PBMC Departmental EOC Safety Survey Checklist

• Site conducted

• Conducted on

  Date

• Inspected by

• Location
  Address
• Department/Office
  Address

• Dept. Director

A. FIRE SAFETY MANAGEMENT PHYSICAL INSPECTION

• Are exit doors and stairwells clear? Main corridors and stairwell exits cannot be blocked by any means.

  Yes

  No

  N/A

• Are exit doors clearly marked "exit" and illuminated? Check for burned out bulbs. Is"No exit" not marked with "Not an exit" sign.

  Yes

  No

  N/A

• Are corridors and passageways free of obstruction? Corridors can have mobile items (wheels on them) that are emergency needed items and are in use.

  Yes

  No

  N/A

• Are pull stations or fire extinguishers unobstructed? There must be nothing obstructing access.

  Yes

  No

  N/A

• Have fire extinguishers been inspected & signed? Inspected monthly.

  Yes

  No

  N/A

• Is top of fire extinguishers more than 5 feet above floor.

  Yes

  No

  N/A

• Are fire doors propped/held open? Doorstops or homemade hold open devices are not allowed.

  Yes

  No

  N/A

• Are all materials, except for permanent cabinets, stored a minimum of 18 inches below sprinkler head? The distance between the sprinkler heads and stored items is 18” for sprinkled buildings.

  Yes

  No

  N/A

• Are sprinkler heads free of dust or foreign material/escutcheon are present & tight to the ceiling?

  Yes

  No

  N/A

• Are Sprinkler System Pipes used to support any other items?

  Yes

  No

  N/A

• Are storage rooms and equipment rooms free of clutter and unsafe conditions? Make sure items are not falling down. The storage areas have clear aisles to the back and are organized.

  Yes

  No

  N/A

• Staff know actions to take during a fire & fire equipment (extinguisher & pull station) locations. Tallies below.

  Yes

  No

  N/A

• Life safety question tallies: # Yes

• Life safety question tallies: #No

• Are holes and other openings in walls fire stopped/ Is I-Beams insulation intact?

  Yes

  No

  N/A

B. SAFETY MANAGEMENT PHYSICAL INSPECTION

• Are showers clean and free of mildew, mold or discoloration? Is caulking, grout or other non-absorbable product intact and functional?

  Yes

  No

  N/A

• Is there evidence of smoking?

  Yes

  No

  N/A

• Are wet floors clearly marked to reduce slipping hazards? When floors are wet, does the staff put out “wet floor” signage?

  Yes

  No

  N/A

• Are the floors/hallways/rooms in good condition? – No broken/missing/lifting laminate on counters or walls, no lifting floor tiles or trip hazards? No peeling paint, wall damage, etc

  Yes

  No

  N/A

• Are ceiling tiles clean, stain free, and in good condition? Indicate where these stained tiles are located

  Yes

  No

  N/A

• Does all non-clinical electrical equipment have an initial electrical safety check inspection sticker? Indicate what equipment needs electrical safety inspections

  Yes

  No

  N/A

• Are all amp drawing appliances like refrigerators, freezers, coffee makers, space heaters, etc. plugged directly into the wall? Do not plug these types of devices into power outlet strips

  Yes

  No

  N/A

• Are Relocatable Power Taps (RPTs) in patient care vicinity & room permanently mounted

  Yes

  No

  N/A

• Are compressed gases stored properly? Compressed gases need to be chained to the wall or on a cart secured. Freestanding bottles are not allowed

  Yes

  No

  N/A

• Do the employees in the dept. have any safety concerns or suggestions? Forward all concerns to system safety officer

• Are there any expired supplies on hand? Note findings below (include room, item, and exp. date).

  Yes

  No

  N/A

• Is the PBMC Safety Guidelines manual accessible and up to date? Online.

  Yes

  No

  N/A

C. UTILITIES PHYSICAL INSPECTION

• Are there any extension cords in this area? Remove these immediately.

  Yes

  No

  N/A

• Are all computer, equipment, telephone cords out of the way?

  Yes

  No

  N/A

• Are electrical cords free of cracks, fraying and cuts, not pinched? Note: include all IS workstations with movable parts.

  Yes

  No

  N/A

• Are all charging/electrical cords that are plugged into the wall connected to their electrical device? Power cords/charging cords for devices like laptops, cell phones, portable vital sign equipment, electric razors, etc. must be unplugged from the outlet when the device is not attached.

  Yes

  No

  N/A

• Are all mechanical, electrical, communications rooms clean with no storage? Indicate which rooms are not clean.

  Yes

  No

  N/A

• Do electrical panels have 3 feet of space all the way around them? Are they assessable?

  Yes

  No

  N/A

D. HAZARDOUS MATERIALS AND WASTE PHYSICAL INSPECTION

• Is there appropriate disposal of waste, including red, chemo, clear bag waste?

  Yes

  No

  N/A

• Are emergency eyewash and/or emergency showers free of obstructions and checked weekly?

  Yes

  No

  N/A

• Are all original and secondary chemical containers properly stored & labeled? Labeled with product name, hazardous ingredients and hazard warning.

  Yes

  No

  N/A

• Are chemicals stored separate from food or other clean items?

  Yes

  No

  N/A

• Is the dept. hazardous chemical inventory up to date and available to all staff? Dept. has an SDS for every chemical in the area.

  Yes

  No

  N/A

• Staff know where to find dept. SDS information. Tallies below.

  Yes

  No

  N/A

• SDS question tallies: # Yes

• SDS question tallies collected. # No

E. SECURITY PHYSICAL INSPECTION

• Are staff's personal items properly secured? Check for purses, billfolds, money, keys, etc. visible.

  Yes

  No

  N/A

• Are all employees/medical staff wearing their ID badges in plain view? Tallies below.

  Yes

  No

  N/A

• ID Badge tallies: # Yes (Wearing)

• ID Badge tallies: # No (Not wearing)

• Are all patient medical records/patient information in a secured location? Check all department locations/cabinets to make sure medical records/patient information is not accessible to unauthorized personnel.

  Yes

  No

  N/A

• Are all mechanical, electrical, housekeeping, communications rooms locked? Indicate which rooms are not locked.

  Yes

  No

  N/A

F. MEDICAL EQUIPMENT MANAGEMENT PHYSICAL INSPECTION

• Does the equipment have any exposed wires? Check the cords and plugs for exposed wires, broken plugs, etc.

  Yes

  No

  N/A

• Does the equipment's cleanliness, paint, wiring, covers appear satisfactory?

  Yes

  No

  N/A

• Are all medical equipment inspection tags current? Check all equipment for expired inspection dates, including leased equipment.

  Yes

  No

  N/A

G. EMERGENCY MANAGEMENT PLAN

• Has the dept. call-back list been reviewed within the last 6 months and/or with any staffing changes? If not, update and distribute updated list to Switchboard, system safety officer, and department.

  Yes

  No

  N/A

• Staff know what a Code Triage is & their dept. duties? Staff tallies for disaster plan below.

  Yes

  No

  N/A

• Code Triage tallies: # Yes

• Code Triage tallies: # No

H. INFECTION CONTROL/ CLINICAL DEPARTMENTS PHYSICAL INSPECTION ITEMS

• Do staff know where the oxygen shut offs are and who is authorized to shut them off? Anyone can but must coordinate with nursing to ensure all oxygen-dependent patients have portable oxygen. Tallies below.

  Yes

  No

  N/A

• O2 question tallies: # Yes

• O2 question tallies: # No

• Are gloves, gowns, eyewear, and masks readily available?

  Yes

  No

  N/A

• Is the linen covered?

  Yes

  No

  N/A

• Is clean linen kept separate from the dirty linen disposal?

  Yes

  No

  N/A

• Are refrigerator temperatures checked and logged daily for medication and patient refrigerators? Is thermometer calibration current?

  Yes

  No

  N/A

• Are medications/needles/syringes kept in locked rooms/locations? Is the door/location closed tight?

  Yes

  No

  N/A

• Are medications and food kept in separate refrigerators?

  Yes

  No

  N/A

• Is medical waste kept in red biohazard bags or containers?

  Yes

  No

  N/A

• Were employees eating or drinking in designated areas only? Staff should not have food/drink in patient care areas

  Yes

  No

  N/A

• Are any patient contact items stored on the floor? Not allowed - infection control issue.

  Yes

  No

  N/A

• Are any food stuffs/bottled water jugs stored on the floor? Not allowed - infection control issue.

  Yes

  No

  N/A

• Are multidose vials dated when opened? Disgard open vial within 28 days of opening.

  Yes

  No

  N/A

• Are Betadine bottles dated when opened? Disgard open bottles within 30 days of opening.

  Yes

  No

  N/A

• Are all pill crushers and cutters clean in clinical areas?

  Yes

  No

  N/A

• Are all upholstered surfaces (i.e. exam tables, stretcher mats, pads, chairs, stools, etc.) intact? Any torn, cracked, ripped surfaces create an un-cleanable surface and infection control issue.

  Yes

  No

  N/A

• Are all casters on equipment in patient areas in good shape? Any rusty casters create an un-cleanable surface and infection control issue.

  Yes

  No

  N/A

• Are all opened packages of electrodes marked with their new expiration date? Keep electrodes in original package.

  Yes

  No

  N/A

I. ADDITIONAL DEFICIENCES & INSPECTION Notes

• Were there additional deficiencies and/or finding (See note for details).

  Yes

  No

  N/A

• Surveyor Notes (please explain all failures)