Thomas Jefferson University Hospital EOC Rounds - 2015

Information

Organization
- TJUH - CENTER CITY
- TJU-JUP
- Ambulatory Site
- TJUH - Methodist
Building/Floor/Area
Unit
Manager
Unit Representative on tour
Vice President
Conducted on
Prepared by
Personnel on Tour

A. PREVIOUS AUDITS

1) Hallways clear of clutter.
2) Exit doors unobstructed.
3) No propped doors.
4) Storage (boxes etc.) and equipment are no less than 18" from the bottom of sprinkler head.
5) Storage (boxes etc.) are 6" above floor.
6) No cracked, stained, or missing ceiling tiles. Escutcheons properly installed for penetrations.
7) No codes written on access control doors.
8) All junction boxes/switch plates are covered.
9) No damaged building materials (e.g. ceilings, caulking, corner casing, ceiling penetration, cove base, door, floor tile, wall board, wall penetrations)

10) Staff can identify Emergency Response Resources. Safety info on ID TJUH Intranet Emergency Response Card
11) Staff are wearing ID cards.
12) Employees know how to access SDSs, Chemical Inventory List available.
13) Personal items kept secured in work areas. (Handbags, Wallets, etc)
14) Employees know the process for reporting a security incident, chemical spill, Code Red. Dial 811/77
15) Staff knows who can shut off medical gases in an emergency.
16) Staff demonstrates knowledge of Code D/Disaster response.
17) Personal Protective Equipment (PPE) available and worn when necessary.

18) Electrical closet/panels, mechanical closets, housekeeping closets are locked.
19) Fire extinguishers are clearly marked (signage).
20) Fire extinguishers unobstructed.
21) Fire extinguisher tag shows monthly inspection (format mm/dd/yr) & current annual tag
22) Exit signs are sufficient, illuminated, clearly and correctly marked.
23) Pull stations unobstructed (3' clear) and intact.
24) Smoke/Fire Doors close freely. (Positive latch)
25) No smoking policy enforced (no visible signs of non-compliance).
26) Fire Tower Exits unlocked from floor (unless approved variance - special conditions).
27) Proper stair identification signage at landings.
28) Fire evacuation diagram signage posted at elevator call stations/landings.
29) Medical gas shut-off valves are unobstructed and labeled to indicate the area served.
30) Access control devices (card readers, combination locks) are in use and working properly.
31) Area is adequately lighted.
32) Sprinkler heads are free of foreign materials.
33) No unauthorized appliances (e.g. fans, space heaters, toasters).
34) Extension cords are not substituted for permanent wiring. (only approved surge power strips)
35) Entrances to areas storing hazardous chemicals are labeled properly. (NFPA Diamond)
36) Chemicals stored properly.
37) Gas cylinders properly secured. Gas storage area has a labeled door stating "Caution oxidizing gases stored within. No smoking"

38) Are the major monitoring areas of equipment?
38A -clean and free from damage.
38B -equipment is free of frayed wires and/or faulty plugs.
38C -carts are clean and free of rust
39) Users of equipment is surveyed for recurring problems.
40) Rechargeable equipment is plugged into a receptacle
41) Equipment is being routinely inspected as indicated by the Equipment management Plan.

42) Alcohol based hand washing solution readily available (staff handwashing).
43) Clean linen cart covered, no items stored on top.
44) No food or drink in clinical work area.
45) Refrigerator log completed and up to date.
46) Clean and soiled linen are separated and never stored together.
47) Standards of cleanliness are maintained throughout.
48) HVAC vents free of dust.
49) Required eye-wash station(s) installed and operational per ANSI Z358.1 standards.
50) Ice machines clean. no scale or growth on dispensing chutes and tubes.
51) Is upholstered furniture in good condition? (No cracks, tears, rips or exposed padding)
52) Nurse Call pull cords in patient accessible bathrooms are appropriate length and accessible? (Not knotted, tied, braided or cut.)