Thomas Jefferson University Hospital EOC Rounds

• Audit Title

• Organization

  Select TJUH - CENTER CITY JUP Site Ambulatory Site TJUH - Methodist

  • TJUH - CENTER CITY
  • JUP Site
  • Ambulatory Site
  • TJUH - Methodist

• Building/Floor/Area

• Unit

• Manager

• Unit Representative on tour

• Vice President

• Conducted on

  Date

• Prepared by

• Personnel on tour

1. PREVIOUS AUDITS

• Has the last audit been reviewed?

  Yes

  No

  N/A

• Are there any outstanding concerns?

  Yes

  No

  N/A
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• Identify outstanding concerns?

A. GENERAL SAFETY

• No damage to building materials (Cielings, chaulking, corner guards, cielings, doors, flooring, handrails, wallboard, wall/cieling penetrations) (Item #9)

  Yes

  No

  N/A

• No access codes written in the area of access controlled doors? (Item # 7)

  Yes

  No

  N/A

• Is all wall hung equipment, devices and decorations properly secured to the wall? (Televisions, paintings, BP cuffs, etc)

  Yes

  No

  N/A

• Is furniture, mill work, etc in good condition? (no chips, cracks, stains, rips, etc)

  Yes

  No

  N/A

• Access control devices (card readers, combonation locks) are in use and working properly? (Item # 30)

  Yes

  No

  N/A

• No staff food or drink in the clinical work area? (Item #44)

  Yes

  No

  N/A

• Are barricades being used for work on unit? (Wet floor, minor constuction, caution tape)

  Yes

  No

  N/A

B. ELECTRICAL SAFETY

• Extension cords only used temporarily but not on a permanent everyday basis? (Item #34)

  Yes

  No

  N/A

• Electrical cords, plugs, plates and switches are in place and in good repair? (Item #8)

  Yes

  No

  N/A

• No evidence of daisy chains (Cords or Surge Protectors)

  Yes

  No

  N/A

• Items are not stored infront of (within 36") electrical panel?

  Yes

  No

  N/A

• The underside of beds and counters are free of electrical “wire nests” where feet could be entangled?

  Yes

  No

  N/A

• Electric panels and closets, mechanical closets, housekeeping closets are locked? (Item #18)

  Yes

  No

  N/A

C. MEDICATION/MEDICAL SUPPLIES

• Medications/medical supplies - have not passed expiration dates?

  Yes

  No

  N/A

• All syringes, basins, cups, containing medication or solutions are labeled with the name of the contents?

  Yes

  No

  N/A

• Supply area is clean? (Item #47)

  Yes

  No

  N/A

• Med Carts/Med Rooms are secured at all times?

  Yes

  No

  N/A

• No boxes on the floor. All supplies 6 inched off the floor? (Item #5)

  Yes

  No

  N/A

• No items stored under the sink

  Yes

  No

  N/A

D. INFECTION PREVENTION

• Staff food is not stored in patient refrigerators?

  Yes

  No

  N/A

• Clean linen cart covered and no items stored on the top of the cart. (Item # 43)

  Yes

  No

  N/A

• Refrigerators/Freezers are clean, frost free, and labeled for type of storage with only those items present (no food and medication in the same refrigerator).

  Yes

  No

  N/A

• Refrigerators/Freezers contain thermometers and a temperature logs are up to date? (Item #45)

  Yes

  No

  N/A

• No open, expired or unlabeled patient nourishment containers in patient food refrigerator?

  Yes

  No

  N/A

• Ice machines are clean, no signs of deposits in tray or dispensing mechanism?

  Yes

  No

  N/A

• Hand sanitizer, anti-microbial soap and paper towels are available for hand washing? (Item # 42)

  Yes

  No

  N/A

• Containers used for regulated or infectious waste are covered, leak proof, and clearly labeled as a biohazard?

  Yes

  No

  N/A

• Disposed sharps are in an approved container?

  Yes

  No

  N/A

• Sharps containers are secured in their holders, not accessible to residents and not more than three-fourths full?

  Yes

  No

  N/A

• Staff (including contracting physicians) perform hand hygiene?

  Yes

  No

  N/A

• Separation of clean and dirty linen/items/material. (Item # 46)

  Yes

  No

  N/A

E. ENVIRONMENTAL

• Ceiling tiles clean and intact? (Item #6)

  Yes

  No

  N/A

• Is the area adequeatly lighted? (Item #31)

  Yes

  No

  N/A

• Floors free of dirt, dust and litter? (Item # 47)

  Yes

  No

  N/A

• Ledges, walls and air vents free of dust? (Item # 48)

  Yes

  No

  N/A

• Toilets and sinks secure and clean? (Item # 48 and Item #9)

  Yes

  No

  N/A

• Privacy curtains clean and unsoiled? (Item # 47)

  Yes

  No

  N/A

F. HAZARDOUS MATERIALS

• Chemicals are properly labeled and secured (Item # 35 and Item #36)

  Yes

  No

  N/A

• Flammable and hazardous materials properly stored and labeled? (Item #36)

  Yes

  No

  N/A

• Entrance to areas storing hazardous chemicals properly labeled (NFPA 507 Label)? (Item #35)

  Yes

  No

  N/A

• Staff knows how they can access Safety Data Sheets (SDS) and the chemical inventory is available? (Item #12)

  Yes

  No

  N/A

• PPE is available (if needed). (Item #17)

  Yes

  No

  N/A

• Eye wash is tested weekly and documented?

  Yes

  No

  N/A

• Are flammable liquids stored in flammable cabinets?

  Yes

  No

  N/A

G. FIRE PREVENTION/ LIFE SAFETY

• <br>Can staff explain what R.A.C.E stands for? (Item #10)

  Yes

  No

  N/A

• Staff can explain P.A.S.S. and what does it stand for?

  Yes

  No

  N/A

• Staff know where the fire extinguishers and pull stations located in their department?

  Yes

  No

  N/A

• Staff knows how to shut off medical gasses in an emergency? (Item #15)

  Yes

  No

  N/A

• Fire evacuation map and signage posted at the elevator lobbies? (Item #28)

  Yes

  No

  N/A

• "No smoking" policy enforced (no visible signs of smokeing non-compliance)? (Item #25)

  Yes

  No

  N/A

• Exit signs visible from each corridor?

  Yes

  No

  N/A

• Halls/Corridors uncluttered and accessible? (Item #1)

  Yes

  No

  N/A

• Smoke detectors with 36" clearance from air supply to return?

  Yes

  No

  N/A

• Are the sprinkler heads free of dust and foreign material? (Item #32)

  Yes

  No

  N/A

• Fire extinguisher (s) recently serviced? (monthly and annually) (Item #21)

  Yes

  No

  N/A

• Automatic fire doors free from obstacles and positively latch when activated? (Doorways should not be blocked or wedged.) (Item #24 and Item #3)

  Yes

  No

  N/A

• Eighteen-inch clearance from ceiling is maintained? (Item #4)

  Yes

  No

  N/A

• Are compressed gases stored in designated areas only and secured? (Item #37)

  Yes

  No

  N/A

• Are med gas zone valves labeled? [Area served] (Item #29)

  Yes

  No

  N/A

• Are full and empty cylinders stored separately according to sign/labels? (Item #37)

  Yes

  No

  N/A

• All lights are working properly and flashlights with good batteries?

  Yes

  No

  N/A

• Fire extinguishers are clearly marked? (Item #19)

  Yes

  No

  N/A

• Fire extinguishers clear of obstructions and within 75 feet? (Item #20)

  Yes

  No

  N/A

• Exits are properly illuminated, and clearly/correctly marked? (Item #22)

  Yes

  No

  N/A

• Manual pull stations unobstructed (3') and intact? (Item #23)

  Yes

  No

  N/A

• Smoke/fire doors close and latch freely (Item #24)

  Yes

  No

  N/A

• Placement of Hand Sanitizer is not adjacent(with-in 6”) to a potential ignition source?

  Yes

  No

  N/A

• Fire tower exits unlocked from the floor (unless approved variance/special condition)? (Item #26)

  Yes

  No

  N/A

• Proper stair tower identification signage in place at landing? (Item #27)

  Yes

  No

  N/A

• No unauthoarized appliances (toasters, toaster ovens, fans, space heaters) (Item #33)

  Yes

  No

  N/A

• Exit doors clear of obstructions? (Item #2)

  Yes

  No

  N/A

H. EMERGENCY MANAGEMENT PROCEDURES

• Staff know the number to call to initiate an emergency/security response [811-TJUH & 77-MHD]? (Item #14)

  Safe

  At Risk

  N/A

• <br>Staff demonstrates knowledge of Code-D? (Item #16)

  Yes

  No

  N/A

I. SECURITY MANAGEMENT

• Staff know how to notify Security in a non-emergency? (Item #14)

  Yes

  No

  N/A

• Employees, volunteers, students, contracted staff, physicians, contractors and venders wearing ID badges? (Item #11)

  Yes

  No

  N/A

• Are valuables/personal items properly stored in department? (Item #13)

  Yes

  No

  N/A

J. EQUIPMENT MANAGEMENT

• Staff know the procedures if a device/equipment does not work properly? (Item #39)

  Yes

  No

  N/A

• Medical equipment is being routinenly inspected as indicated in the Equipment Management Plan? (Item #41)

  Yes

  No

  N/A

• Equipment is clean and free of damage and free of frayed wires and faulty plugs? (Item #38)

  Yes

  No

  N/A

• Crash cart is locked, logs complete, oxygen is full and defibrillator is pluged in? (Item #40)

  Yes

  No

  N/A

• Battery operated equipment is plugged in and charging? (Item #40)

  Yes

  No

  N/A

K. UTILITY MANAGEMENT

• Staff know what to do for an electrical failure?

  Yes

  No

  N/A

• Staff know who is authorized to shut off medical gases?

  Yes

  No

  N/A

OR specific

• Hyperthermia cart is locked with log completed?

  Yes

  No

  N/A

• Staff know location of hyperthermia cart?

  Yes

  No

  N/A

• Sterilizer is clean and parameters are maintained?

  Yes

  No

  N/A

• Sterilizer has documented PM?

  Yes

  No

  N/A

• Sterilizer testing is up to date?

  Yes

  No

  N/A

Mechanical areas

• Floor is clean?

  Yes

  No

  N/A

• Power tools have guards in place?

  Yes

  No

  N/A

• PPE readily available?

  Yes

  No

  N/A

• 36" clearance maintained around electric panels?

  Yes

  No

  N/A

• Fall protection for areas above 6 feet high?

  Yes

  No

  N/A

• LOTO equipment readily available?

  Yes

  No

  N/A

• Isolation exhaust fans are labeled?

  Yes

  No

  N/A

Additional Findings

• Is there any additional findings?

  Yes

  No

  N/A
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• Additionally findings:

Actions

• Preventive action is not required?

  Yes

  No

  N/A

• Preventive Action Plan:

• Corrective action is not required?

  Yes

  No

  N/A

• Corrective Action Plan:

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• Auditor

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