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?
All sizes sm, med, lg, xlg ?

Do you know what Nonconforming tag is and it process?

Orange Nonconforming tag to be filled out completely for all items that broken, do not work, or wrong item ordered.

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?

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?
No more than 12 cylinders present?

Alcohol hand gel is not empty and in good condition?

Note: not within 6" center to center of a light switch or 6" center to center of above a receptacle
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?

All critical patient devices need to be plugged into a RED outlet.

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) ?
(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)


Defibrillator Operation checks are performed daily and checked once per shift? For departments open 24/7.
(Verify log Sheet checks are preferred at the beginning of each shift)

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?

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?
No paper, discarded items on the floor
Floor is clean free of dust and dirt including behind door and corners

No soiled items present

Clean Linen Cart is properly covered ?
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.
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?
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?
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 ?
Main Campus - ext. 2-4444
North Campus - ext.4-2200

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

Staff knows what to do when a Severe Thunderstorm WARNING means?

"A severe thunderstorm is occurring or about to occur"

Staff knows what a Tornado Watch means and what to do?

"Conditions are favorable for tornados to develop"

"Close blinds, locate extra blankets, pillows, and flashlights"

Staff knows what a TORNADO WARNING means and what to do?

"A Tornado has been spotted that may have an impact on our facility"

Move patients that are able into hallways,
Patients that are not able be be moved put pillows and blankets around them.

Staff knows what Code Silver means?

"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.
Risk Management will forward a corrective action plan to the Department Director to be completed and returned

Date Corrective Action Plan to be implemented

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.