24 - Survey - Environmental Tour Template

S = Satisfactory, N/I = Needs Improvement; N/A = Not Applicable, Not Questioned or Not Observed, PFI = Plan for Improvement, POC = Point of Contact

Page 1 of 16, Revised: 03/07/0902/04/09Author: Jenny Demaris, (541) 574-4749

Samaritan Pacific Communities Hospital - Survey, Environmental Tour

Date of Survey: Work Center Names:

Survey #:

Facility:

Survey Conducted By: Survey Attendees:

(Name, Department)

Dept. Leadership:

Plan for Improvements (PFI's) Survey Compliance Scores

Date Survey Distributed to Department LeadershipS N/I N/A

0 0 0SCORE - Employee Knowledge Compliance

# PFI's Required - Total#DIV/0!

0 0 2SCORE - Work Center (Dept) Survey Compliance

Date of Final PFI Suspense Date#DIV/0!

0 0 0SCORE - Physical Environment Compliance

# PFI's Completed within Appropriate Timeframe#DIV/0!

0 0 0SCORE - Clinical Equipment Compliance

# PFI's Completed - Total#DIV/0!

0 0 2

Date Plan for Improvements Completed#DIV/0!

Surveyor Comments

SCORE - TOTAL SURVEY COMPLIANCE





Survey #:

Facility:





Survey #:

Facility:

# S N/I N/A Employee General Knowledge # S N/I N/A Clinical/Medical Equipment ManagementA Back-up Power, Red Outlets/Flashlights, Battery Lights 8 0 0 0 # of Equip. w/Elec. Safety Check Label PresentB Defective Equipment Labels, Location & Use Of 9 0 0 0 # of Equip. w/Control ID# or Other Label PresentC Emergency Paging Ext. or Phone Number (911 or x No.) 10 0 0 0 # of Equip. w/PMI Expiration Date or N/A Labels PresentD Emergency Quick Reference Guides, Location Of 11 0 0 0 # of Equip. within Appropriate PMI Date TimeframeE Employee Safety Committee, How to Access/Representative 12 0 0 0 # of Equip. in PMI DatabaseF Employee Safety Committee, Where Minutes are Posted 13 OtherG Fire/Smoke Compartments - Evac. Routes-Exits, Location of 0 0 0 TotalH Fire Extinguishers, Location of & Use of Pass #DIV/0! % of Compliance = #S/(#S+#U)I Gas Shut-Off Valves, Authorization/How to # S N/I N/A Clinical/Medical Equipment Mgmt. ComplianceJ Material Safety Data Sheets, Access to 14 Satisfactory Score = 95% or above scoreK Reporting/Response of Cardiac ArrestL Reporting/Response of Code Decon # S N/I N/A Log Sheet, DocumentationM Reporting/Response of Fire, Code Red (RACE) 15 Crash Carts/AED's, DailyN Reporting/Response of Haz. Material Exposure/Spill 16 1 Dishwashers, DailyO Reporting/Response of Infant/Child Abduction 17 1 Eye Wash Stations, WeeklyP Reporting/Response of Infectious Waste Exposure/Spill 18 Fire Extinguishers, MonthlyQ Reporting/Response of Injuries (Pt., Visitor, Employee) 19 Refrigeration, Food/Specimens/Meds/Products, DailyR Reporting/Response of Security Threat/CrimeS Reporting/Response of Utility Failures # S N/I N/A Fire Prevention - Life SafetyT Response of Disaster Code 20 Doors Closed, Soiled/Clean/Hazardous AreasU SMDA - Safe Medical Device Act - Actions to Take 21 Doors Fire, <1/8 Inch Gaps & < 3/4 Inch UndercutV Secondary Container Labels, Location & Use of 22 Doors Fire, Appropriate Label VisibleW Other: 23 Doors Fire/Smoke, Positively Close/Latch

0 0 0 Total 24 Doors Interior, Approp. Labeled with Function or Not An Exit#DIV/0! % of Knowledge = #S/(#S+#U) 25 Doors Wedged Open, None Found

# S N/I N/A Employee Knowledge Compliance 26 Emergency Exit Corridors/Doors, Clear1 Satisfactory Score = 95% or above score 27 Exit Signs, In Appropriate Locations

28 Exit Signs, Lighted# S N/I N/A Emergency Management 29 Fire Extinguishers, Visible2 Dept. Disaster Box, Available/Stocked 30 Flammables, Stored Appropriately3 Dept. First Aid Supplies, Available 31 Penetrations Wall/Ceiling/Floors, None Present4 Emergency Quick Reference Guides Available (flipcharts) 32 Sprinkler Heads/Smoke Detectors, Clean & Intact5 Earthquake Mitigation Measures in Place 33 Sprinklers, 18" Ceiling Clearance6 Flashlights Available, With Extra Charged Batteries 34 Other:7 Other:





Survey #:

Facility:

0 0 0 1st Page Sub-Total: SIDE A 0 0 2 1st Page Sub-Total: SIDE B# S N/I N/A Hazardous Materials & Waste # S N/I N/A Safety (General/Electrical)

35 Appropriate Product Used for Task/Job 67 Defective Equipment Stickers Available36 Eye Wash Available, As Appropriate 68 Desks, Chairs, Furniture in Safe Condition - No Hazards37 Gas/Cylinder Safety - Cylinders Stored Appropriately 69 Electrical Cords/Plugs/Outlets in Safe Condition38 Gas/Cylinder Safety - Gauges/Regulators Working Properly 70 Electrical Extension Cords, None in Use39 Hazardous Material Areas, Food/Drinks Not Present 71 Electrical Outlets GFI, Within 6 Feet of each Sink40 Hazardous Materials, Handled Appropriately 72 Electrical Outlets - Safety Covers Exam/Waiting Areas41 Hood Vents, Certification Current 73 Electrical Panels, Accessible (36" Rule)42 MSDS Available for All Products 74 Electrical Plugs, 3 Pin Type in Patient Care Areas43 MSDS Inventory, Current List Available 75 Employee Safety Committee Minutes Posted44 Personal Protective Equip., Appropriate Type Available 76 Expiration Dates Current - Products, Medications, Foods45 Products Properly Labeled (Secondary Cont. Labels) 77 Forms Available: Employee Injury, Unusual Occurrence46 Products Properly Stored 78 Grab Bars/Handles Secured to Walls/Fixtures47 Spill Kit, Appropriate Type Available 79 Nurse Call Devices - Operational48 Secondary Container Labels Available 80 Signage Appropriate for Area/Services49 Other: 81 Storage/Mechanical Rooms, Clean/Uncluttered

Hazardous Materials - Waste Storage/Container Use 82 Trip Hazards, None Present50 Biohazard Wastes, Stored Appropriately 83 Walls/Floors/Ceilings/Doors in Safe Condition - No Hazards51 Chemical Wastes, Stored Appropriately 84 Other:52 Chemo Therapy Waste, Stored Appropriately53 Containers, Appropriate for Area # S N/I N/A Security54 Containers, Appropriate Location/Height 85 Confidential Material Secured/Protected55 Sharps, None overfilled (Sealed for Disposal) 86 Department Petty Cash Secured56 Other: 87 High Risk Pt./Equip. Areas, Haz. Material Rooms Secured

88 Medications Secured# S N/I N/A Utility, Mechanical Systems - Physical Environment 89 Personal Belongings Secured

57 Ceiling Tiles, None Discolored/Wet/Missing/Damaged 90 Security Door Key Pad Codes Recently Changed58 Emergency Back-up Lights Operational 91 Security Doors Operational (Key Pad Doors/Magnets)59 Humidity, Within Appropriate Range (40-60%) 92 Security Wrist (Panic) Alarms Available/Operational60 HVAC Systems-Air Temp within Comfortable Range 93 Other:61 Lighting, No Lights Out Personnel Identification62 Plumbing, Faucets/Toilets/Drains Operational (No Leaks) A # Personnel Wearing Badges

63 Water Temp, Within Appropriate Range (<120°, 90°) B # Personnel Not Wearing Badges64 Phone Service: 911 Feature Operational (off-site bldgs) #DIV/0! % of Compliance = A(A+B)65 Public Address System-Audible/Functional/Approp for Area? 94 Personnel Identification (Satisfactory Score = 100%)





Survey #:

Facility:

66 Other: 95 Yellow Emergency Code Cards Present with Badges0 0 0 2nd Page Sub-Total: SIDE A 0 0 0 2nd Page Sub-Total: SIDE B

(*) Refers to Item# from survey form.Page 6 of 16

Samaritan Pacific Communities Hospital - Survey, Environmental Tour - Plan for Improvement

Date of Survey: 30-Dec-99 Work Center Names: 0

Survey #: 0 0

Facility: 0 0

Survey - Corrective Action Required POC - Action Taken

Corrective Action to be Taken Date CommentsItem #(*)

Suspense Date

Point of Contact - Department

Specific Location or ID No. or Product

Info

(*) Refers to Item# from survey form.Page 7 of 16

Samaritan Pacific Communities Hospital - Survey, Environmental Tour - Plan for Improvement

Date of Survey: 30-Dec-99 Work Center Names: 0

Survey #: 0 0

Facility: 0 0

Survey - Corrective Action Required POC - Action Taken

Corrective Action to be Taken Date CommentsItem #(*)

Suspense Date

Point of Contact - Department

Specific Location or ID No. or Product

Info

SPCH - Environment of CareSurvey, Environmental Tour - Reference Information

Revised: 02/04/09Page 8 of 16

# Indicator Description - Definition

Employee General Knowledge

A

B

C

D

E

F

G

H

I

J

K

L

M

N

Back-Up Power, Red Outlets/Flashlights: Hospital Building: All critical clinical equipment should be plugged into the red outlets (East Wing only) which are on emergency generator power when city power is disconnected. The majority of the West Wing does not have red outlets as the entire wing is provided with emergency power. The East Wing primarily has red outlets which are located only in key clinical areas, patient rooms. Off-Site Buildings: Off-site buildings do not have emergency power. Battery back-up lights are provided to assist with evacuation during loss of power and are only available for 30-45 minutes after loss of city power. Each department should have flashlights available for use during emergency situations.

Defective Equipment Labels, Location & Use Of: Defective equipment labels are to be utilized for any item that is a hazard or may cause injury to another individual. The label is used in conjunction with an engineering/bio-medical work order to identify the item as "do not use". All personnel should know where to locate the labels and how to use. The labels can be obtained from Material Management.

Emergency Paging Ext. or Phone Number (911 or x NO.): Hospital Building: Dial x 1003 to overhead page. Off-Site Buildings: dial 911 for emergency assistance and use their internal paging ext. no.

Emergency Quick Reference Guides, Location of: This indicator is not yet in use, however, most areas and/or employees may have an emergency code listing on their phones or name badges that define what the emergency codes are used for.

Employee Safety Committee, How to Access a Representative: Personnel should be familiar with those persons listed as members/representatives and/or know how to contact the committee.

Employee Safety Committee, Minutes Posting: Personnel should be able to locate the most current copy of the minutes. The most current monthly Safety Committee Minutes should be posted for employee review at all times. This is a OR State OSHA requirement.

Fire/Smoke Compartments - Evac. Routes-Exits, Location of: All personnel should know the options for evacuating their areas to other fire compartments or directly to the outside. Hospital Building - Type I: Each area can evacuate to the next compartment (adjacent to or below) or if next compartment is blocked then directly to the outside. Off-Site Buildings - Type B: Evacuation is always directly to the outside.

Fire Extinguishers, Location and Use of (PASS): All personnel should know the location of the fire extinguishers in their areas and where to look for them in common areas and know how to use a fire extinguisher, using the acronym "PASS", Pull-Aim-Squeeze-Sweep.

Gas Shut-Off Valves, Authorization and How to: Each department that utilizes a gas system, i.e., medical gasses and/or natural gas must either designate one position to shut-off, i.e., Charge Nurse, and/or train all staff on the proper situations to shut-off and how to shut-off.

Material Safety Data Sheets (MSDS), Access to: Each department should have a hardcopy MSDS manual in their area and all departments with internet access can utilize the "Dolphin On-Line MSDS program", through the SHS Intranet - Library page.

Reporting/Response of Cardiac Arrest: Hospital Building: Ext. 1003 to overhead page "Code 99" for internal medical assistance. Off-Site Buildings: Dial 911 then contact Quality Management during business hours or the Nursing Supervisor after-hours. Both areas need to complete an unusual occurrence report for this type of incident.

Reporting/Response of Fire, Code Red (RACE): Follow the fire response acronym "RACE" Rescue, Alarm, Confine, Extinguish or Evacuate. Hospital Building - Type I: Activate a manual fire alarm pull station and dial Ext. 1003 to overhead page "Code Red - Location". Off-Site Buildings - Type B: Activate a manual fire alarm pull station and dial 911 for emergency assistance. Contact Engineering during business hours and the Nursing Supervisor after-hours if fire alarm system is activated.

Reporting/Response of Hazardous Material Exposure/Spill: Personnel should know how to contain, isolate, and secure the spill, incident and report the incident to appropriate personnel. Hospital Building: Contact Housekeeping or if an emergency situation page "CODE ORANGE" for response. Off-Site Buildings: Contact Engineering at ext. 1808 during business hours and the Nursing Supervisor after-hours. All "hazardous material spills/exposures" should be documented utilizing an unusual occurrence report. Depending on the size and hazard rating the spill can be cleaned-up by either the employee who caused/found, housekeeping, engineering, and/or an external contracted vendor.

Reporting/Response of Infant/Child Abduction: Hospital Building: Dial ext.1003 x to overhead page "Code Pink (child or infant)". Each department should complete a sweep of all areas within their department and assist to monitor doors, hallways, elevators the code is activated. Off-Site Buildings: Contact immediate supervisor on site, begin sweep of interior/exterior of building, monitor hallways and exits, contact Administration and the local police department 911.




O

P

Reporting/Response of Injuries (Pt./Visitor/Employee):

Q

R

S

T

U

V Not in UseW Not in Use

Emergency Management23

4

5

6

7 Not in UseClinical/Medical Equipment Management

8

Reporting/Response of Infectious Waste Exposure/Spills: All personnel should know either how to properly clean up infectious waste spills using personal protective equipment and/or the appropriate department to request assistance, i.e., Housekeeping.

Employee Injuries: Dependent upon the nature/extent of the injury employees should apply first aid and/or seek medical attention via employee health nurse and/or the emergency department, contact their immediate supervisor and complete an employee injury report.

Patient Injuries: Dependent upon the nature/extent of the injury the patient care taker should apply first aid and/or contact the Nursing Supervisor/Clinic Coordinator for direction regarding additional medical treatment. An Unusual Occurrence report should be completed for these incidents.

Visitor Injuries: Dependent upon the nature/extent of the injury the employee who first comes upon an injured visitor should assist with first aid and/or refer the visitor to the emergency department for medical assistance. If visitor is not located within the main hospital then as needed the employee will contact 911 for assistance. An Unusual Occurrence report should be completed for any visitor injuries that occur on SHS property.

Reporting/Response of Security Threat/Crime: Hospital Building: Contact Engineering x 1808 during business hours and the Nursing Supervisor after-hours. The "panic wrist alarms" should be activated for emergency situations for those areas who have a wrist alarm. When the blue light security system is activated the Nursing Supervisor, Engineering and other available personnel should respond to assist. The "zone" or location is identified on each blue light station. Off-Site Buildings: Dial 911 for emergency situations and/or contact Engineering x 1808 to report non-emergency situations. An Unusual Occurrence Report should be completed for all reports of security incidents.

Reporting/Response to Utility Failures: All personnel in all buildings should know who they would contact for utility failures and how to respond when services are disrupted. Contact Engineering Services during business hours and the Nursing Supervisor after-hours.

Response of Disaster Code: Decision to implement the disaster code is authorized only by the Nursing Supervisor/Administrator or On-Call Administrator/Safety Officer. Announcement is "Code Triage". An incident command center will be established for hospital or off-site buildings. Employees responding to the main hospital building for assistance during a disaster should enter the building through the gift shop entrance.

SMDA - Safe Medical Device Act - Actions to Take: If a medical device (equipment - electrical or non-electrical) causes injury or death to a patient the Clinician must take the following steps: A) Continue care of the patient with alternate equipment. B) Isolate, quarantine the equipment including any disposables utilized C) Apply a defective sticker to the device D) Contact immediate supervisor and Nursing Supervisor/Clinic Coordinator E) Complete an unusual occurrence report documenting the incident. The incident will be investigated by the Safety Officer and the Bio-Medical Technician and appropriate documentation completed and forwarded to the FDA and manufacturer.

Secondary Container Labels, Location and Use of: Secondary container labels are utilized when the product or mixed solution is transferred from the original manufacturer container(s) and placed into a non-labeled secondary container. Personnel should be able to locate, fill-out and utilize secondary container labels. Labels are to be available in every department and can be obtained from Material Management.

Dept. Disaster Box, Available/Stocked - this indicator will be implemented later this year .Dept. First Aid Supplies, Available - does your area have the necessary supplies to complete basic first aid?

Emergency Quick Reference Guides (Flipcharts) Posted - these are not yet in place at SPHS, however, there are labels on some phones and the backside of employee badges providing a definition of the emergency codes.

Earthquake Mitigation Measures in Place - Each area should have measures in place to prevent injury and/or property damage in the event an earthquake may occur. Measures include: securing of cabinets/bookcases/filing cabinets/heavy equipment, storing glass containers behind secure cabinet doors or on low shelves with edge stoppers, securing glass picture frames to walls, etc.

Flashlights Available, With Extra Charged Batteries - all areas should have at least 1-2 flashlights based on size and complexity of rooms.

Elec. Safety Check Label Present - Medical equipment regardless of ownership must be electrical safety checked prior to use. Includes rental, loaner, trial, patient owned, company owned equipment.




9

10

11

12

13 Not in Use

14

Log Sheet, Documentation

15

161718

19

Fire Prevention - Response Management2021222324

25

26272829

30

3132

33

34 Not in UseHazardous Materials Management

3536

37

38 Gas/Cylinder Safety - Gauges/Regulators Working Properly3940414243

44

45

46

Control ID Number Tag Present - Medical equipment that is owned by SPHS (SHS) must be tagged with an appropriate control number ID tag. (Currently there are 2 different styles of ID tags in place - PCH and SHS).

PMI Expiration Date or N/A Label Present - Medical equipment that is owned by SPHS (SHS) must have a label present (green) that indicates when the last PMI (preventive maintenance inspection) was completed, by whom and when the next PMI is due or if no PMI is required then N/A must be written on the label.

Equipment Within Appropriate PMI Timeframe - The timeframe must be within the appropriate range for those pieces of medical equipment that have required PMI's. This will be determined by reviewing records within the Eng/Bio-Medical equipment database.

Equipment Within the PMI Database - Medical equipment that is owned by SPHS (SHS) must be logged and tracked within the ENG/Bio-Med Medical equipment database.

Compliance Score - This field is utilized to determine the overall Clinical/Medical Equipment Management compliance score. A score of 95% is required to meet this indicator.

Crash Carts/AED's, Daily - Completed by departmental personnel in departments where crash carts are located.

Dishwashers, Daily - Completed by Nutrition Services personnelEye Wash Stations, Weekly - Completed by Departmental PersonnelFire Extinguishers, Monthly - Completed by Engineering Personnel

Refrigeration, Food/Specimens/Meds/Products, Daily - Completed by departmental personnel where refrigeration equipment is located.

Doors Closed, Soiled/Clean/Hazardous Areas - these doors are to be kept closed at all times.Doors Fire, <1/8 Inch Gaps & < 3/4 Inch Undercut - Engineering ResponsibilityDoors Fire, Appropriate Label Visible - Engineering ResponsibilityDoors Fire/Smoke, Positively Close/Latch - Engineering Responsibility Doors Interior, Approp. Labeled with Function or Not An Exit - Engineering Responsibility

Doors Wedged Open, None Found - doors opening unto an emergency exit corridor can not be wedged open unless the door is held open by a magnet fire alarm system device.

Emergency Exit Corridors/Doors, Clear - no obstructions of any kind are found in these corridors.Exit Signs, In Appropriate Locations - Engineering ResponsibilityExit Signs, Lighted - Engineering ResponsibilityFire Extinguishers, Visible - Engineering Responsibility

Flammables, Stored Appropriately - stored in approved containers, storage units and/or away from heat sources.

Penetrations Wall/Ceiling/Floors, None Present - Engineering ResponsibilitySprinkler Heads/Smoke Detectors, Clean/Intact - Housekeeping/Engineering Responsibility

Sprinklers, 18" Ceiling Clearance - no items stored within 18" of the bottom of sprinkler heads, on parallel plane.

Appropriate Product Used for Task/Job - personnel can demonstrate or are observed utilizingEye Wash Available, As Appropriate

Gas/Cylinder Safety - Cylinders Stored Appropriately - cylinders based on size are kept in appropriate holders and/or securely chained.

Hazardous Material Areas, Food/Drinks Not Present - personnel should not eat or drink in hazardous areas.Hazardous Materials, Handled Appropriately - personnel can demonstrate or are observedHood Vents, Certification Current - External vendor should apply "sticker" noting complianceMSDS Available for All Products - a sample of 3-7 products will be checked to verify MSDS is availableMSDS Inventory, Current List Available - a sample of 3-7 products will be checked to verify MSDS is available

Personal Protective Equip., Appropriate Type Available - is the appropriate PPE available for personnel use and are they using it?

Products Properly Labeled (Secondary Container Labels) - no items should be found with missing or unreadable labels, secondary labels are okay if information is filled in correctly.

Products Properly Stored - products should be stored appropriately based on hazard rating, reactivity and flammability




47

48

49 Not in UseHazardous Material Waste Storage/Container Use

505152

53

545556 Not in Use

Utilities Management

57

585960 HVAC Systems-Air Temp within Comfortable Range61

62

63646566 Not in Use

Safety Management (General/Electrical)

67

68

69

70

71 Electrical Outlets GFI, Within 6 Feet of each Sink

72

7374

75

76

77

78

79

8081 Storage/Mechanical Rooms, Clean/Uncluttered82 Trip Hazards, None Present83 Walls/Floors/Ceilings/Doors in Safe Condition - No Hazards84 Not in Use

Security Management

Spill Kit, Appropriate Type Available - non-hospital areas should have a small spill kit available, hospital areas would rely on the "facility" spill kit but may have specific kits for specific products, i.e., mercury, etc.

Secondary Container Lables Available - labels should be available for use in all departments. Labels can be obtained from Material Management.

Biohazard Wastes, Stored Appropriately - soiled utility rooms, not kept in public common areasChemical Wastes, Stored Appropriately - kept in hazardous chemical cabinets as appropriate for the product.Chemo Therapy Waste, Stored Appropriately - kept in containers clearly identifying the type of material.

Containers, Appropriate for Area - personnel have appropriate containers, storage cabinets available to store wastes.

Containers, Appropriate Location/Height - to prevent risk, injuriesSharps, None overfilled - Sealed for Disposal

Ceiling Tiles, None Discolored/Wet/Missing/Damaged - Personnel should contact Engineering to report ceiling tile concerns.

Emergency Back-up Lights Operational - Engineering ResponsibilityHumidity, Within Appropriate Range (40-60%) - Engineering Responsibility

Lighting, No Lights Out - Personnel should contact Engineering to report lighting outages.

Plumbing, Faucets/Toilets/Drains Operational (No Leaks) - Personnel should report plumbing concerns to Engineering.

Water Temp, Within Appropriate Range (<120°, 90°) - Engineering responsibilityPhone Service: 911 Feature Operational (Off-Site Buildings) - Verification of 911 line operation.Public Address System - Audible/Functional/Appropriate for Area?

Defective Equipment Stickers Available - All departments should have defective equipment stickers available to identify hazardous equipment to prevent additional or potential injuries by others.

Desks, Chairs, Furniture in Safe Condition - No Hazards: All items should be in good working condition and hazardous or unsafe equipment tagged defective and a work order submitted for repair/disposal.

Electrical Cords/Plugs/Outlets in Safe Condition - personnel should periodically check the cords/plugs of the equipment they are using for unsafe conditions, i.e., frayed wires, bent prongs, missing prongs.

Electrical Extension Cords, None in Use - these are only permitted for use in Engineering Services and/or by Engineering personnel on temporary basis.

Electrical Outlets Safety Covers, Exam/Waiting Areas - exam and waiting areas should have in place tamper resistant outlets or outlet safety covers. These are to prevent children from risk of injury if they were to tamper with the outlet.

Electrical Panels, Accessible (36" Rule) - no items are stored in front of electrical panelsElectrical Plugs, 3 Pin Type in Patient Care Areas - hospital grade plugs "green dot" for hospital use.

Employee Safety Committee Minutes Posted - The most current monthly Safety Committee Minutes should be posted for employee review at all times. This is a OR State OSHA requirement.

Expiration Dates Current - Products, Medications, Foods - items should be checked periodically for expiration dates. Any items with expired dates must be removed from use immediate and disposed of appropriately.

Forms Available - Employee Injury, Unusual Occurrence - are forms readily available and can employees locate them.

Grab Bars, Handles Secured to Walls/Fixtures - No loose or unsafe items found.

Nurse Call Devices, Operational - is the pull string within reach of the patient, when pulled does it ring the appropriate area, if light available is it lit? Did someone respond?

Signage Appropriate for Area/Services - are there any signs that need to be moved, deleted, added, revised?




85

86

87

88

89

90

91 Security Doors Operational (Key Pad Doors/Magnets)

92

93 Not in Use

94

95

Confidential Material Secured/Protected - material should be secured/protected, areas with medical records should not be left unattended or unsecured.

Department Petty Cash Secured - Who does and who should have access to petty cash.

High Risk Pt./Equipment Areas, Haz. Material Rooms Secured - These areas include OB Unit, Engineering Work/Utility Rooms, Medical Records, Surgical Services, Janitors Closets in public areas. Some of these areas may be unlocked but only while occupied by appropriate department personnel.

Medications Secured - dependent upon type of medications are they secured in drug cabinet or in med room? Who does and who should have access to these areas? Are they to be kept unlocked during business hours?

Personal Belongings Secured - do personnel in this area each have a place to secure their personal belongings?

Security Door Key Pad Codes Recently Changed - Depending on the department area the key pads should be changed at least quarterly and/or or more frequently if there are personnel changes within the department.

Security Wrist (Panic) Alarms Available/Operational - departments with wrist alarms should have alarms readily available and they should be operational.

Personnel Identification - all SHS personnel and medical staff are required to have their identification displayed appropriately while on duty at all times. Are personnel wearing their badges? 100% compliance required.

Blue Emergency Code Cards Present - Blue cards should be available with badges.

Page 13 of 16

Samaritan Pacific Communities Hospital - Survey, Environmental TourClinical/Medical Equipment Management Survey

Date of Survey: 0 Work Center: 0

Comments/Other/Room NumberControl # ID/ Description

Elec. Safety Check Label Present (#8)

Control ID# or Other Label Present (#9)

Date of PMI Expiration on

Sticker

PMI Expiration Date or N/A

Labels Present (#10)

PMI Within Date Timeframe (#11)

Equip. in PMI Database (#12)

Page 14 of 16

Satisfactory 0 0 0 0 0

Unsatisfactory 0 0 0 0 0

N/A 0 0 0 0 0

Employee Name Badges 12/30/1899 0

# Wearing # Not Wearing

Product Expiration Dates

# Expired

Misc. Checks - Operational/Ok?

# of Missing Yellow Cards

Fire Extinguishers

Battery Back-up Lights & Flashlights

Exit Coorridors - Clear

Exit Signs - Lighted

Use these cheat sheets to assign tasks to the employee safety committee members when completing the surveys.

Documents

24 - Survey - Environmental Tour Template