Wing Environment of Care Checklist

• Department Surveyed

• Department Type

  Patient Care Area

  Non-Patient Care Area

• Inspection Frequency

  Annual

  Semi-Annual

  Quarterly

  Other

• Conducted on

  Date

• Survey Team

ENVIRONMENT

• Preventative Maintenance (PM) sticker on all medical equipment?

  Yes

  No

  N/A

• Inspection sticker showing Engineering check prior to initial use?

  Yes

  No

  N/A

• Cord and trip hazards are identified?

  Yes

  No

  N/A

• All employees are wearing a Hospital Badge?

  Yes

  No

  N/A

• Furniture is free of tears, holes and stains?

  Yes

  No

  N/A

• All medications are properly secured behind a locked door?

  Yes

  No

  N/A

• No liquid bleach being stored in the area?

  Yes

  No

  N/A

• Able to clearly identify clean vs dirty equipment?

  Yes

  No

  N/A

• Electrical panels are locked and unobstructed?

  Yes

  No

  N/A

• Storage areas 21"from ceiling?

  Yes

  No

  N/A

• Ceiling tiles have no stains or holes?

  Yes

  No

  N/A

• No boxes/supplies are stored on the floor or on wooden pallets?

  Yes

  No

  N/A

• Chemicals are stored below eye level?

  Yes

  No

  N/A

• All chemical are properly labeled with manufacturers' label and appraise expiration dates are visible if applicable?

  Yes

  No

  N/A

• Nothing is stored under the sinks?

  Yes

  No

  N/A

• No liquids are stored above sterile supplies?

  Yes

  No

  N/A

• Appropriate signage posted for isolation/precaution rooms?

  Yes

  No

  N/A

• No doors in appropriately propped open?

  Yes

  No

  N/A

• Weekly eye wash logs are present and up to date?

  Yes

  No

  N/A

• All HIPPA guidelines are followed and no PHI is discarded in the normal trash?

  Yes

  No

  N/A

LIFE SAFETY EQUIPMENT

• Fire extinguishers are dated and easily accessible?

  Yes

  No

  N/A

• No fire extinguishers are blocked?

  Yes

  No

  N/A

• Medical gases are secured to cards or chained to the wall?

  Yes

  No

  N/A

• Numbered lock tags are present on crash carts?

  Yes

  No

  N/A

GENERAL APPEARANCE

• Clutter is removed from hallways and offices?

  Yes

  No

  N/A

• Chemicals (hand lotions, etc.) are hospital approved?

  Yes

  No

  N/A

• Paper signs are not taped to walls/doors?

  Yes

  No

  N/A

• There is no food or drink in patient care areas or specimen areas?

  Yes

  No

  N/A

• No dust (check high surfaces, picture frames, corners, etc.)?

  Yes

  No

  N/A

• Hallways are clear and unobstructed ( no blockage from equipment, carts or stretchers?

  Yes

  No

  N/A

EXPIRATION DATES

• Outdated products/supplies are discarded?<br> - includes: Dietary supplements<br> Supplies, such as tongue depressors, medication<br> Hospital approved hand sanitizer

  Yes

  No

  N/A

• All products have/supplies that have expiration dates are not expired?

  Yes

  No

  N/A

REFRIGERATORS

• Dietary and staff refrigerators have 12 month temperature logs?

  Yes

  No

  N/A

• There is no food at all in medication refrigerators?

  Yes

  No

  N/A

• There is no staff food in patient refrigerators?

  Yes

  No

  N/A

• There is no patient food in staff refrigerators?

  Yes

  No

  N/A