Patient Room Annual Pm

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

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.

  Date

• 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.

  Yes

  No

  N/A

• Check thermostat for calibration.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Bed 1 Operational checks.

• Check head up function for correct operation.

  Yes

  No

  N/A

• Check head down function for correct operation.

  Yes

  No

  N/A

• Check knee up function for correct operation.

  Yes

  No

  N/A

• Check knee down function for correct operation.

  Yes

  No

  N/A

• Check bed up function for correct operation.

  Yes

  No

  N/A

• Check bed down function for correct operation.

  Yes

  No

  N/A

• Check tend up function for correct operation.

  Yes

  No

  N/A

• Check tend down function for correct operation.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Check power cord and wall outlet.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• Check head down function for correct operation.

  Yes

  No

  N/A

• Check knee up function for correct operation.

  Yes

  No

  N/A

• Check knee down function for correct operation.

  Yes

  No

  N/A

• Check bed up function for correct operation.

  Yes

  No

  N/A

• Check bed down function for correct operation.

  Yes

  No

  N/A

• Check tend up function for correct operation.

  Yes

  No

  N/A

• Check tend down function for correct operation.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Check power cord and wall outlet.

  Yes

  No

  N/A

• 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.<br><br>

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Check head wall night light. For correct operation.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Bed 1 T/V and light control checks.

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Bed 2 T/V and light control checks.

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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.

  Yes

  No

  N/A

• Check all faucet Handel for correct alignment.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Vacuum Outlets Medical Gas.

• Outlet 1 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Outlet 2 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Outlet 3 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Outlet 4 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Medical Air Outlets Medical Gas.

• Outlet 1 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• Outlet 2 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• Outlet 3 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• Outlet 4 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

Oxygen Outlets. Medical Gas.

• Outlet 1 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• Outlet 2 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• Outlet 3 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• Outlet 4 (Leak test) check for any leakage.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

Carpentry

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Bathroom Floor/Ceiling: Cove base in good condition?

  Yes

  No

  N/A

• Bathroom Floor/Ceiling: Floor tile in good condition?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

Painting

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Main door: General condition of the finish.

  Excellent

  Average

  Poor

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Bathroom Paint: All vinyl wall covering in good condition?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Bathroom door: General condition of the finish.

  Excellent

  Average

  Poor

Signage

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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.

  Date

• 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.

  Date

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