Physical Environment Safety Rounds

• Yes

  No

  N/A

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Revised 5-4-16. Reviewed 5-4-16

Environmental Safety

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• EXIT lights are lit not burned out?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Privacy curtains clean and free of damage?

  Yes

  No

  N/A

• No visible signs of pests bugs mice etc.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• No under sink storage?

  Yes

  No

  N/A

Fire and Life Safety

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are Fire Pull Stations clear of obstructions?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

• All storage is 18" from ceiling

  Yes

  No

  N/A

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

  Yes

  No

  N/A
Utilities Management

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

  Yes

  No

  N/A

• Surface Mounted Electrical Panels are locked?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A
Hazardous Materials

• Eye Wash Station -plumbed checked Weekly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Staff knows how to clean up a small spill?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A
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.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Code Cart is Locked?

  Yes

  No

  N/A
Soiled Utility Room

• Only Soiled item present, items contained?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A
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

  Yes

  No

  N/A

• No soiled items present

  Yes

  No

  N/A

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

  Yes

  No

  N/A
Patient Nourishment area

• Refrigerator Temperature Log is up to date?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Microwaves a clean and good condition?

  Yes

  No

  N/A

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

  Yes

  No

  N/A
Staff Break Room

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

  Yes

  No

  N/A

• No storage under sink?

  Yes

  No

  N/A
Documentation Control

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

  Yes

  No

  N/A

• Prescription Pads are not left out?

  Yes

  No

  N/A

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

  Yes

  No

  N/A
Emergency Management

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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"

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

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

  Yes

  No

  N/A
Action to be taken by Director/Manager

• Additional Education needed for staff?

  Yes

  No

• 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

  Yes

  No

• Date Corrective Action Plan to be implemented

  Yes

  No

  N/A