• Facility Surveillance Report

  • Emerus McKinney

  • Conducted on

  • Dan Baas, RN CEN Nurse Manager

  • Add signature

  • Craig Ranch


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

  • Check "E" cylinders oxygen supply.

  • Temperature logs signed off?

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

  • Add media

  • Fire extinguisher inspection x 5 (documented on tags)

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

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

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

  • Is the patient nutrition refrigerator clean and defrosted?

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

  • Are there space heaters present?


  • Every room, closet, and enclosure is inspected.

  • Every drain is flushed with running water.

  • Clean linen stored off ground.

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

  • Clean linen stored separate from dirty linen.

  • Clean "clean linen rack" monthly.

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

  • Any soiled bags leaking fluid(s).

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

  • Ceilings clear of staining.

  • Hand washing posters posted.

  • Report to local health department.

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

  • Are there supplies stored under sinks.

  • Other issues identified.

  • Weekly cleaning log complete and placed in facility binder.


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

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

  • All medications checked for expiration date.

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

  • No food stored in medication refrigerator.

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

  • Only authorized medications and supplies are present.

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

  • Poison control telephone number clearly posted.

  • NO concentrated electrolytes are available in unit.

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

  • Flammable items stored properly.


  • Controls and supplies are not expired.

  • Temperatures documented on LabDaq computer twice daily.

  • Levy Jennings controls for CBC reviewed.

  • Liquid controls for Piccolo completed.

  • NO food or drink in lab area.

  • No food or drink in lab refrigerator.

  • Wave testing log in order.

  • Send out computer logs reviewed.


  • Chart reviews completed.

  • HVAC issues.

  • Water supply issues

  • Security related issues.

  • Safety related issues.

  • Sewer related issues.

  • Life safety issues.

  • Trash/waste/biohazard disposal issues.

  • Other related issues.


  • Fire drill both shifts.

  • Clinical alarms checked and documented.

  • Hand washing data compiled for Infection Control meeting.

  • Needle stick log given to Safety Committee for meeting.

  • Medical gas system panels checked and operating.

  • Area alarms functioning.

  • Automatic pressure switches functioning.

  • Shut off valves operational.

  • Flexible connectors and valves functioning.


  • Local fire department approval of plan.

  • Inspection of sprinkler system.

  • Inspection of fire extinguishers.

  • Inspection of back flow valve.

  • Inspection of riser room.

  • Policy and procedure review.

  • Medical gas inspections.

  • Service generator.

  • Disaster exercise.

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


  • Dan Baas, RN CEN Nurse Manager

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.