ST. Mary's Health Care System EOC Rounding Checklist

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Name and address of facility

Anesthesia Carts

• Med labeling- All medications secured / correctly labeled.

  Yes

  No

  N/A

• Meds Expiration- Cart medications are current, no expired dates of any Meds.<br>

  Yes

  No

  N/A

• Cart. Meds on top- No Meds on top of carts?

  Yes

  No

  N/A

• Medications Carts are secured and locked?

  Yes

  No

  N/A

• Medication Syringes are stored in secure location?

  Yes

  No

  N/A

Provision of Care/ Med Management

• All entries are dated and timed?

  Yes

  No

  N/A

• Admission Assessment completed with 12 hours of admission?

  Yes

  No

  N/A

• H&P completed within 24 hours of admission.

  Yes

  No

  N/A

• H&P completed and updated prior to surgery or other invasive procedure?

  Yes

  No

  N/A

• Nursing care plans based on identified pt needs?

  Yes

  No

  N/A

• Care plan reflects changes in patient assessment since initial assessment?

  Yes

  No

  N/A

• There are treatment plans and goals addressed on the care plan.

  Yes

  No

  N/A

• Fall risk assessment completed?

  Yes

  No

  N/A

• Pain assessments are done correctly according to pain goal?

  Yes

  No

  N/A

• Time out done and documented?

  Yes

  No

  N/A

• Site marked by physician?

  Yes

  No

  N/A

• Immediate physician post-op note documented?

  Yes

  No

  N/A

• Restraints documented every four hours?

  Yes

  No

  N/A

• Renewal orders every calendar day sign/ dated and timed?

  Yes

  No

  N/A

• Telephone orders RAV, dated/ timed/ signed by receiving nurse?

  Yes

  No

  N/A

• There is a signed/ dated/ timed consent for surgery/ invasive procedure?

  Yes

  No

  N/A

• There are no unapproved abbreviations on the chart?

  Yes

  No

  N/A

• Medication Reconciliation done correctly on admission?

  Yes

  No

  N/A

• Medication Reconciliation done each time patient transferred to another unit?

  Yes

  No

  N/A

• All PRN medications have a reason why?

  Yes

  No

  N/A

• There is documentation of education given to patient about medications?

  Yes

  No

  N/A

• Patient was asked for Advanced Directive?

  Yes

  No

  N/A

Clean & Soiled Utility

• Cart Shelf Covers- All lower shelves and carts for clean / sterile supplies are covered?

  Yes

  No

  N/A

• Clean Utility Door Closed- doors to clean utility rooms are closed?

  Yes

  No

  N/A

• PPE Storage- Supply of PPE required equipment is available and accessible?

  Yes

  No

  N/A

• Sterile Trays- Packaging / Labeling is intact and dated where needed?

  Yes

  No

  N/A

Code Cart

• Code Cart. Checklist- Checklist are complete for patients?

  Yes

  No

  N/A

• Code Cart Defibrillator Record-Defibrillator log complete / current on all carts?

  Yes

  No

  N/A

• Code Cart Meds Secure- Medications are secured?

  Yes

  No

  N/A

• Code Cart Meds Current- No expired Meds on cart?

  Yes

  No

  N/A

• Code Cart Supplies Current- No expired supplies on carts?

  Yes

  No

  N/A

• Code Cart Sterile Supplies- Packaging / Labeling is intact and dated?

  Yes

  No

  N/A

Engineering

• Ceiling Tiles- intact with no evidence of damage, water marks and stains?

  Yes

  No

  N/A

• Bed Rails - in proper working order?<br><br>

  Yes

  No

  N/A

• Linen Chute Doors- are secured and closing correctly?

  Yes

  No

  N/A

• Cylinder Storage- no more than 12 E cylinders stored in the open compartment?

  Yes

  No

  N/A

• Medical gas shut offs are labeled clearly?

  Yes

  No

  N/A

• O2 Usage is labeled at all rooms with O2 being used?

  Yes

  No

  N/A

• Gas Cylinders- All Gas cylinders are secure and working correctly?

  Yes

  No

  N/A

• Exit Lighting- Exit lights are in correct location and working?

  Yes

  No

  N/A

• lighting- All fixtures in good repair and operational?

  Yes

  No

  N/A

• Electrical Cords- Cords, plugs, strain reliefs in working order?

  Yes

  No

  N/A

• Electric Outlets- are in operating order and not overloaded?

  Yes

  No

  N/A

• Electrical Outlets- have proper cover plates installed and not damaged?

  Yes

  No

  N/A

• Electrical Panels- are not blocked and have 3 foot clearance in front?

  Yes

  No

  N/A

• Electrical Panels- All panels are locked?

  Yes

  No

  N/A

• Fire Doors- less than 1/8" is between door edges where they meet?

  Yes

  No

  N/A

• Fire Door- space at bottom of door to floor is less than 3/4"?

  Yes

  No

  N/A

• Doors on unit to other areas are free of damage and operating correctly?

  Yes

  No

  N/A

• Door closures are working correctly and not leaking?

  Yes

  No

  N/A

• Door hardware is working correctly?

  Yes

  No

  N/A

• Automatic doors are operating correctly?

  Yes

  No

  N/A

• Walls are without damage?

  Yes

  No

  N/A

• Walls paint is in good condition?

  Yes

  No

  N/A

• Flooring condition is without damage or loose materials?

  Yes

  No

  N/A

• Nurse Call System is working correctly.

  Yes

  No

  N/A

• Nurse Call is answered by staff quickly?

  Yes

  No

  N/A

• Hospital Bed is set with proper protocols for patient ?

  Yes

  No

  N/A

• Signage is correct and in good condition?

  Yes

  No

  N/A

• Cabinetry is in good condition and in no need of repair?

  Yes

  No

  N/A

• Sprinkler heads are clean and free of rust, paint, lint or dust?

  Yes

  No

  N/A

• Sprinkler heads are fit tightly in ceiling tile with no gaps?

  Yes

  No

  N/A

• Sprinkler head clearance is at least 18"?

  Yes

  No

  N/A

• Sinks are operating correctly and without leaks?

  Yes

  No

  N/A

• Sinks have handles positioned at 8 and 4 o'clock ?

  Yes

  No

  N/A

• Nothing stored under sinks?

  Yes

  No

  N/A

• Tub / showers are free of leaks and drips?

  Yes

  No

  N/A

• Tub /showers have no loose caulk?

  Yes

  No

  N/A

• Portable space heaters are not present?

  Yes

  No

  N/A

• Storage rooms are equipped with automatic door closure, positive latching, 1 3/4" thick door, sprinkler protection and walls must got to ceiling on one side of all walls?

  Yes

  No

  N/A

• Linen chute doors lock, latch and are operational?

  Yes

  No

  N/A

Equipment / Furniture

• Wheelchairs are clean and in good repair?

  Yes

  No

  N/A

• Stretchers are clean, without tears in mattress and in working order?

  Yes

  No

  N/A

• Furniture is clean and free of damage?

  Yes

  No

  N/A

• Task chairs are clean, free of tears in fabric and operational?

  Yes

  No

  N/A

• Patient room furniture is clean, free of damage and operational?

  Yes

  No

  N/A

• Waiting room furniture is clean and free of damage

  Yes

  No

  N/A

Environmental

• Chemicals properly labeled and in proper container?

  Yes

  No

  N/A

• Restrooms are clean and all supplies stocked?

  Yes

  No

  N/A

• Linen chute area is clean and free of trash?

  Yes

  No

  N/A

• Patient bathrooms are clean and stocked.

  Yes

  No

  N/A

• Patient room is clean and free of dust, lint on all surfaces?

  Yes

  No

  N/A

• Patient room floors are clean and waxed if required?

  Yes

  No

  N/A

• Patient room furniture is clean and without damage?

  Yes

  No

  N/A

• Patient equipment I pole, wheelchairs, scales, lifts and walkers are clean and free of damage?

  Yes

  No

  N/A

• Patient room walls are clean and lint free?

  Yes

  No

  N/A

• Soiled linen is being controlled and not on floor?

  Yes

  No

  N/A

• All emergency pull cords are in place and not wrapped on grab bars?

  Yes

  No

  N/A

• Trash cans and trash receptacles are clean and not over full?

  Yes

  No

  N/A

General items

• Furniture is suitable for the patient population?

  Yes

  No

  N/A

• Corridors are clean and equipment all to one side?

  Yes

  No

  N/A

• Entrances to units are clean free of trash and smoking bi-products?

  Yes

  No

  N/A

• No insects or bugs present on unit?

  Yes

  No

  N/A

Chemicals

• Chemicals are properly stored?

  Yes

  No

  N/A

• Chemicals are properly labeled?

  Yes

  No

  N/A

• Eyewash station is in place if required and is within 10 seconds accessible?

  Yes

  No

  N/A

• MSDS sheets are on record for chemicals on unit?

  Yes

  No

  N/A

• Eyewash stations were checked weekly and recorded on tag?

  Yes

  No

  N/A

• Eyewash stations operating correctly and clean?

  Yes

  No

  N/A

• Eyewash station has proper signage marking location?

  Yes

  No

  N/A

• Staff know the proper way tol obtain copy of MSDS?

  Yes

  No

  N/A

• Chemical disposal- staff can describe or demonstrate proper chemical disposal procedures?

  Yes

  No

  N/A

• Chemical inventory- chemical inventory is present and complete?

  Yes

  No

  N/A

• Chemical Spill Procedure- staff can describe or demonstrate knowledge of how to report and contain spill?

  Yes

  No

  N/A

• PPE equipment - staff understand and can explain the proper PPE equipment required to work with chemicals?

  Yes

  No

  N/A

Gluteraldehyde USE

• Gluteraldehyde Ventilation- appropriate ventilation for use?

  Yes

  No

  N/A

• Gluteraldehyde Disposal- gluteraldehyde is disposed of properly?

  Yes

  No

  N/A

• Gluteraldehyde Solution Age- age of solution is not more than 14 days?

  Yes

  No

  N/A

• Gluteraldehyde Test Strips- strips are properly used/ recorded?

  Yes

  No

  N/A

HIPAA Privacy Rule

• HIPAA DOcuments- All documents with confidential patient information is kept face down or concealed to avoid observations by unauthorized persons.

  Yes

  No

  N/A

• HIPAA Fax Cover Sheets-Fax cover sheets contain confidentiality clause?

  Yes

  No

  N/A

• HIPAA Regulations-Staff demonstrates knowledge about the Privacy Act and HIPAA Privacy Rule regulations and guidelines regarding data confidentiality?

  Yes

  No

  N/A

• HIPAA rule incident Reporting- Staff demonstrates knowledge about how to report Privacy Act/HIPAA Privacy Rule confidentiality incidents?

  Yes

  No

  N/A

• HIPAA Training- Staff have completed or is scheduled to attend HIPAA Privacy Rule training within time limits?

  Yes

  No

  N/A

• HIPAA Used Printers- All confidential documents are retrieved promptly from printers, copiers and fax machines?

  Yes

  No

  N/A

• Patient Lists- All patient lists, including scheduling procedures with patient information beyond room assignment, is kept up viewable to patients or visitors?

  Yes

  No

  N/A

• Patient Records Secure- All patient records are secure?

  Yes

  No

  N/A

Ice Machines / Refrigerators

• Patient Refrigerators have all items dated and within date range?

  Yes

  No

  N/A

• Patient Refrigerators have proper log sheet and dates are current?

  Yes

  No

  N/A

• Refrigerators with freezers do not have a buildup of frost or ice?

  Yes

  No

  N/A

• Food Refrigerators have not medications stored in them?

  Yes

  No

  N/A

• Food Refrigerators Temperature I'd between 35 - 45F and logged daily?

  Yes

  No

  N/A

• Medication Refrigerators are clean and defrosted?

  Yes

  No

  N/A

• Refrigerators with food, as covers, tops, and are sealed food containers?

  Yes

  No

  N/A

• Medication Refrigerators have all medications within proper date ranges?

  Yes

  No

  N/A

• Medication Refrigerators have no food stored in them?

  Yes

  No

  N/A

• Medication Refrigerators Temperature Range is between 35 - 45F and logged?

  Yes

  No

  N/A

• Ice Machines are clean and have no deposits built up on drain pan or chutes?

  Yes

  No

  N/A

• Ice Machines are free of dust on intake grills?

  Yes

  No

  N/A

• Ice Machines are serviced within the PM schedules set by Engineering?

  Yes

  No

  N/A

• Ice Machines are not leaking water on floor?

  Yes

  No

  N/A

Infection Control Measures

• All safety glasses and face shields are NIOSH approved?

  Yes

  No

  N/A

• All PPE Equipment is in good working condition?

  Yes

  No

  N/A

• Blood exposure- employees can describe the proper technics for responding to exposure to body fluids and blood?

  Yes

  No

  N/A

• Hand Hygiene- Proper hand hygiene procedures are understands by staff and practiced?

  Yes

  No

  N/A

• Hand Hygiene Products- Hand hygiene products are available for the staff to use?

  Yes

  No

  N/A

• Infection Control Procedures- Procedures are obtainable by staff and staff understand how to find them?

  Yes

  No

  N/A

• Irrigation Supplies Disposal- Irrigation solutions are labeled and discarded in accordance with the manufacturers recommendations?

  Yes

  No

  N/A

• Isolation Carts / Caddies- all carts and caddies are clean and contain correct supplies for the type of isolation?

  Yes

  No

  N/A

• Isolation Precautions- are understood by staff and followed per the facilities policy?

  Yes

  No

  N/A

• Isolation Rooms- Staff understand the procedure for setting up isolation rooms?

  Yes

  No

  N/A

• Isolation Rooms- Staff understand the proper procedure for setting up Negative Pressure Room?

  Yes

  No

  N/A

• PPD Skin. Test- Staff have annual PPD skin test as outlined by policy?

  Yes

  No

  N/A

• Disinfection Patient Equipment- Staff understand the proper technic for disinfection of patient equipment?

  Yes

  No

  N/A

Regulated Medical Waste

• Staff understand the disposal of waste and the different containers?

  Yes

  No

  N/A

• Sharps Containers are correctly contained and emptied at the 3/4 full level?

  Yes

  No

  N/A

• Sharps Containers are securely mounted to wall?

  Yes

  No

  N/A

• Sharps Containers are within immediate access for the staff's use?

  Yes

  No

  N/A

• Sharps Containers are not left in unsecured areas?

  Yes

  No

  N/A

• Sharps Containers storage trailer is secured and locked?

  Yes

  No

  N/A

• Sharps and waste containers have properly fit lids and are DOT rated?

  Yes

  No

  N/A

• Sharps containers are mounted so top is below 4' 10"?

  Yes

  No

  N/A

• Medication Wasting Procedure is understood and followed by Staff?

  Yes

  No

  N/A

• Red Bag Waste is disposed of correctly and has the appropriate items discarded in red bags?

  Yes

  No

  N/A

• Specimen Refrigerators are ID and specimens are disposed of correctly?

  Yes

  No

  N/A

Security

• Emergency number is known by staff for reporting?

  Yes

  No

  N/A

• Employees are wearing ID badges correctly?

  Yes

  No

  N/A

• Students are wearing school ID?

  Yes

  No

  N/A

• Staff understand proper way to report security situations?

  Yes

  No

  N/A

• Prescription pads are properly secured and out public access?

  Yes

  No

  N/A

• Narcotics are properly stored and secured?

  Yes

  No

  N/A

• Security Systems are installed correctly and working.<br>

  Yes

  No

  N/A

• Code Pink is understood by staff as to their roles during a code?

  Yes

  No

  N/A

• Code 10-33 all staff know role and actions during code as potentially violent situation?

  Yes

  No

  N/A

• Code Gray Alert staff know role during bomb threat?

  Yes

  No

  N/A

• Code Gray Verified staff know their roles in internal explosion or structural damage?

  Yes

  No

  N/A

• Code Triage staff know their role during community disaster?

  Yes

  No

  N/A

• Code Orange staff know their role during chemical, biological and radiological events?

  Yes

  No

  N/A

• Code Blue staff understand their role during Cardiac Arrest situation in their area?

  Yes

  No

  N/A

• Rapid Response announcement staff know their role?

  Yes

  No

  N/A

• Code Tornado staff know their role?

  Yes

  No

  N/A

• Code Purple staff know their role during neonatal code blue?

  Yes

  No

  N/A

• Code Amber staff know their role during a missing person announcement?

  Yes

  No

  N/A

• Personal property is secured to prevent theft?

  Yes

  No

  N/A

• Emergency restroom keys are available and staff know location?a

  Yes

  No

  N/A

• Safety Officer is known by staff?

  Yes

  No

  N/A

Materiel Management

• Soiled Linen is handled correctly and staff know the procedure?

  Yes

  No

  N/A

• Soiled Storage has no clean supplies stored in them?

  Yes

  No

  N/A

• Soiled Storage rooms have positive closing doors and latching?

  Yes

  No

  N/A

• Clean Supply rooms have all supplies stored correctly and nothing on the floor?

  Yes

  No

  N/A

• Linen carts are clean and free of dust, lint and strings?

  Yes

  No

  N/A

• Linen carts are covered at all times?

  Yes

  No

  N/A

• Storage rooms have all items below red line or 18" from sprinkler heads?z

  Yes

  No

  N/A

Medical Equipment

• Clinical Alarms are working correctly?

  Yes

  No

  N/A

• Equipment Alarms- can staff describe or demonstrate which equipment is alarming?

  Yes

  No

  N/A

• Medical equipment has permanent tag numbers and Bio Med testing / checking tags?

  Yes

  No

  N/A

• Medical Equipment Malfunction Events- staff understand and know the proper method of labeling, and reporting equipment not functioning correctly?

  Yes

  No

  N/A

• Equipment Service History- all medical equipment has a complete and accurate service history including repairs and preventative maintenance?

  Yes

  No

  N/A

• Medical Equipment Service Schedules- staff can identify whether and when medical equipment is past due for service?

  Yes

  No

  N/A

• Personal Equipment- all electric or electronic patient, staff, physician personal equipment has been inspected by Engineering or Bio Medical and sticker was placed showing date of inspection?

  Yes

  No

  N/A

• Patient lifting equipment is being used as designed?

  Yes

  No

  N/A

• Patient L fit equipment batteries are being recharged and staff know the location of chargers?

  Yes

  No

  N/A

Medical Gases

• Medical Gas shutoff valves are labeled for areas served?

  Yes

  No

  N/A

• Staff understand the procedure for shutting off main gas valves?

  Yes

  No

  N/A

• O2 tanks quantity doesn't exceed 12 full cylinders in storage or use per compartment?

  Yes

  No

  N/A

• O2 tanks are stored correctly?

  Yes

  No

  N/A

• O2 Storage is marked as FULL, PARTIAL and Empty?

  Yes

  No

  N/A

Life Safety

• All walls have limited decorations and no fire door is obstructed by decorations?

  Yes

  No

  N/A

• Fire Compartmentalizations- staff can describe or demonstrate what they would do during fire?

  Yes

  No

  N/A

• All doors are working as designed with no door wedges being used to hold door open?

  Yes

  No

  N/A

• Egress Obstructions- Means of Egress is unobstructed by portable equipment or stationary equipment?

  Yes

  No

  N/A

• Evacuation Procedures staff can demonstrate or discuss the procedure for evacuating patients from compartment to compartment and then floor to floor evacuation?

  Yes

  No

  N/A

• Egress / Exit signs are in proper locations, direction and are not obstructed?

  Yes

  No

  N/A

• Fire Pull Station Location staff knows and how to operate?

  Yes

  No

  N/A

• Fire Doors- staff know the location and doors are obstructed?

  Yes

  No

  N/A

• Fire Extinguishers staff understand operation and location?

  Yes

  No

  N/A

• Fire Extinguishers have been inspected on the monthly by Engineering staff?

  Yes

  No

  N/A

• Fire Extinguisher has proper annual inspection tag?

  Yes

  No

  N/A

• Fire Alarm staff know their role in a fire alarm condition?

  Yes

  No

  N/A

• Flammable Chemicals are not stored on unit?

  Yes

  No

  N/A

• Stairwells are not used for storage of any kind?

  Yes

  No

  N/A

• Doors to patient rooms latch correctly and have no type of locking means on them?

  Yes

  No

  N/A

• Heating devices are not present on unit like space heaters, candle warders, heated air fresheners, hot plates, toaster ovens, and toasters.

  Yes

  No

  N/A

• Power outlets staff know the difference between emergency power and normal power outlets?

  Yes

  No

  N/A

• Bed Power Outlet staff know the location and operation?

  Yes

  No

  N/A

• Electrical Closets are free of stored items and panels are locked?

  Yes

  No

  N/A

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