Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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3 foot clearance maintained between fire panels, med gas shut offs, fire extinguishers, and pull stations
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All drinks are covered and no staff food in patient care areas
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All laryngoscope blades & handles are clean and in original packaging (blades are in a peel pack or sterile tray, handles in a zip lock bag clearly marked clean, airways are individually wrapped in original packaging and sealed)
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All non-patient room doors are closed and devoid of door props (look for offices supply rooms, break rooms, and so on)
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All personal health information secured (face sheets, unlocked computers, patient stickers all have PHI on them)
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All staff members, physicians, contractors and vendors have appropriate name tag attached above his or her waist
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Ceiling tiles are in good condition with no stains or visible damage
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Ceiling vents are clean and free of visible dust, dirt, or discoloration
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Clean linen is kept covered no pillows on top
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All logs are appropriately up-to-date with no blanks.<br>• Code Carts: Daily check unless unit is closed. If unit is closed, this must be marked on the log<br>• Eyewash: Weekly for plumbed eyewash stations, check by expiration date for bottles<br>• Fridge and freezer logs: Daily
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Doors close, latch, and are in good condition (look for dents, damage, or chipped paint)
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Food in patient nutrition refrigerator labeled and dated with patient information and the kitchen space is clean
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Furniture is in good condition with no stains, chips, or damaged fabric. Please check at least 5 pieces of furniture
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Hallways, fire doors, and exits are clean and clear, all wheeled objects need to be moved out of the egress corridor. Only crash carts and/or isolation carts may be stored in corridors
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O2 cylinders secured (i.e. in appropriate cage tanks and not stored on wheelies, leaning against walls, etc.) and there are no more than 12 cylinders stored in a smoke compartment.
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Preventive maintenance (PM) stickers current. Please check at least 5 pieces of equipment
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Supplies are within the expiration date, including lab specimen tubes. <br>NOTE: Open supplies (EKG leads, spiked IV bags, IV bags outside of the protective packaging) expire much quicker than supplies within the bag. Expiration must be dated and timed.
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Sharps container has only sharps (no medication vials, band aids, PHI, other trash) <br>Please check at least 3 bins
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All cleaning supplies (buckets, spray bottles, etc.) are appropriately labeled with type of cleaning agent
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Testing strips (5 months) & QC solutions (3 months) for glucose monitors are dated
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The unit is clear from shipping boxes and wooden pallets (boxes may be in dirty utility room, off the floor)
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Unit/department is clean including drawers and cabinets. (Please look on top of high surfaces for dusting- think picture frames)
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Walls are in good condition and devoid of dents or chipped paint
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All suction tubing and single patient use supplies are in protective packaging<br>**Check supply/airway carts to ensure items are individually packaged as required
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Ultrasound gel bottles dated with 30 day expiration date. <br>Multiuse medication bottles/vials. Once opened need a new expiration date 28 days after opening.
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Saline and saline flushes, as well as IV supplies, are secured and not accessible to patients
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Emergency pull cords in patient bathrooms are not looped around grab bars
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EOC Buddy Hand Hygiene<br>• For nursing units and procedural areas only!<br>• Watch for staff performing hand hygiene (foam or soap & water) as they enter or exit patient rooms <br>• Document good and bad hand hygiene by staff type (i.e. RN – Yes, PCT – No, MD – Yes)<br>• Only count hand hygiene if you are 100% sure the staff member did or did not foam or wash their hands<br>• Be secretive; don’t tell staff you are watching hand hygiene compliance!
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OTHER: Document any other items you have observed.