Outpatient Services Manager/Supervisor/Lead Rounding Report

• Site conducted

  Select

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• LOCATION/UNIT:

• WHICH SHIFT

• DEPT MANAGER/LEADER:

• INSPECTOR(S):

• DATE:

  Date

SECURITY MANAGEMENT

• Associates are wearing DHHS identification badges

  Compliant

  Non-Compliant

  N/A

• Patient Information is kept private/confidential

  Compliant

  Non-Compliant

  N/A

• Are medications properly secured in the Medication Room

  Compliant

  Non-Compliant

  N/A

• Compliant

  Non-Compliant

  N/A

SAFETY MANAGEMENT

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

  Compliant

  Non-Compliant

  N/A

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

  Compliant

  Non-Compliant

  N/A

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

  Compliant

  Non-Compliant

  N/A

• Exit signs are posted and lit

  Compliant

  Non-Compliant

  N/A

• Storage areas appropriately utilized

  Compliant

  Non-Compliant

  N/A

• Patient refrigerator / freezer temperature monitoring log compliant

  Compliant

  Non-Compliant

  N/A

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

  Compliant

  Non-Compliant

  N/A

• There were no expired supplies found in supplies and medication room

  Compliant

  Non-Compliant

  N/A

• Emergency eye wash station are inspected weekly In Triage

  Compliant

  Non-Compliant

  N/A

• Emergency eye wash station are inspected weekly In ER

  Compliant

  Non-Compliant

  N/A

• No broken, defective or nonfunctional equipment/furniture found

  Compliant

  Non-Compliant

  N/A

• Emergency Lighting is operational.

  Compliant

  Non-Compliant

  N/A

Crash Cart

• Portable suction present on crash cart

  Compliant

  Non-Compliant

  N/A

• Portable Oxygen Tank present on crash cart

  Compliant

  Non-Compliant

  N/A

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

  Compliant

  Non-Compliant

  N/A

• Cardiac Monitors have all attachments

  Compliant

  Non-Compliant

  N/A

Review of Clinic Proper

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

  Yes

  No

  N/A

• Hand Hygiene compliance observed

  Compliant

  Non-Compliant

  N/A

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

  Compliant

  Non-Compliant

  N/A

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

  Compliant

  Non-Compliant

  N/A

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

  Compliant

  Non-Compliant

  N/A

• Nurse call button, code button operational. Test conducted

  Compliant

  Non-Compliant

  N/A

• Dinamap fully functional (Triage )

  Compliant

  Non-Compliant

  N/A

• Nursing station clean and free of clutter

  Compliant

  Non-Compliant

  N/A

Physician Room Review

• Each cubicle had alaris pump

  Compliant

  Non-Compliant

  N/A

• All Cardiac Monitors are functional with all attachments

  Compliant

  Non-Compliant

  N/A

• Each Room has Pediatric facemask (2)

  Compliant

  Non-Compliant

  N/A

• Each Cubicle has Pediatric NC (2)

  Compliant

  Non-Compliant

  N/A

• Each Cubicle has Pediatric Nebulizer

  Compliant

  Non-Compliant

  N/A

• Each Cubicle has Adult Facemask

  Compliant

  Non-Compliant

  N/A

• Each Cubicle has an Adult NRFM

  Compliant

  Non-Compliant

  N/A

• Each Cubicle has an Adult NC

  Compliant

  Non-Compliant

  N/A

• Each Cubicle has Disposable gowns, sheets, blue pads

  Compliant

  Non-Compliant

  N/A

• Cubicle 6 have vaginal speculum(s)

  Compliant

  Non-Compliant

  N/A

• Each cubicle has a suction device setup

  Compliant

  Non-Compliant

  N/A

• Each cubicle has sterile gloves 2 pairs in each size

  Compliant

  Non-Compliant

  N/A

OVERALL SCORE: