WELLSTAR PAULDING NURSING CENTER

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

RESULTS

• TOTAL NUMBER OF FINDINGS

• NUMBER OF EVS WORK ORDERS GENERATED?

• NUMBER OF ENGINEERING WORK ORDERS GENERATED?

• NUMBER OF EDUCATIONAL OPPORTUNITIES IDENTIFIED?

1. PREVIOUS AUDITS

• 1.1 Has the last audit been reviewed?

  Yes

  No

  N/A

• 1.2 Are there any outstanding concerns?

  Yes

  No

  N/A

A. SAFETY/GENERAL SAFETY

• A1. Warning signs or barricades are placed when work creates a hazard (wet floor, maintenance work in ceiling)?

  Yes

  No

  N/A

• A2. Medication cart is locked, neat and tidy, without expired medicines/products?

  Yes

  No

  N/A

• A3. Clean linen is covered with nothing on top of cart?

  Yes

  No

  N/A

• A4. All furniture and equipment is in sound condition? (no chipped or torn surfaces- no leaky faucets)

  Yes

  No

  N/A

• A5. This area is free from sharp objects?

  Yes

  No

  N/A

• A6. All wall-mounted devices (lights, TV’s, pictures, signs, containers, handrails, etc.) are secure and not loose?

  Yes

  No

  N/A

• A7. Cleaning chemicals are properly labeled and are not accessible by residents and visitors?

  Yes

  No

  N/A

• A8. Quality Control logs for Refrigerators/Freezers, freezers, and warmers are complete and corrective actions documented as appropriate?

  Yes

  No

  N/A

• A9. Boxes of patient care items/supplies are not stored directly on the floor? (must be elevated 6")

  Yes

  No

  N/A

• A10. Items are not stored under sink(s)? (If items found - list in comment section.)

  Yes

  No

  N/A

B. ELECTRICAL SAFETY

• B1. Items are not stored within 30” of an electrical panel?

  Yes

  No

  N/A

• B2. Electrical cords, plugs, plates and switches are in good repair?

  Yes

  No

  N/A

• B3. Extension cords only used temporarily but not on a permanent everyday basis?

  Yes

  No

  N/A

• B4. The underside of beds and counters are free of electrical “wire nests” where feet could be entangled?

  Yes

  No

  N/A

C. MEDICATION/MEDICAL SUPPLIES

• C1. Medications/medical supplies - have not passed expiration dates?

  Yes

  No

  N/A

• C2. All syringes, basins, cups, containing medication or solutions are labeled with the name of the contents?

  Yes

  No

  N/A

D. INFECTION PREVENTION

• D1. Staff food is not stored in patient kitchen or refrigerators?

  Yes

  No

  N/A

• D2. Refrigerators/Freezers contain thermometers and the refrigerator graphs are up-to-date? (thermometer should be located in the back)

  Yes

  No

  N/A

• D3. No open or expired patient nourishment containers in refrigerator?

  Yes

  No

  N/A

• D4. Ice machines are clean, no signs of deposits in tray or dispensing mechanism?

  Yes

  No

  N/A

• D5. Anti-microbial soap and paper towels are available for hand washing?

  Yes

  No

  N/A

• D6. Containers used for regulated or infectious waste are covered, leak proof, and clearly labeled as a biohazard?

  Yes

  No

  N/A

• D7. Disposed sharps are in an approved container?

  Yes

  No

  N/A

• D8. Sharps containers are secured in their holders, not accessible to residents and not more than three-fourths full?

  Yes

  No

  N/A

• D9. Staff (including contracting physicians) perform hand hygiene when entering room?

  Yes

  No

  N/A

E. ENVIRONMENTAL

• E1. Floors free of dirt, dust and litter?

  Yes

  No

  N/A

• E2. Ledges, walls and air vents free of dust?

  Yes

  No

  N/A

• E3. Toilets and sinks secure?

  Yes

  No

  N/A

• E4. Privacy curtains clean and unsoiled?

  Yes

  No

  N/A

F. HAZARDOUS MATERIALS

• F1. ** How can you access Material Safety Data Sheets (MSDS)?

  Yes

  No

  N/A

• F2. ** Do you know where your PPE is located?

  Yes

  No

  N/A

• F3. Material Safety Data Sheets available for all chemicals in this unit?

  Yes

  No

  N/A

G. FIRE PREVENTION/ LIFE SAFETY

• G1. ** Can you explain when you would implement R.A.C.E. and what does it stand for?

  Yes

  No

  N/A

• G2. ** Can you explain P.A.S.S. and what does it stand for?

  Yes

  No

  N/A

• G3. ** Where are the fire extinguishers and pull stations located in your department?

  Yes

  No

  N/A

• G4. Two exit signs visible from each corridor?

  Yes

  No

  N/A

• G5. Halls/Corridors uncluttered and accessible?

  Yes

  No

  N/A

• G6. Wheeled items such as the WOW’s are stored in corridor less then 30 minutes at a time?

  Yes

  No

  N/A

• G7. Are ceiling tiles in place, not stained and not broken?

  Yes

  No

  N/A

• G8. Are the sprinkler heads free of dust?

  Yes

  No

  N/A

• G9. Fire extinguisher (s) recently serviced? (monthly)

  Yes

  No

  N/A

• G10. Automatic fire doors free from obstacles and positively latch when activated? (Doorways should not be blocked or wedged.)

  Yes

  No

  N/A

• G11. Eighteen-inch clearance from sprinkler head ensuring no obstruction?

  Yes

  No

  N/A

• G12. Are compressed gases stored in designated areas only?

  Yes

  No

  N/A

• G13. Are full and empty cylinders stored separately according to sign/labels?

  Yes

  No

  N/A

• G14. All lights are working properly?

  Yes

  No

  N/A

• G15. Flammable and hazardous materials properly stored and labeled?

  Yes

  No

  N/A

• G16. Fire extinguishers and pull stations clear of obstructions?

  Yes

  No

  N/A

• G17. Placement of Hand Sanitizer is not adjacent(with-in 6”) to a potential ignition source?

  Yes

  No

  N/A

• G18. Exits clear of obstructions?

  Yes

  No

  N/A

H. EMERGENCY MANAGEMENT PROCEDURES

• H1. ** Can you tell me the number you would dial to initiate an emergency response?

  Yes

  No

  N/A

• H2. ** Where are your IT Downtime Forms? Do you have an IT Downtime Box? Are the forms current?

  Yes

  No

  N/A

• H3. ** Does your unit/department have a disaster supply kit? What is in it? Where is it?

  Yes

  No

  N/A

• H4. The unit disaster supply kit is available and locked?

  Yes

  No

  N/A

• H5. All inventory in the disaster kit works and is accounted for?

  Yes

  No

  N/A

• H6. Weather radios are plugged in and have good reception?

  Yes

  No

  N/A

I. SECURITY MANAGEMENT

• I1. ** How do you notify Security in a non-emergency?

  Yes

  No

  N/A

• I2. Employees, volunteers, students, contracted staff, physicians, contractors and venders wearing ID badges @ eye level?

  Yes

  No

  N/A

• I3. Are valuables properly stored in department?

  Yes

  No

  N/A

J. EQUIPMENT MANAGEMENT

• J1. ** What are the procedures if a device/equipment does not work properly OR if the device is involved in a resident related incident?

  Yes

  No

  N/A

• J2. All medical equipment/devices has a current Bio-Medical sticker?

  Yes

  No

  N/A

K. UTILITY MANAGEMENT

• K1. ** Where are your emergency backup procedures located for a loss of utility services?

  Yes

  No

  N/A

• K2. ** In case of a fire on the unit, who is authorized to shut off medical gases?

  Yes

  No

  N/A

L. RISK MANAGEMENT

• L1. ** Can you show me how to initiate an online Event report?

  Yes

  No

  N/A

• L2. Patient Health Information is not visible(computer screens protected, hard copies covered, patient charts closed)

  Yes

  No

  N/A

M. RESIDENT SAFETY

• M1. ** Name two patient identifiers?

  Yes

  No

  N/A

• M2. ** Describe the Falls Prevention efforts in your department.

  Yes

  No

  N/A

N. BRALY UNIT

• N1. FREE OF PERVASIVE ODORS?

  Yes

  No

  N/A

COMMENTS/OBSERVATIONS

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• Department/Unit Representative

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• Auditor

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