Monthly Facility Survey-CraigRanch

• Facility Surveillance Report

• Emerus McKinney

• Conducted on

  Date

• Dan Baas, RN CEN Nurse Manager

• Add signature

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• Craig Ranch
  Address

• Date of inspection.

  Date

SAFETY

• Are compressed gas cylinders strapped to the wall or otherwise secured in a non-tip base?

  Safe

  At Risk

  N/A

• Check "E" cylinders oxygen supply.

  Safe

  At Risk

  N/A

• Temperature logs signed off?

  Yes

  No

  N/A

• Are electrical panels kept clear within 3 feet in front of breaker panels?

  Yes

  No

  N/A

• Fire extinguisher inspection x 5 (documented on tags)

  Yes

  No

  N/A

• Are sharps containers disposed of when 3/4 full?

  Yes

  No

  N/A

• Eye wash station expiration date checked and verified to be in date?

  Yes

  No

  N/A

• Are the hallways free and clear of stored items or obstructions?

  Yes

  No

  N/A

• Is the patient nutrition refrigerator clean and defrosted?

  Yes

  No

  N/A

• Is the patient microwave clean and in good working order?

  Yes

  No

  N/A

• Are there space heaters present?

  Yes

  No

  N/A

INFECTION CONTROL

• Every room, closet, and enclosure is inspected.

  Yes

  No

  N/A

• Every drain is flushed with running water.

  Yes

  No

  N/A

• Clean linen stored off ground.

  Yes

  No

  N/A

• Clean linen properly store in clean utility room and covered and unwrapped from plastic.

  Yes

  No

  N/A

• Clean linen stored separate from dirty linen.

  Yes

  No

  N/A

• Clean "clean linen rack" monthly.

  Yes

  No

  N/A

• Soiled linen stored in proper linen bags in soiled utility room.

  Yes

  No

  N/A

• Any soiled bags leaking fluid(s).

  Yes

  No

  N/A

• High cleaning done. This includes dusting of air conditioning ventilation openings, top of refrigerators, and tall equipment.

  Yes

  No

  N/A

• Ceilings clear of staining.

  Yes

  No

  N/A

• Hand washing posters posted.

  Yes

  No

  N/A

• Report to local health department.

  Yes

  No

  N/A

• I'VE fluids stored properly and "in date".

  Yes

  No

  N/A

• Are there supplies stored under sinks.

  Yes

  No

  N/A

• Other issues identified.

  Yes

  No

  N/A

• Weekly cleaning log complete and placed in facility binder.

  Yes

  No

  N/A

PHARMACY

• Control medications properly stored and log sheets signed and verified by pharmacist.

  Yes

  No

  N/A

• Code cart medications checked for expiration date status and minimum quantity verified.

  Yes

  No

  N/A

• All medications checked for expiration date.

  Yes

  No

  N/A

• Medication refrigerator log checked and verified contents kept between 2-8 degrees Celsius daily.

  Yes

  No

  N/A

• No food stored in medication refrigerator.

  Yes

  No

  N/A

• Open multi dose medications correctly marked, dated, and properly stored.

  Yes

  No

  N/A

• Only authorized medications and supplies are present.

  Yes

  No

  N/A

• Medications are secured to include suture cart locked and not accessible to public.

  Yes

  No

  N/A

• Poison control telephone number clearly posted.

  Yes

  No

  N/A

• NO concentrated electrolytes are available in unit.

  Yes

  No

  N/A

• Topical medications are kept separate from PO and I'VE medications.

  Yes

  No

  N/A

• Flammable items stored properly.

  Yes

  No

  N/A

LABORATORY

• Controls and supplies are not expired.

  Yes

  No

  N/A

• Temperatures documented on LabDaq computer twice daily.

  Yes

  No

  N/A

• Levy Jennings controls for CBC reviewed.

  Yes

  No

  N/A

• Liquid controls for Piccolo completed.

  Yes

  No

  N/A

• NO food or drink in lab area.

  Yes

  No

  N/A

• No food or drink in lab refrigerator.

  Yes

  No

  N/A

• Wave testing log in order.

  Yes

  No

  N/A

• Send out computer logs reviewed.

  Yes

  No

  N/A

OTHER

• Chart reviews completed.

  Yes

  No

  N/A

• HVAC issues.

  Yes

  No

  N/A

• Water supply issues

  Yes

  No

  N/A

• Security related issues.

  Yes

  No

  N/A

• Safety related issues.

  Yes

  No

  N/A

• Sewer related issues.

  Yes

  No

  N/A

• Life safety issues.

  Yes

  No

  N/A

• Trash/waste/biohazard disposal issues.

  Yes

  No

  N/A

• Other related issues.

  Yes

  No

  N/A

QUARTERLY (MARCH, JUNE, SEPTEMBER, DECEMBER)

• Fire drill both shifts.

  Yes

  No

  N/A

• Clinical alarms checked and documented.

  Yes

  No

  N/A

• Hand washing data compiled for Infection Control meeting.

  Yes

  No

  N/A

• Needle stick log given to Safety Committee for meeting.

  Yes

  No

  N/A

• Medical gas system panels checked and operating.

  Yes

  No

  N/A

• Area alarms functioning.

  Yes

  No

  N/A

• Automatic pressure switches functioning.

  Yes

  No

  N/A

• Shut off valves operational.

  Yes

  No

  N/A

• Flexible connectors and valves functioning.

  Yes

  No

  N/A

ANNUALLY. (REPORT IN JUNE)

• Local fire department approval of plan.

  Yes

  No

  N/A

• Inspection of sprinkler system.

  Yes

  No

  N/A

• Inspection of fire extinguishers.

  Yes

  No

  N/A

• Inspection of back flow valve.

  Yes

  No

  N/A

• Inspection of riser room.

  Yes

  No

  N/A

• Policy and procedure review.

  Yes

  No

  N/A

• Medical gas inspections.

  Yes

  No

  N/A

• Service generator.

  Yes

  No

  N/A

• Disaster exercise.

  Yes

  No

  N/A

• Fit testing for all staff completed and in HR file at corporate.

  Yes

  No

  N/A

ADDITIONAL NOTES OR COMMENTS

• Dan Baas, RN CEN Nurse Manager

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