Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Revised 5-4-16. Reviewed 5-4-16

    Environmental Safety
  • Are floors free of cracks, holes or damage, carpeting secure without frayed edges?

  • Furniture (Chairs, recliners, end tables, bed side table, over bed table, cabinet, cabinet doors, drawers,) in good condition?

  • Area free of dust (Floors, high shelving, tops of picture frames, counter tops, cabinets, ledges, air vents)

  • EXIT lights are lit not burned out?

  • Toilets, Sinks are secure clean and free of damage.

  • Privacy curtains clean and free of damage?

  • No visible signs of pests bugs mice etc.

  • PPE is available gowns, masks, gloves?<br>All sizes sm, med, lg, xlg ?

  • Do you know what Nonconforming tag is and it process?<br><br>Orange Nonconforming tag to be filled out completely for all items that broken, do not work, or wrong item ordered.<br><br>All Nonconforming Equipment must be cleaned on the floor prior to being repaired. EVS will Clean and place a GREEN cleaned tag. If equipment does not have the tag it will not be picked up until it is cleaned.

  • Nurse Station - no food or drinks, casework is in good shape not chipped, broken, cabinet doors and drawers in working order?

  • Wall mounted items secure and free of damage (pictures, signs, containers, hand rails, tv's etc.)

  • No under sink storage?

Fire and Life Safety

  • Can you explain what RACE and PASS means?<br>

  • Do you know where the nearest Fire Pull Station is?

  • Do you know the location of the nearest Fire Extinguisher is?

  • Are Fire Pull Stations clear of obstructions?

  • Are corridors free of obstructions/clutter? Includes Exits, Exit Egress routes

  • Corridor doors (Fire Rated doors self close and latch) (Smoke rated doors self close latch not necessary) (Patient Room doors close and latch)

  • Ceiling tiles are in place, dry free of stains cracks and holes?

  • O2 e-cylinders are properly supported ? Must be stored in rack or cart?<br>No more than 12 cylinders present?<br>

  • Alcohol hand gel is not empty and in good condition?<br><br>Note: not within 6" center to center of a light switch or 6" center to center of above a receptacle<br>A "dollar bill is 6" long" can use for a measuring tool.

  • All storage is 18" from ceiling

  • No Electric Space Heaters (space heaters of any type are prohibited in healthcare)

  • Utilities Management
  • Are Electrical Room, Mechanical Room, Telecomm room Doors locked?

  • Surface Mounted Electrical Panels are locked?

  • Surge Protectors are securely mounted to wall or desk? (Multi outlet strips)

  • Do you know what the RED outlets are for?<br><br>All critical patient devices need to be plugged into a RED outlet. <br><br>RED outlets are powered by the Emergency Generator.

  • Hazardous Materials
  • Eye Wash Station -plumbed checked Weekly?

  • Eye Wash Station -portable safety seal is intact checked monthly?

  • Sharps containers not over full should max fill at 2/3 full

  • Does staff know how to find the Safety Data Sheet (SDS) ?<br>(Found on the portal) (was MSDS now SDS)

  • Staff knows how to clean up a small spill?

  • Spill kits are available for hazardous substances (I.e. Formalin, chemotherapy, blood, etc..)

  • All Medical Waste containers are covered at all times? (Bio-Hazard)

  • All regulated Medical Waste containers are properly labeled or marked? (Bio-Hazard waste)

  • CODE CART
  • Defibrillator Operation checks are performed daily and checked once per shift? For departments open 24/7. <br>(Verify log Sheet checks are preferred at the beginning of each shift)<br><br>For departments NOT open 24/7 check must be performed at beginning of each shift prior to provision of patient care services including call backs for emergency services.

  • Defibrillator on Code Cart is plugged in and green lights are illuminated?

  • Code Cart is Locked?

  • Soiled Utility Room
  • Only Soiled item present, items contained?

  • Bio-Medical waste stored appropriately in bio waste containers and or red bags

  • Cart used for storage of used patient food trays is not excessively dirty?<br><br>If cart is dirty have Nurse Manager contact Food & Nutrition

  • Soiled Linen is covered or appropriately placed in dirty laundry bin or laundry chute?

  • Clean Utility Room
  • Room is clean organized?<br>No paper, discarded items on the floor <br>Floor is clean free of dust and dirt including behind door and corners

  • No soiled items present

  • Clean Linen Cart is properly covered ?<br>No holes or rips in the cover?

  • Patient Nourishment area
  • Refrigerator Temperature Log is up to date?

  • Refrigerator is clean inside and out,no frost build up and overall condition is in good shape.<br>NO Staff food items allowed!

  • Food is packaged, covered, dated, labeled and no expired items.

  • Microwaves a clean and good condition?

  • Ice Machine clean,no signs of deposits in tray? <br>Floor and wall is clean and dry beside and behind the ice machine?

  • Staff Break Room
  • Refrigerator is clean inside and out and no buildup of frost?<br>NO Patient food allowed!

  • No storage under sink?

  • Documentation Control
  • All Bulletin Boards have bulletin board ledger in left hand corner and appropriately checked?

  • Prescription Pads are not left out?

  • No policies or forms posted on walls, doors, or bulletin boards?

  • Emergency Management
  • Staff knows the number to call a CODE ?<br>Main Campus - ext. 2-4444<br>North Campus - ext.4-2200

  • Staff can verbalized location of Emergency Management Operations Plan?<br>On Portal and Quick Reference Clipboard

  • Staff knows what to do when a Severe Thunderstorm WARNING means?<br><br>"A severe thunderstorm is occurring or about to occur"

  • Staff knows what a Tornado Watch means and what to do?<br><br>"Conditions are favorable for tornados to develop"<br><br>"Close blinds, locate extra blankets, pillows, and flashlights"

  • Staff knows what a TORNADO WARNING means and what to do?<br><br>"A Tornado has been spotted that may have an impact on our facility"<br><br>Move patients that are able into hallways, <br>Patients that are not able be be moved put pillows and blankets around them.

  • Staff knows what Code Silver means?<br><br>"Person with a weapon or hostage situation"

  • Action to be taken by Director/Manager
  • Additional Education needed for staff?

  • Corrective Action Plan needs to be developed. <br>Risk Management will forward a corrective action plan to the Department Director to be completed and returned

  • Date Corrective Action Plan to be implemented

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