Wright Memorial Hospital

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

PREVIOUS AUDITS

• Has the last audit been reviewed?

  Yes

  No

  N/A

• Are there any outstanding concerns?

  Yes

  No

  N/A

FIRE PREVENTION/ LIFE SAFETY

• ** Can you explain when you would implement R.A.C.E. (rescue, activate alarm, confine the fire, evacuate/extinguish)and what does it stand for?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Fire extinguishers and pull stations clear of obstructions?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Fire extinguisher < or =75'

  Yes

  No

  N/A

• Two exit signs visible from each corridor with appropriate arrow direction?

  Yes

  No

  N/A

• Halls/Corridors uncluttered and accessible?

  Yes

  No

  N/A

• Are ceiling tiles in place / not damaged?

  Yes

  No

  N/A

• Are the sprinkler heads free of dust?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are compressed gases stored in designated areas only and less than 12 cylinders per smoke compartment?

  Yes

  No

  N/A

• Are oxygen cylinders properly segregated and in proper storage?

  Yes

  No

  N/A

• All lights are working properly?

  Yes

  No

  N/A

• Flammable and hazardous materials properly stored and labeled?

  Yes

  No

  N/A

• Placement of Hand Sanitizer (>6" from electrical outlet and not directly above an electrical outlet)?

  Yes

  No

  N/A

• Exits clear of obstructions?

  Yes

  No

  N/A

• Evacuation routes posted and current

  Yes

  No

  N/A

• WOWs servers/charting surfaces kept secure when not in use

  Yes

  No

  N/A

• Equipment located on one side of the aisle?

  Yes

  No

  N/A

• Smoking policy enforced?

  Yes

  No

  N/A

ELECTRICAL SAFETY

• Electrical safety checks performed by Facilities as required?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Extension cords are not in use except where permitted?

  Yes

  No

  N/A

• Use of potable heating devices prohibited in patient treatment areas; except physician-ordered treatment devices?

  Yes

  No

  N/A

• Portable heating devices prohibited in employee areas except when approved by facilities (non sleeping staff and employee areas and heating elements <212 deg.)?

  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

• Blanket Warner's safely used (correct temperature setting <=130 deg., not overloaded, adequate clearance on bottom rack, etc.)

  Yes

  No

  N/A

HAZARDOUS MATERIALS

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• When corrosive chemicals are present, is there a portable eye was station available (within 15 second access uninstructed), operable, and tested/checked weekly?

  Yes

  No

  N/A

• Sharps containers are in proper location and secure?

  Yes

  No

  N/A

• Sharps containers contain appropriate material (ie. no gloves, gauze and tubing.)

  Yes

  No

  N/A

• Items in BioHazardous Waste box is appropriate?

  Yes

  No

  N/A

• Containers properly labeled (identity and hazard warnings)?

  Yes

  No

  N/A

SAFETY/GENERAL SAFETY

• Handrails accessible and properly secure?

  Yes

  No

  N/A

• Work Surface Clean

  Yes

  No

  N/A

• Wet floor signs available and used?

  Yes

  No

  N/A

• Code cart is locked, neat and tidy?

  Yes

  No

  N/A

• Emergency cart/drug box/defibrillator checks are current.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Refrigerator/freezer temperature checks are current?

  Yes

  No

  N/A

• Expiration dates checked (meds, food, supplies)?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Patient care items/supplies are not stored directly on the floor?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

SECURITY MANAGEMENT

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are valuables properly stored in department?

  Yes

  No

  N/A

• Are latches on Patient doors in working order with emergency access?

  Yes

  No

  N/A

• Rooms/offices secure when unattended?

  Yes

  No

  N/A

• Panic alarms present/functioning?

  Yes

  No

  N/A

ENVIRONMENTAL

• Floors free of dirt, dust and litter?

  Yes

  No

  N/A

• Ledges, walls and air vents free of dust?

  Yes

  No

  N/A

• Toilets and sinks secure?

  Yes

  No

  N/A

• Privacy curtains clean and unsoiled?

  Yes

  No

  N/A

• Ventilation, temperature/humidity levels suitable for patient care?

  Yes

  No

  N/A

EMERGENCY PREPAREDNESS

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

  Yes

  No

  N/A

• Are Emergency light (Flashlights) available?

  Yes

  No

  N/A

• **Staff can identify the location of the hospital Emergency Operations Plan.

  Yes

  No

  N/A

• **Staff can identify correct actions to take in a Code Gray (tornado) situation.

  Yes

  No

  N/A

• **Staff can identify correct actions to take in a Code Pink (abduction) situation.

  Yes

  No

  N/A

INFECTION PREVENTION

• Staff food is not stored in patient refrigerators?

  Yes

  No

  N/A

• No open or expired patient nourishment containers in refrigerator?

  Yes

  No

  N/A

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

  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

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

  Yes

  No

  N/A

EQUIPMENT MANAGEMENT

• ** 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

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

  Yes

  No

  N/A

UTILITY MANAGEMENT

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

COMMENTS/OBSERVATIONS