Information
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Audit Title
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Conducted on
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Surveyor Signature
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Staff Signature
ENVIRONMENT OF CARE
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No items stored under sinks?
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Equipment / Furniture:<br> * No broken equipment or furniture stored on the patient care units.<br> * Coverings are intact - no rips or repairs needed.
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Potential safety hazards: Housekeeping & Maintenance carts & buckets are attended and locked. All fluids are labeled.
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Laundry and trash chute accesses are locked.
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Hazardous rooms are locked: EVS closets, supply closets, mechanical rooms and electrical panels.
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Hazardous chemicals and flammable agents are labeled and stored properly.
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Eyewash stations: Inspection tags are present and up to date.
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Refrigerators: Contain only those items designed for that refrigerator (specimen, medications or patient food)
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Refrigerators: If manually monitored, logs are complete. Both manual and temp track-documentation is present for actions taken to correct out of range temps.
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Blanket, item warmers: Set to maintain temp of 130. Necessary logs completed including actions taken to out of range temperature readings.
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Electrical safety: Use of hospital grade power strips, plugs & receptacles in good condition.
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No outer shipping carton boxes in patient care areas.
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No expired items.
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Preventative Maintenance:<br> * Equipment checked with up to date bio-med sticker.
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Central Alarm Monitor:<br> * Logs accurate and complete.
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EMERGENCY PREPAREDNESS
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Can staff locate medical gas zone shutoff valves.
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INFORMATION MANAGEMENT
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Confidential Patient Information:<br>Cannot be overheard or seen by unauthorized persons:<br> * Computer terminals signed off when not in use.<br> * Patient information is not discussed in public areas.<br> * Labels and PHI are obliterated before discarding in the trash.
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No clipboards displayed as sign-in sheets when multiple patient names on the list.
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If fax machine is in public area, patient information is quickly removed.
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LIFE SAFETY
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Appropriate storage of boxes and pt care items:<br> * Not directly on floor.<br> * 18" clearance from sprinkler head.<br> * Boxes stored on shelves close to floor must have solid bottom and high enough to not incur water damage from mopping.<br> * Volume of combustible material is not stored in large quantity as to create a fire hazard.
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Oxygen or other combustible compressed gas cylinders are stored properly:<br> * Secured in floor stand, carrier or secured to the wall by a mount. (not laying on the floor or against wall)<br> * Limited to 12 E-cylinders per smoke compartment.<br> * Greater than 12 stored in a secured room.
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Fire exits and hallways are cleared:<br> * Egress corridors must have 8ft clearance.<br> * Equipment in corridors must be actively accessed to be in use.
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Fire alarm pull stations, fire extinguishers, medical gas shutoff valves are not blocked.
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Fire extinguishers have been inspected monthly.
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Maximum of 2-32 gallon trash cans in a 10x10 room. (unless fire rated)
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Fire doors are not blocked or propped and when closed there is positive latching.
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Exit signs are illuminated.
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Evacuation route posted & current.
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Everyone has ID badges and worn appropriately:<br> * Staff and Visitors
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Ceiling tiles are in place, no cracks, holes, misaligned or visible stains.
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Floors, ceilings, walls, and other surfaces intact and free from holes.
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Nurse call lights working.
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PATIENT SAFETY / NATIONAL PATIENT SAFETY GOALS
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Are PSG posted on unit.
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STANDARD PERFORMANCE IMPROVEMENT
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Are units quality improvement dashboards posted on unit.
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Is unit's PI project data posted.
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PROVISION OF CARE TREATMENT AND SERVICES
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Are there any alarms sounding that staff is not attending to in a timely manner.
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INFECTION PREVENTION
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Food and drink in designated areas:<br> * No evidence of it in patient rooms/area, perches, hazardous chemical storage area, laboratory specimen area.
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Hand Hygiene Products:<br> * No empty alcohol gel bottles<br> * No empty soap or paper towels<br> * No unapproved lotions
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PPE:<br> * Readily available<br> * Clearly marked<br> * Worn correctly<br>
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Patient food & drinks: No expired items.
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Biohazard Waste:<br> * Discard in Red Bags with a biohazard symbol<br> * Not overfilled<br> * Covered when transported<br>
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Soiled Linen: Properly stored and not overfilled.
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Separation of clean vs. dirty supplies & equipment:<br> * Clearly marked<br> * Clean items if stored in soiled utility are covered & clearly marked
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Patient care supplies:<br> * Not expired, damaged, soiled.
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Linen and Linen Carts: Covered and carts have solid bottoms.
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Sharps Waste:<br> * Placed in puncture resistant sharps container.<br> * Disposed of when 3/4 full or "full" indicator<br> * Mounted appropriately
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General Cleanliness:<br> * Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms<br> * No blood or bodily fluids
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Air vents: Clean
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All items in PT care area that are not disposable are able to be wiped down.
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Curtains, drapes or blinds clean.
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Negative and Positive air flow rooms function appropriately.
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Ice machines clean.
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Water fountains clean and functioning.
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MEDICATION MANAGEMENT
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Medication rooms are clean and uncluttered.
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Laminar flow hood is used for IV admixture when appropriate.
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Visual inspection of medication containers: No Issues.
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Area free of distractions.
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Medication is appropriately labeled.<br> * Expiration dates, directions, etc..
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All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance.
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Controlled substances stored to prevent diversion.
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Medications stored appropriately to maintain stability.
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Medications, formula, & solutions not expired beyond expiration date.
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Opened multi-dose vials dated and initialed. Not expired.
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Code Carts:<br> * Locked and marked with then first drug to expire.<br> * Checked per policy.<br> * Include defibrillator check.<br> * Extra locks kept secured.<br> * All supplies & drugs that are on the inventory list are on the cart.<br> *. Cart is clean.<br> *. O2 tank is >1/2 full
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Syringes are labeled when in use.
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Medication refrigerator: Only contain medications for current patients.
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Breast Milk Refrigerators: Only contain milk for current patients.
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Patient Bedside: <br> *. IV tubing is labeled per policy.<br> *. Medication is secured and labeled.<br> *. All solutions are labeled at the bedside.
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Medication Carts: Doors and drawers are locked.
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RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL
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Patients and families properly informed of their rights.<br> *. Rights and Responsibilities statement
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Family guides provided to all families on admissions.
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WAIVED TESTING / POINT OF CARE TESTING
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Point of Care testing lab controls documented and control solution labeled & dated.<br> *. Reagents, i Stat analyzes, glucometers, GEMS
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Point of Care Testing Quality Control:<br> *. Consistently and correctly documented<br> *. Dates missing initials<br> *. Performed by qualified person<br> *. Out of range is followed<br> *. Logged numbers match bottle ID numbers<br>
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DESCRIBE THE UNITS RESPONSE TO YOUR ARRIVAL
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Greet the team with smiles and introductions.
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Have a space designated for the team to conduct interviews and file reviews.
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Promptly deliver materials required for review to the tracer team.
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Any additional comments regarding positive or suboptimal issues observed during the tracer.
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Other Comments
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