SLHS Environment of Care Safety Assessment Form

• Location
  Address

• Department

• Conducted on

  Date

• Prepared by

• Personnel

FIRE / LIFE SAFETY

• Fire extinguishers readily available/unobstructed

  Yes

  No

  N/A

• Fire extinguishers tagged and inspected monthly

  Yes

  No

  N/A

• Travel distance to fire extinguisher < or =75'

  Yes

  No

  N/A

• Doors in egress corridor self-closing or automatic closing

  Yes

  No

  N/A

• Doors not propped open

  Yes

  No

  N/A

• Doors in egress corridor positive latching

  Yes

  No

  N/A

• Fire doors free of obstructions to allow proper closing

  Yes

  No

  N/A

• Shred-it containers are at least 8 feet away from each other. Trash cans are stored at least 8 feet away from shred-it containers

  Yes

  No

  N/A

• Ceiling tiles in place/not damaged (limits transfer of smoke)

  Yes

  No

  N/A

• Evacuation routes posted and current

  Yes

  No

  N/A

• Hall is free of obstructions that could block free movement

  Yes

  No

  N/A

• Portable equipment located on one side of the corridor

  Yes

  No

  N/A

• Stairwell lighting in good condition

  Yes

  No

  N/A

• Exits free of obstructions

  Yes

  No

  N/A

• Exits signs adequately illuminated/ marked

  Yes

  No

  N/A

• Exits signs readily visible from any direction of access

  Yes

  No

  N/A

• Exit signs provided with a directional indicator that shows direction of travel when nearest exit is not apparent

  Yes

  No

  N/A

• Fire alarm pull boxes well marked and unobstructed

  Yes

  No

  N/A

• Medical Gas Zone Valves: staff can describe location, rooms they serve, and who can operate the valves

  Yes

  No

  N/A

• Fire sprinkler heads in good condition and unobstructed and have 18" clearance below head

  Yes

  No

  N/A

• Fire sprinkler heads are clean

  Yes

  No

  N/A

• Patient privacy curtains have 18" netting at top.

  Yes

  No

  N/A

• Alcohol-Based Dispensers installed per standards

  Yes

  No

  N/A

• No smoking policy enforced

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

ELECTRICAL SAFETY

• Equip is in good working order with no visible electrical hazards

  Yes

  No

  N/A

• Electrical safety checks performed by Biomed/Facilities as required

  Yes

  No

  N/A

• Electrical plugs and cords in good repair

  Yes

  No

  N/A

• Biomed/Facilities notified of defective equipment

  Yes

  No

  N/A

• Electrical extension cords are not in use, except where permitted. power Strips are not daisy chained.

  Yes

  No

  N/A

• Use of portable heating devices prohibited in patient treatment areas; except physician-ordered treatment devices

  Yes

  No

  N/A

• Portable heating devices in office/non-patient areas approved by Facilities

  Yes

  No

  N/A

• Blanket Warmers safely used (correct setting <=130 deg., not overloaded, adequate clearance on bottom rack, etc.)

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

HAZARDOUS CHEMICALS/HAZARDOUS WASTE

• Biohazardous waste properly handled, segragated, stored, disposed

  Yes

  No

  N/A

• Chemotherapy drugs properly handled, stored, and disposed

  Yes

  No

  N/A

• Acids, solvents, and other chemicals safely handled, stored and disposed

  Yes

  No

  N/A

• Chemical spill equipment available and personnel instructed in use

  Yes

  No

  N/A

• Containers properly labeled (identify and hazard warnings)

  Yes

  No

  N/A

• O2 shut-off Valves labeled with the proper room numbers

  Yes

  No

  N/A

• Eyewash stations available, operate, and tested

  Yes

  No

  N/A

• Access to SDSs (via Internet or Security)

  Yes

  No

  N/A

• Compressed gas tanks properly stored and secured

  Yes

  No

  N/A

• Oxygen storage limited to 12 E-cylinders (unless 1 hr. fire rated room)

  Yes

  No

  N/A

• Medical gas tanks can be identified as full or empty

  Yes

  No

  N/A

• Medical gas tanks are not stored in the same racks

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

GENERAL SAFETY

• Storage areas neat and orderly, free of clutter

  Yes

  No

  N/A

• Appropriate PPE is available for use in the department or area at the time of survey

  Yes

  No

  N/A

• Storage greater than 18" from fire sprinkler heads

  Yes

  No

  N/A

• Carts, stretcher, IV poles, chairs, shower chairs etc in good condition

  Yes

  No

  N/A

• Walking/climbing surfaces (floors, stairs, etc.) clear/safe

  Yes

  No

  N/A

• Wet floor signs available and used

  Yes

  No

  N/A

• Handrails in halls present, accessible and properly secure

  Yes

  No

  N/A

• Eyewash and emergency shower stations being checked weekly

  Yes

  No

  N/A

• Eyewash stations not obstructed by equipment or other items

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

SECURITY

• Employees/staff wearing ID badges

  Yes

  No

  N/A

• Staff personal belongings are secured properly

  Yes

  No

  N/A

• Panic alarms present/functioning

  Yes

  No

  N/A

• Rooms/offices secure when unattended

  Yes

  No

  N/A

• Emergency access to all locked and occupied spaces

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

PATIENT CARE ENVIRONMENT (EC.02.06.01)

• Interior spaces safe and suitable for patient care/tx/svcs

  Yes

  No

  N/A

• Storage space appropriate to meet patient needs

  Yes

  No

  N/A

• Lighting is suitable for care, treatment, and services

  Yes

  No

  N/A

• Ventilation, temp, / humidity levels suitable for patient care

  Yes

  No

  N/A

• Interior spaces accommodate equipment, wheelchairs, etc.

  Yes

  No

  N/A

• Areas clean, sanitary and free of offensive odors

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

STAFF KNOWLEDGE EM/EOC QUESTIONS

• Do you know where to find SLHS emergency operations plan

  Yes

  No

  N/A

• Do you know where to find SLHS emergency preparedness guide (red book)

  Yes

  No

  N/A

• How do you access a SDS (safety data sheet)

  Yes

  No

  N/A

• Explain how to report an incident or injury involving a visitor, patient, property

  Yes

  No

  N/A

• Do you know how/when to report and document personal work related injury

  Yes

  No

  N/A

• What is your depart/unit role in an event of a Mass Casualty Event

  Yes

  No

  N/A

• If you discover a fire how would you respond

  Yes

  No

  N/A

• Do you understand the process for partial or complete unit evacuation (horizontal and vertical evacuation)

  Yes

  No

  N/A

• Where is the nearest fire extinguisher

  Yes

  No

  N/A

• Do you know the location of fire alarm pull stations & extinguishers

  Yes

  No

  N/A

• How would you activate a fire alarm

  Yes

  No

  N/A

• Where are your exits and where do they discharge the building

  Yes

  No

  N/A

• Can you define Code Pink and what are your dept/areas responsibilities

  Yes

  No

  N/A

• Can you define Code Black and what are your dept/areas responsibilities

  Yes

  No

  N/A

• Can you define Code Blue and what are your dept/areas responsibilities

  Yes

  No

  N/A

• Can you explain what your department does when the hospital activates its severe weather response plan for severe thunderstorm

  Yes

  No

  N/A

• Can you explain what your department does when the hospital activates its severe weather response plan for tornado

  Yes

  No

  N/A

• Can you define an active shooter/hostage situation and what is your response/responsibilities

  Yes

  No

  N/A

• Can staff locate flashlights, batteries, and glow sticks (if applicable) in the event of power loss

  Yes

  No

  N/A

• What are your responsibilities for a Security Alert-Missing Persons alert

  Yes

  No

  N/A

• Other:

  Yes

  No

  N/A

This form was developed by the SLHS (Environment of Care) EOC Committee to provide a common set of areas to be assessed when conducting annual or semi-annual EOC Safety assessments of departments, entities or spaces owned/ leased by SLHS. The above areas of assessment are the minimum areas to be reviewed during EOC Safety assessments. The areas of assessment listed above may not included all areas or questions asked by those staff conducting the EOC Safety Assessments, instead should be considered a template tool that may include additional Environment of Care areas of focus. Score each section by dividing the number correct by the total number of areas assessed. It is possible that some areas of assessment listed on this form may not apply to some departments, SLHS entities or lease spaces. In that case these areas should not be included in the total possible for that section being scored. Scores generated by this form can be used to track overall status of an entity’s Environment of Care program, validate recent changes or education initiatives. These scores may also be used to help identify departments, entities or EOC areas of focus that need improvement. All scores should be communicated to the appropriate SLHS Entity EOC Committee.