St.

Anthony's Medical Center

ENVIRONMENTAL TOUR- CLINICAL AREA

AREA/DEPARTMENT INSPECTED: Inspected By:

Department Director: Date/Time: Date/Time:
Item # Description Room Number COMMENTS
Jan-June Jul-Dec and Specific
FIRE SAFETY PHYSICAL INSPECTION Rating Yes No N/A Yes No N/A Location
Are exit doors and stairwells clear? Main, corridor, and stairwell
1
exits cannot be blocked by any means. 1
Are exit doors clearly marked "exit" and illuminated? Check for
2
burned out bulbs
Do fire doors latch properly? Close the fire doors to see if they 2
latch properly and see that there is no gap >1/8 inch in the
3
middle. 2
Are corridors and passageways free of obstruction? The
4 corridors can have mobile items (wheels on them) that are
pateint care or emergency needed items and are in use. 2
Are pull stations or fire extinguishers unobstructed? There must
5
be nothing to obstruct access. 1
Are doors not propped/held open? Doorstops or homemade held
open devices are not allowed while no one is in the area. They
are allowed as long as someone is in the area but once they are
6 out of the area, it must be removed. Tape is not allowed over
any corridor doors. Any of these items must be removed
immediately. 1

Is there any excessive decorations of possibly flammable

materials? Decorations or other objects shall not be placed in a
manner that would obstruct access or visibility to EXIT signs, fire
7 alarm equipment, fire alarm pullboxes, fire extinguishers/cabinets
etc. Fire/smoke doors may not be decorated including the glass
vision panels in these doors. Desks, walls, columns, doors,
ceilings etc. can not be decorated with flammable decorations. 1
Are all materials stored a minimum of 18 inches from sprinkler
8 deflectors? The distance between the sprinkler deflector and
stored items is 18” for sprinkled buildings. 2
Are storage rooms and equipment rooms free of clutter and
9 unsafe conditions? Make sure that items are not falling down or
overstocked. This is a judgment call. 3

SAFETY MANAGEMENT PHYSICAL INSPECTION

10 Is area free from evidence of smoking? 1
11 Are the floors/hallways in good condition? 3
12 Do the walls need paint or repair? 4
466832694.xls 1 St. Anthony's Medical Center
 St. Anthony's Medical Center
ENVIRONMENTAL TOUR- CLINICAL AREA

13 Are cables or wires exposed? 4

Are ceiling tiles clean, stain free, and in good condition? Indicate
14
where these bad tiles are located in the comments. 3
Are heavy items stored at low levels or mid levels in storage?
15 Make sure the heavy items are stored at waist level or lower
shelves 3

466832694.xls 2 St. Anthony's Medical Center

 St. Anthony's Medical Center
ENVIRONMENTAL TOUR- CLINICAL AREA

Room Number and

Jan-June Jul-Dec Specific COMMENTS
SAFETY MANAGEMENT PHYSICAL INSPECTION (contd) Rating Yes No N/A Yes No N/A Location
16 Are general areas clean and free of clutter? 2
Are compressed gases stored properly and is proper signage
indicating oxygen storage in place? Compressed gases need to
17 be chained to the wall or on a cart secured. Freestanding bottles
are not allowed. 1
UTILITIES PHYSICAL INSPECTION
Are all mechanical, electrical, janitorial, communications rooms
18 clean with and no storage? Indicate which rooms are not clean
that are itemized here. 3
INFECTION CONTROL PHYSICAL INSPECTION
19 Are gloves, gowns, eyewear, and masks readily available? 1
20 Is clean linen covered? 1
21 Is clean linen kept separate from the dirty linen disposal? 1

22 Are refrigerator logs maintained and up to date in medicine and

patient refrigerators? 1
23 Are medicines and food kept in separate refrigerator? 1
24 Are needle boxes under 2/3 full? 2
25 Are there any expired hand sanitizer dispensers or bottles? 1
Were employees eating or drinking in designated areas only?
26
Staff should not have food/drink in patient care areas. 1
INSPECTION
Is only appropriate medical waste kept in red biohazard bags or
27
containers? 1
Are secondary chemical containers labeled with product name,
28 hazard label and manufacturer? Indicate any chemical that is in
a container other than the original container. 2
29 initialed. 2
Are chemicals stored separately from patient contact or other
30
clean items? 1

466832694.xls 3 St. Anthony's Medical Center

 St. Anthony's Medical Center
ENVIRONMENTAL TOUR- CLINICAL AREA

Room Number and

Jan-June Jul-Dec Specific COMMENTS
HAZARDOUS MATERIALS & WASTE (contd) Rating Yes No N/A Yes No N/A
Is the Hazardous Chemical Inventory adequate and available to
all employees? OSHA requires that each Department have an up
35 to date chemical inventory log that is available to employees at
all times. 4
Are appropriate procedures, instructions, or directions available
36 for obtaining Safety Data Sheets (SDS)? There should be
instructions within the department to access the SDS. 4
SECURITY PHYSICAL INSPECTION
Is staff's personal items properly secured? Check for purses,
37
billfolds, money, keys, etc left out for you to take. 2
38 Are
Are all
all employees
mechanical,wearing their
electrical, ID badges
janitorial, in plain view? rooms
communications 1
locked? Indicate which rooms are not locked that are itemized
39
here. 1
40 Are medications kept in locked rooms? 1
MEDICAL EQUIPMENT PHYSICAL INSPECTION
Does equipment have any exposed wires? Check the plug for
41
exposed wires. 2
Are all medical equipment tags current? Check all equipment for
42 expiration dates. Leased equipment must also have been initially
inspected. 2
Does the equipment's cleanliness, paint, wiring, and covers
43
appear satisfactory? 2
Do storage room doors self close and latch? Ensure these doors
45
are not propped open and close easily. 2
EMERGENCY MANAGEMENT
Do employees know where to access the Emergency Operations
49
Plans?
STAFF KNOWLEDGE QUESTIONS Yes No N/A
50 Do staff know how to obtain the SDS?
Do staff know the proper way to deal with a potentially combative
51 patient?
52 Do staff know how to report a safety Incident?
Do staff know the department specific response in the event of
53 an emergency?

Rating Scale 1- immediately

2- 24-48 hours
3- 15 days
4- 30 days

466832694.xls 4 St. Anthony's Medical Center

 St. Anthony's Medical Center
ENVIRONMENTAL TOUR- CLINICAL AREA

SURVEYOR NOTES (please explain all failures):

Date Comments WO# Completion Specifics Date

466832694.xls 5 St. Anthony's Medical Center

 FOLLOWUP DEFICIENCES TO HAZARD SURVEILLANCE INSPECTION

Estimated
Completion Supervisor/
Item # ACTION TAKEN Date Manager
PLEASE EXPLAIN ALL ACTIONS REQUIRING MORE THAN 30 DAYS TO CORRECT (If applicable) Signature/Date