is the correct type of fire extinguisher available?

  Yes

  No

  N/A

• Are compressed gases stored properly? Compressed gases need to be chained to the wall or on a cart secured. Free standing bottles are not allowed.

  Yes

  No

  N/A

• Is Staff Aware of PASS and RACE

  Yes

  No

  N/A

• Is area free from evidence of smoking?

  Yes

  No

  N/A

• Are wet floors clearly marked to reduce tripping hazards? When floors are wet, does the staff put out wet floor signage?

  Yes

  No

  N/A

• Are the floors/ hallways in good condition?

  Yes

  No

  N/A

• Are ceiling tiles clean, stain free, and in good condition? Indicate where these bad tiles are located in the comments.

  Yes

  No

  N/A

• Are heavy items stored at low levels or mid levels in storage? Make sure the heavy items are stored at waist level or lower shelves.

  Yes

  No

  N/A

• Are general areas clean and free of clutter?

  Yes

  No

  N/A

• Are stair risers all the same height with no tripping hazards apparent?

  Yes

  No

  N/A

• Are stairwells properly lit to ensure safe evacuation when required. and are stairwell lights on emergency power?

  Yes

  No

  N/A

• Are handrails installed if yes are they installed at proper height? secured? and not damaged?

  Yes

  No

  N/A

• Are ladders used and stored appropriately?

  Yes

  No

  N/A

• Are any 2 pronged or damaged electrical cords in use?

  Yes

  No

  N/A

• Are electrical or cords keep away from walking paths?

  Yes

  No

  N/A

• Are there any unauthorized heaters or other mechanical equipment?

  Yes

  No

  N/A

• Are there any unauthorized extension cords?

  Yes

  No

  N/A

• Are residential lights being utilized for decoration purposes?

  Yes

  No

  N/A

• Are surge protectors piggybacked?

  Yes

  No

  N/A

• Are staff refrigerators, approved heaters and or microwaves in dedicated circuits.

  Yes

  No

  N/A

• Are there downtime procedures in place?

  Yes

  No

  N/A

• How is proper personnel notified when emergency operations are put into place?

  Yes

  No

  N/A

• Are secondary chemical containers labeled with product name, hazard label and manufacturer? Indicate any chemical that is in a container other than the original container.

  Yes

  No

  N/A

• Are chemicals stored separately from patient care contact or other clean items?

  Yes

  No

  N/A

• Is the Hazardous Chemical Inventory adequate and available to all employees? The hazardous chemical inventory list will be in the SDS book within the department.

  Yes

  No

  N/A

• Are appropriate procedures, instructions, or directions available for obtaining SDS? There should be instructions within the department to access the SDS.

  Yes

  No

  N/A

• Are unapproved items stored under sinks?

  Yes

  No

  N/A

• Is biohazardous materials properly disposed of? Sharps containers and red bags?

  Yes

  No

  N/A

• Is there regular trash in the biohazardous waste containers?

  Yes

  No

  N/A

• Are any hazardous materials produced or disposed of in the department? (other than IMW)

  Yes

  No

  N/A

• Is staff's personal items properly secured? Check for purses, billfolds, money, keys, etc. left out for you to take.

  Yes

  No

  N/A

• Are all employees wearing their ID badges in plain view?

  Yes

  No

  N/A

• Are all mechanical, electrical, janitorial, communications rooms locked? Indicate which rooms are not locked.

  Yes

  No

  N/A

• Off-site Departments - Is staff aware of the 500#?

  Yes

  No

  N/A

• Is staff aware of emergency codes? and their role?

  Yes

  No

  N/A

• Is staff aware of the departments evacuation routes and assigned meeting place after evacuation?

  Yes

  No

  N/A

• How is security personnel contacted? Law Enforcement?

  Yes

  No

  N/A

• Does the medical equipment appear clean, and is equipment rusty or have chipped paint?

  Yes

  No

  N/A

• Are the castors in good condition, allowing equipment on wheels to roll properly?

  Yes

  No

  N/A

• Is all medical equipment accounted for?

  Yes

  No

  N/A

• Is there defective medical equipment in need of repair? If yes is it properly labeled?

  Yes

  No

  N/A

• Does staff know procedures for reporting defective equipment?

  Yes

  No

  N/A

Safety

• Explain how to report an injury involving a staff member.

Security

• Explain your response to a Code Silver.

• Explain your response to a Code Pink.

Life Safety

• What does RACE stand for?

• Where is the nearest fire alarm pull station in your location?

• Where is your nearest fire extinguisher?

Emergency

• What is a Code Green?

• Where are the MedSled Evacuation Sleds located?

Haz Mat and Waste

• What goes into biohazard red bag waste?

Medical Equipment

• How do you report a medical equipment problem?

• Explain information found on the medical equipment sticker.

Utilities

• If the power in the hospital fails, explain how to locate outlets powered by the emergency generator.