Safety Rounds Inspection Form

SAFETY ROUNDS INSPECTION FORM Directors Version

Fire Safety Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Are area means of exit: a. Clearly and correctly marked? b. Unlocked from inside? c. Clear of debris and equipment?

2. Extinguisher inspections current?

3. Is extinguisher accessible?

4. Are floors and walls free from holes, clean and dry?

5. Are ceiling tiles clean and dry?

6. Are fire doors propped open?

7. Do all fire doors operate as required?

8. Do all trash and linen chutes latch?

9. Are combustible materials stored properly?

10. Are materials stored 18” below sprinkler heads?

11. Personnel know location of fire alarm pull stations?

12. Spot check smoke/fire barrier for penetration. Electrical Safety Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Outlet checks: a. Are emergency outlets properly identified? b. Do outlets appear in good shape?

2. Equipment check: a. Are power plugs 3 prong (patient care equipment)? b. Are power plugs and cords in good visual shape? c. staff knows the procedure to report defective CE equipment? d. Staff knows lockout/tagout procedure for CE equipment? e. Does staff have problems operating CE equipment?

3. Are extension cords/multi outlet in use? List location.

Personal Protective Equipment Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Are PPEs available to protect employees’ body area? a. Head b. Eyes and face c. Body d. Hands e. Feet and legs f. Respiratory

2. Have eye hazard areas been established? Chemical Safety Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Do personnel know location of MSDS manual? a. How to use it? b. Chemical list reviewed annually?

2. Do personnel know chemical spill Procedures?

3. Dept. knows location/operation of eye wash station?

4. Are eye wash stations checked weekly?

5. HazMat labels on secondary containers?

6. Are hazardous chemical uses appropriate? a. Selection b. Handling c. Storing d. Transporting e. Using f. Disposing

7. Hazardous medication properly disposed?

Waste Management Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Are sharps containers overfilled?

2. Are containers secured away from patients and visitors? a. If not, are they secured to a wall or cart? 3. Are unused sharps secured? a. If not, in a staffed or locked area?

Environment of Care Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Can staff identify a physical risk?

2. Can staff describe methods to correct/report physical risk identified?

3. Can staff demonstrate actions to take in the event of an incident?

4. Any observation of violation of smoking policy?

5. Trash/debris removed daily?

Life Safety Code Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Does staff know where exits are located?

Compressed Gases Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Are compressed gases stored in designated areas only?

2. Full and empty cylinders are stored separately?

3. Are empty cylinders labeled “empty”?

4. Are flammable and non-flammable cylinders stored separately? Medical Gases Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Does staff know the location of med gas shut off valves? a. What to do, how to shut off?

Infection Control Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Only non-permeable cleaning supplies under sinks?

2. Are there any boxes on the floor?

3. Are refrigerator temperature logs complete?

4. Are refrigerators clean?

5. Are patient/staff food in separate refrigerators?

6. Are linen hampers covered?

7. Are linens kept off the floor?

8. Outdated supplies/meds?

Hazardous Energy Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Proper posting?

2. Proper screening?

3. Proper safety equipment used? Patient/Employee Confidentiality Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Is patient/employee confidentiality practiced?

2. Audio privacy?

3. Visual privacy? a. Charts b. Medications c. Schedules 4. Are all occupants identifiable? a. Staff b. Patients c. Visitors d. Reps/vendors

Utilities – Employee Knowledge Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Can staff locate and identify emergency outlets?

2. Does staff know what to do during a water outage?

3. Can staff locate emergency phone? a. Knows dialing list location and numbers?

Space Needs Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Is patient storage space adequate?

2. Is lighting suitable for care, treatment and services?

3. Are offensive odors present?

4. Is furniture in good repair? Physical Plant Recommendations Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement

Miscellaneous Recommendations Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement

Open Comments Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement

Revised 1/15/09