<p> SAFETY ROUNDS INSPECTION FORM Directors Version</p><p>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?</p><p>2. Extinguisher inspections current?</p><p>3. Is extinguisher accessible?</p><p>4. Are floors and walls free from holes, clean and dry?</p><p>5. Are ceiling tiles clean and dry?</p><p>6. Are fire doors propped open?</p><p>7. Do all fire doors operate as required?</p><p>8. Do all trash and linen chutes latch?</p><p>9. Are combustible materials stored properly?</p><p>10. Are materials stored 18” below sprinkler heads?</p><p>11. Personnel know location of fire alarm pull stations?</p><p>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?</p><p>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? </p><p>3. Are extension cords/multi outlet in use? List location.</p><p>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</p><p>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?</p><p>2. Do personnel know chemical spill Procedures?</p><p>3. Dept. knows location/operation of eye wash station?</p><p>4. Are eye wash stations checked weekly?</p><p>5. HazMat labels on secondary containers?</p><p>6. Are hazardous chemical uses appropriate? a. Selection b. Handling c. Storing d. Transporting e. Using f. Disposing</p><p>7. Hazardous medication properly disposed?</p><p>Waste Management Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Are sharps containers overfilled?</p><p>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?</p><p>Environment of Care Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Can staff identify a physical risk?</p><p>2. Can staff describe methods to correct/report physical risk identified?</p><p>3. Can staff demonstrate actions to take in the event of an incident?</p><p>4. Any observation of violation of smoking policy?</p><p>5. Trash/debris removed daily?</p><p>Life Safety Code Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Does staff know where exits are located?</p><p>Compressed Gases Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Are compressed gases stored in designated areas only?</p><p>2. Full and empty cylinders are stored separately?</p><p>3. Are empty cylinders labeled “empty”?</p><p>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?</p><p>Infection Control Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Only non-permeable cleaning supplies under sinks?</p><p>2. Are there any boxes on the floor?</p><p>3. Are refrigerator temperature logs complete?</p><p>4. Are refrigerators clean?</p><p>5. Are patient/staff food in separate refrigerators?</p><p>6. Are linen hampers covered?</p><p>7. Are linens kept off the floor?</p><p>8. Outdated supplies/meds?</p><p>Hazardous Energy Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Proper posting?</p><p>2. Proper screening?</p><p>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?</p><p>2. Audio privacy?</p><p>3. Visual privacy? a. Charts b. Medications c. Schedules 4. Are all occupants identifiable? a. Staff b. Patients c. Visitors d. Reps/vendors</p><p>Utilities – Employee Knowledge Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Can staff locate and identify emergency outlets?</p><p>2. Does staff know what to do during a water outage?</p><p>3. Can staff locate emergency phone? a. Knows dialing list location and numbers?</p><p>Space Needs Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement 1. Is patient storage space adequate?</p><p>2. Is lighting suitable for care, treatment and services?</p><p>3. Are offensive odors present?</p><p>4. Is furniture in good repair? Physical Plant Recommendations Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement</p><p>Miscellaneous Recommendations Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement</p><p>Open Comments Yes No N/A Location/Hazard Description Action/Recommendation – Safety Improvement</p><p>Revised 1/15/09</p>