Audit

Annual Room Preventative Maintenance.

This Room Pm programs has been developed in conjunction with Environmental Services and the Facilities Department. In order to assure that all patient rooms are kept in a safe and comfortable environment for our patients and visitors. EVS department will complete a terminal clean to include floor care on each room after Facilities has completed all needed PM's. Please notify EVS that we have started a PM on this room. Provided them with the estimated time of completion. EVS will add this to their scheduled for terminal clean at that time.

Call 26646 Record the time and date that you spoke to Environmental Services.

Enter the name of the person that you spoke to in EVS

Room Details

Enter Room Number

Enter Site 10.01 Pm WorkOrder Number

HVAC Inspections.

Remove and clean all return and exhaust grills.

Check thermostat for calibration.

Clean and change filter in fan coil unit. (if used)

Bed 1 Operational checks.

Check head up function for correct operation.

Check head down function for correct operation.

Check knee up function for correct operation.

Check knee down function for correct operation.

Check bed up function for correct operation.

Check bed down function for correct operation.

Check tend up function for correct operation.

Check tend down function for correct operation.

Check night light on bed for correct operation. (note: this is on a photo cell and will need to be covered)

Check all side rails for correct operation. (this will included locking in the up position along with testing all rail switches for proper operation.)

Check power cord and wall outlet.

Enter bed 1 equipment number (on the bed rail) This is very important to document this number.

Bed 2 Operational checks

Check head up function for correct operation.

Check head down function for correct operation.

Check knee up function for correct operation.

Check knee down function for correct operation.

Check bed up function for correct operation.

Check bed down function for correct operation.

Check tend up function for correct operation.

Check tend down function for correct operation.

Check night light on bed for correct operation. (note: this is on a photo cell and will need to be covered)

Check all side rails for correct operation. (this will included locking in the up position along with testing all rail switches for proper operation.)

Check power cord and wall outlet.

Enter bed 2 equipment number (on the bed rail) This is very important to document this number.

Electrical Inspections.

Bed 1 check over bed light and switches. (pull cords, wall switches and lamps) For correct operation.

Bed 2 check over bed light and switches. (pull cords, wall switches and lamps) For correct operation.

Check head wall night light. For correct operation.

Check bathroom light, switches and lamps. For correct operation.

Check bathroom night light lamps. For correct operation. Note: This light should burn at all times and not be switched.

Check all outlets for Polarity, integrity, and tension. For correct operation.

Test all GFI outlets with approved tester. For correct operation.

Enter the total amount of outlets checked in this room (included all bathroom outlets and GFI's)

Bed 1 Nurse call system checks.

(Always Notify nursing that you will be testing the nurse call system.)

Activate nurse call at the pillow speaker. Did the light above the door turn on?

Activate nurse call at the pillow speaker. Could audio sound be heard in the hallway?

Activate nurse call at the pillow speaker. Check at the nurse station console did the system indicate correct room number?

Activate nurse call at the pillow speaker. Check the nurse station console was their audio sound at the console ?

Bed 2 Nurse call system checks.

(Always Notify nursing that you will be testing the nurse call system.)

Activate nurse call at the pillow speaker. Did the light above the door turn on?

Activate nurse call at the pillow speaker. Could audio sound be heard in the hallway?

Activate nurse call at the pillow speaker. Check at the nurse station console did the system indicate correct room number?

Activate nurse call at the pillow speaker. Check the nurse station console was their audio sound at the console ?

Bathroom emergency switch. Nurse call system checks.

(Always Notify nursing that you will be testing the nurse call system.)

Activate the emergency switch in the bathroom. Did the light above the door flash at high rate indicating a emergency call?

Activate the emergency switch in the bathroom. Could emergency tone be heard in the hallway?

Activate the emergency switch in the bathroom. Does the nurse console indicate correct room number?

Activate the emergency switch in the bathroom. Does the nurse console have audio tone indicating emergency call?

Bed 1 Code Blue Nurse call system checks.

(Always Notify nursing that you will be testing the nurse call system.)

Activate Code Blue switch. Did the light above the door flash at high rate indicating a emergency call?

Activate Code Blue switch. Could emergency tone be heard in the hallway?

Activate Code Blue switch. Does the nurse console indicate correct room number?

Activate Code Blue switch. Does the nurse console have audio tone indicating emergency call?

Bed 2 Code Blue Nurse call system checks.

Activate Code Blue switch. Did the light above the door flash at high rate indicating a emergency call?

Activate Code Blue switch. Could emergency tone be heard in the hallway?

Activate Code Blue switch. Does the nurse console indicate correct room number?

Activate Code Blue switch. Does the nurse console have audio tone indicating emergency call?

Bed 1 T/V and light control checks.

Using the pillow speaker control. Operate the Chanel control changing channels. Did they operate correctly?

Using the pillow speaker control. Operate the Volume control loud and clear and operate correctly?

Using the pillow speaker control. Operate light control. Did everything function correctly?

Bed 2 T/V and light control checks.

Using the pillow speaker control. Operate the Chanel control changing channels. Did they operate correctly?

Using the pillow speaker control. Operate the Volume control loud and clear and operate correctly?

Using the pillow speaker control. Operate light control. Did everything function correctly?

Plumbing and fixture inspection.

Check all plumbing for leaks. (checking floor and walls for signs of leaks) Replace all parts that are corroded or Rusty.

Check all faucet Handel for correct alignment.

Check toilet set for tightens also check for damage or wear.

Vacuum Outlets Medical Gas.

Outlet 1 (Leak test) check for any leakage.

Outlet 1 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 1 (Flow Tested) NOTE: Outlet must flow more than 3 SCFM in order pass this test.

Outlet 2 (Leak test) check for any leakage.

Outlet 2 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 2 (Flow Tested) NOTE: Outlet must flow more than 3 SCFM in order pass this test.

Outlet 3 (Leak test) check for any leakage.

Outlet 3 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 3 (Flow Tested) NOTE: Outlet must flow more than 3 SCFM in order pass this test.

Outlet 4 (Leak test) check for any leakage.

Outlet 4 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 4 (Flow Tested) NOTE: Outlet must flow more than 3 SCFM in order pass this test.

Medical Air Outlets Medical Gas.

Outlet 1 (Leak test) check for any leakage.

Outlet 1 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 1 (Flow Tested) NOTE: Outlet must flow more than 7 SCFM in order pass this test. Also must have line pressure of 55 PSI.

Outlet 1 (Purity Tested) NOTE: Must not be greater than 29 present Oxygen. Anything greater room must be taken out of service. Notify your Lead immediately.

Outlet 2 (Leak test) check for any leakage.

Outlet 2 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 2 (Flow Tested) NOTE: Outlet must flow more than 7 SCFM in order pass this test. Also must have line pressure of 55 PSI.

Outlet 2 (Purity Tested) NOTE: Must not be greater than 29 present Oxygen. Anything greater room must be taken out of service. Notify your Lead immediately.

Outlet 3 (Leak test) check for any leakage.

Outlet 3 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 3 (Flow Tested) NOTE: Outlet must flow more than 7 SCFM in order pass this test. Also must have line pressure of 55 PSI.

Outlet 3 (Purity Tested) NOTE: Must not be greater than 29 present Oxygen. Anything greater room must be taken out of service. Notify your Lead immediately.

Outlet 4 (Leak test) check for any leakage.

Outlet 4 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 4 (Flow Tested) NOTE: Outlet must flow more than 7 SCFM in order pass this test. Also must have line pressure of 55 PSI.

Outlet 4 (Purity Tested) NOTE: Must not be greater than 29 present Oxygen. Anything greater room must be taken out of service. Notify your Lead immediately.

Oxygen Outlets. Medical Gas.

Outlet 1 (Leak test) check for any leakage.

Outlet 1 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 1 (Flow Tested) NOTE: Outlet must flow more than 7 SCFM in order pass this test. Also must have line pressure of 55 PSI.

Outlet 1 (Purity Tested) NOTE: Must not be greater than 29 present Oxygen. Anything greater room must be taken out of service. Notify your Lead immediately.

Outlet 2 (Leak test) check for any leakage.

Outlet 2 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 2 (Flow Tested) NOTE: Outlet must flow more than 7 SCFM in order pass this test. Also must have line pressure of 55 PSI.

Outlet 2 (Purity Tested) NOTE: Must not be greater than 29 present Oxygen. Anything greater room must be taken out of service. Notify your Lead immediately.

Outlet 3 (Leak test) check for any leakage.

Outlet 3 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 3 (Flow Tested) NOTE: Outlet must flow more than 7 SCFM in order pass this test. Also must have line pressure of 55 PSI.

Outlet 3 (Purity Tested) NOTE: Must not be greater than 29 present Oxygen. Anything greater room must be taken out of service. Notify your Lead immediately.

Outlet 4 (Leak test) check for any leakage.

Outlet 4 (Latch Tested) Check outlet to make sure it latches to all adapters.

Outlet 4 (Flow Tested) NOTE: Outlet must flow more than 7 SCFM in order pass this test. Also must have line pressure of 55 PSI.

Outlet 4 (Purity Tested) NOTE: Must not be greater than 29 present Oxygen. Anything greater room must be taken out of service. Notify your Lead immediately.

Carpentry

Main door: Lockset and hardware. Inspect for correct operation.

Main door: Clearance/Gaps. (1/8" side and top, 1" undercut Non-Rated door, 3/4" undercut Rated door) Does door have correct clearance?

Main door: Hinges and closing operation. Inspect for proper operation did the door positively latch.

Main door: Inspect smoke gasket. Are all gaskets in place?

Main Room fixtures: Pictures/Wall hangings/Bulletin boards/Dispensers/Sharps. All in good shape hung strait and well secured and in good working order?

Main Room fixtures: Window blinds. Good condition hung strait and well secured and in good working order?

Main Room fixtures: Wall protection and corner guard installed and in good condition?

Main Room Floor/Ceiling: Cove base in good condition?

Main Room Floor/Ceiling: Floor tile in good condition?

Main Room Floor/Ceiling: Ceiling tile and track in good condition?

Main Room Floor/Ceiling: Cubical track and hooks in good condition?

Bed 1 Nurse Server. (Clean and inspect for proper operation.) NOTE; Danger/ Warning sharps have been found while cleaning use extreme Caution.

Bed Nurse Server. (Clean and inspect for proper operation.) NOTE; Danger/ Warning sharps have been found while cleaning use extreme Caution.

Bathroom door: Lockset and hardware. Inspect for correct operation.

Bathroom door: Hinges and closing operation. Inspect proper operation (With the door locked can it be opened from the outside?)

Bathroom fixtures: Pictures/Wall hangings/Bulletin boards/Dispensers/Sharps. All in good shape hung strait and well secured and in good working order?

Bathroom fixtures: Wall protection and corner guard installed and in good condition?

Bathroom Floor/Ceiling: Cove base in good condition?

Bathroom Floor/Ceiling: Floor tile in good condition?

Bathroom Floor/Ceiling: Ceiling tile and track in good condition?

Hallway: (Enter the hallway from the room) Look both directions are there (2) lighted and visible Exit Sings?

Hallway: (Enter the hallway from the room) Follow the first (1) path of egress. Are all ceiling lights working and does the door leading to stairway operate correctly? (Self closing and positively latching)

Hallway: (Enter the hallway from the room) Follow the second (2) path of egress. Are all ceiling lights working and does the door leading to stairway operate correctly? (Self closing and positively latching)

Painting

Main room Paint: Primary walls free of scratches and paint in good condition?

Main room Paint: Headwalls free of scratches and paint in good condition?

Main room Paint: All vinyl wall covering in good condition?

Main room Paint: Door frame free of scratches and paint in good condition?

Main door: General condition of the finish.

Bathroom Paint: Primary walls free of scratches and paint in good condition?

Bathroom Paint: Headwalls free of scratches and paint in good condition?

Bathroom Paint: All vinyl wall covering in good condition?

Bathroom Paint: Door frame free of scratches and paint in good condition?

Bathroom door: General condition of the finish.

Signage

Main room Signage: Hallway room number sign not damaged and secured?

Main room Signage: Door frame number in place and in good condition?

Main room Signage: In Room signage in good condition and secured? (NOTE; Remove all hand written signage.)

Hallway: In the path of egress is there a correct signage for emergency egress?

Completed room PM notification.
Call 26646 Notify EVS room PM is complete and is ready for terminal cleaning. Record the time and date that you spoke to Environmental Services.

Enter the name of the person that you spoke to in EVS

Contact nurse station on unit let them know Room PM is complete. Record time and date.

Enter the name of the person that you spoke with at the nurses station.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.