Information
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Audit Title
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Conducted on
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Prepared by
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Location
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Personnel
ENVIRONMENT OF CARE
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No items stored under sinks?
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Equipment / Furniture:<br> * No broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips or repairs needed.
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Potential safety hazards: Housekeeping & Maintenance carts & buckets are attended and locked. All fluids are labeled.
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Laundry and trash chute accesses are locked.
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Hazardous rooms are locked: EVS closets, supply closets, mechanical rooms and electrical panels.
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Hazardous chemicals and flammable agents are labeled and stored properly.
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Eyewash stations: Inspection tags are present and up to date.
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Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)
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Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.
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Blanket, item warmers: Set to maintain temp of 130. Necessary logs completed including actions taken to out of range temperature readings.
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Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.
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No outer shipping carton boxes in patient care areas.
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No expired items.
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Preventative Maintenance:<br> * Equipment checked with up to date bio-med sticker.
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Central Alarm Monitor:<br> * Logs accurate and complete.
EMERGENCY PREPAREDNESS
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Can staff locate medical gas zone shutoff valves.
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Can Team Members code definitions.<br> * Red<br> * Yellow<br> * Orange <br> * Green<br> * Black<br> * Pink<br> * Silver<br> * Blue
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Define PASS
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Define RACE<br>
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Do Team Members know where nearest Extinguishers are?
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Do Team Members know evacuation routes?
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Do Team Members know where nearest pull stations are?
LIFE SAFETY
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Appropriate storage of boxes and pt 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.<br> * Volume of combustible material is not stored in large quantity as to create a fire hazard.
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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.<br> * Greater than 12 stored in a secured room.
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Fire exits and hallways are cleared:<br> * Egress corridors must have 8ft clearance.<br> * Equipment in corridors must be actively accessed to be in use.
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Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.
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Fire extinguishers have been inspected monthly.
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Maximum of 2-32 gallon trash cans in a 10x10 room. (unless fire rated)
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Fire doors are not blocked or propped and when closed there is positive latching.
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Exit signs are illuminated.
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Evacuation route posted & current.
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Everyone has ID badges and worn appropriately:<br> * Staff and Visitors
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Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.
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Floors, ceilings, walls, and other surfaces intact and free from holes.
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Nurse call lights working.
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Are there any alarms operating appropriately?
DESCRIBE THE DEPARTMENTS RESPONSE TO ARRIVAL
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Greet the team with smiles and introductions.
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Have a space designated for the team to conduct interviews and file reviews.
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Promptly deliver materials required for review to the tracer team.
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Any additional comments regarding positive or suboptimal issues observed during the tracer.
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Surveyors Signature