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Methodist Hospital

E.O.C. Inspection Form

Associated Event   
* DEPARTMENT/UNIT INSPECTED
  Offsite/Other
* DATE OF INSPECTION
  MANAGER
* TIME/SHIFT OF INSPECTION
* SURVEYED BY:
PATIENT SAFETY
  ARE CORRIDORS KEPT CLEAR TO ALLOW AMBULATION OF PATIENTS AND VISITORS TO WALK SAFELY? YES     NO     N/A    
  ARE CORRIDORS KEPT CLEAR TO ALLOW CARTS, WHEELCHAIRS AND BEDS TO PASS WITH ADEQUATE CLEARANCE? YES     NO     N/A    
  ARE FLOORS CLEAR, AND SLIP-RESISTANT? YES     NO     N/A    
  HOW MANY ITEMS APPEAR TO HAVE BEEN "STORED" IN CORRIDOR?
MEDICATION STORAGE
  ARE MEDICATION ROOMS/ CARTS LOCKED WHEN NOT ATTENDED? YES     NO     N/A    
  IS MEDICATION LEFT UNATTENDED? YES     NO     N/A    
FIRE SAFETY
  ARE THE MEANS OF EGRESS/EXIT DOORS CLEARLY & CORRECTLY MARKED? YES     NO     N/A    
  ARE THE MEANS OF EGRESS/EXIT DOORS CLEAR OF DEBRIS & EQUIPMENT? YES     NO     N/A    
  IS ALL EQUIPMENT PLACED TO ONE SIDE OF THE HALL? YES     NO     N/A    
  DO ALL IDENTIFIED FIRE EXTINGUISHER LOCATIONS HAVE CLEARLY VISIBLE SIGNS? YES     NO     N/A    
  DO ALL IDENTIFIED FIRE EXTINGUISHER LOCATIONS HAVE CURRENT INSPECTION TAGS? YES     NO     N/A    
  DO ALL IDENTIFIED FIRE EXTINGUISHER LOCATIONS HAVE 3-FOOT ACCESS CLEARANCE? (ALL AROUND THE EXTINGUISHER) YES     NO     N/A    
  HOW MANY EXTINGUISHERS ARE LOCATED IN THIS AREA?
  HOW MANY EXTINGUISHER INSPECTION TAGS WERE PAST DUE?
  ARE THE FIRE ALARM PULL STATIONS ACCESSIBLE WITH 3 FOOT CLEARANCE? YES     NO     N/A    
  ARE THE FIRE ALARM PULL STATIONS IN GOOD CONDITION (GLASS BAR IN PLACE)? YES     NO     N/A    
  ARE COMBUSTIBLE MATERIALS: ( CARDBOARD BOXES, PAPER, LINEN, WASTES) STORED IN PROPER TYPE OF CONTAINERS? YES     NO     N/A    
  ARE COMBUSTIBLE MATERIALS: ( CARDBOARD BOXES, PAPER, LINEN, WASTES) KEPT IN MINIMUM QUANTITIES NECESSARY FOR DAILY USE? YES     NO     N/A    
  ARE COMBUSTIBLE MATERIALS: ( CARDBOARD BOXES, PAPER, LINEN, WASTES) PROPERLY LABELED? YES     NO     N/A    
  ARE COMBUSTIBLE MATERIALS: ( CARDBOARD BOXES, PAPER, LINEN, WASTES) KEPT IN A SAFE, DESIGNATED LOCATION? YES     NO     N/A    
  ARE ALL DOORS FREE OF BEING PROPPED/ HELD/ WEDGED OPEN? YES     NO     N/A    
  ALL DOORWAYS ARE CLEAR AND DOORS UNOBSTRUCTED? YES     NO     N/A    
  DO FIRE AND STAIRWELL DOORS LATCH FIRMLY? YES     NO     N/A    
  ALL DOOR HARDWARE IS IN GOOD OPERATING CONDITION? YES     NO     N/A    
  ARE DOOR WEDGES PRESENT? YES     NO     N/A    
  ARE ITEMS STORED AT LEAST 18" BELOW CEILING? YES     NO     N/A    
  DO PATIENT PRIVACY CURTAINS HAVE 18" NET AT TOP? YES     NO     N/A    
  ARE PORTABLE SPACE HEATERS PRESENT IN PATIENT SLEEPING AREAS? YES     NO     N/A    
SAFE ENVIRONMENT
  ARE ALL FLOORS IN GOOD CONDITION? YES     NO     N/A    
  ARE ALL FLOORS CLEAN AND DRY? YES     NO     N/A    
  ARE ALL FLOORS FREE FROM TRIPPING/ FALL HAZARDS? YES     NO     N/A    
  ARE WET FLOOR SIGNS BEING USED PROPERLY? YES     NO     N/A    
  IS CARPET LYING FLAT ON THE FLOOR? (NO TRIPPING HAZARDS PRESENT) YES     NO     N/A    
  ARE CABLES/WIRES RAN ACROSS WALKWAYS CREATING A POSSIBLE HAZARD? YES     NO     N/A    
  ARE THE WALLS IN GOOD CONDITION? (FREE FROM HOLES OR WATER DAMAGE) YES     NO     N/A    
  ANY EXPOSED WIRES/ CABLES PRESENT ON WALLS? YES     NO     N/A    
  ANY ELECTRICAL BOXES, OUTLETS, OR COVERS DAMAGED/MISSING? YES     NO     N/A    
  ALL CEILING TILES ARE IN PLACE AND IN GOOD CONDITION? YES     NO     N/A    
  ALL CEILING TILES ARE FREE FROM DIRT, MOLD, DUST, ETC.? YES     NO     N/A    
  ALL CEILING TILES ARE DRY WITHOUT EVIDENCE OF PREVIOUS WATER DAMAGE? YES     NO     N/A    
INFECTION CONTROL PRACTICES
  ARE NEEDLE BOXES LESS THAN 75% FULL? YES     NO     N/A    
  IS CLEAN LINEN COVERED? YES     NO     N/A    
  IS CLEAN LINEN STORED SEPARATELY FROM DIRTY LINEN? YES     NO     N/A    
  IS MEDICATION PROPERLY LABELED & DATED? YES     NO     N/A    
  ARE REFRIGERATORS PROPERLY LABELED? (PT. FOOD ONLY, MEDS ONLY, STAFF FOOD ONLY) YES     NO     N/A    
  DO REFRIGERATORS HAVE CURRENT TEMPERATURE LOGS? YES     NO     N/A    
  ARE ALL CARDBOARD BOXES OFF OF THE FLOOR, AND NO SHIPPING BOXES ON THE UNIT? YES     NO     N/A    
  ARE BLOODBORNE PATHOGEN PRECAUTIONS IN EVIDENCE? (e.g.. GLOVES, MASKS, GOWNS, SEPERATION OF WASTE) YES     NO     N/A    
  IS PERSONAL PROTECTIVE EQUIPMENT READILY AVAILABLE & IN GOOD CONDITION? YES     NO     N/A    
  ARE THE AREAS UNDER THE SINKS FREE OF PATIENT CONTACT ITEMS? (CLEANING PRODUCTS ONLY ALLOWED) YES     NO     N/A    
  ARE COMPRESSED GASES STORED/USED IN THIS AREA SECURED? IS THERE LESS THAN 300 CU FT OXYGEN STORED IN AREA? (12 E TANKS) YES     NO     N/A    
HAZARDOUS MATERIALS AND WASTE
  ARE HAZARDOUS CHEMICALS USED IN THIS ARE STORED CORRECTLY? (FLAMMABLE, CORROSIVE STORAGE AREAS) YES     NO     N/A    
  ARE HAZARDOUS CHEMICALS USED IN THIS AREA LABELED CORRECTLY? YES     NO     N/A    
  ARE HAZARDOUS CHEMICALS USED IN THIS AREA DISPOSED OF CORRECTLY? (ARE THERE PROCEDURES FOR DISPOSAL) YES     NO     N/A    
  IS STAFF FAMILIAR WITH MSDS ONLY SYSTEM & USE? YES     NO     N/A    
  IS AREA/DEPARTMENT EQUIPPED WITH MSDS ONLINE SERVICE? YES     NO     N/A    
  CAN STAFF DESCRIBE HOW MSDS ONLINE WORKS? YES     NO     N/A    
  SELECT 3 CHEMICALS USED IN AREA, CAN STAFF LOCATE MSDS? YES     NO     N/A    
  HOW MANY OF THE 3 SELECTED CHEMICALS WERE LOCATED USING MSDS ONLINE? YES     NO     N/A    
  ARE MEDICAL WASTES IN RED BIOHAZARD BAGS/LABELED CONTAINERS? YES     NO     N/A    
  ARE MEDICAL WASTES PROPERLY STORED AND DISPOSED OF? YES     NO     N/A    
  ARE MEDICAL WASTES PROPERLY SEPARATED AND DISPOSED OF? YES     NO     N/A    
MEDICAL EQUIPMENT
  IS THERE MEDICAL EQUIPMENT IN USE OR USED IN THIS AREA? YES     NO     N/A    
  ARE INSPECTION TAGS CURRENT? YES     NO     N/A    
  CAN STAFF EXPLAIN IF EQUIPMENT IS CURRENT? YES     NO     N/A    
  IS EQUIPMENT CLEAN AND STORED PROPERLY? YES     NO     N/A    
  CAN STAFF DESCRIBE TRAINING REQUIREMENTS FOR EQUIPMENT? YES     NO     N/A    
  CAN STAFF EXPLAIN EMERGENCY PROCEDURES FOR LIFE SUPPORT EQUIPMENT? YES     NO     N/A    
  LIST THREE (3) DIFFERENT HOSPITAL TAG NUMBERS
UTILITY SYSTEMS
  ARE EMERGENCY POWER OUTLETS CLEARLY MARKED WITH RED COVERS/OUTLETS? YES     NO     N/A    
  ARE EMERGENCY POWER OUTLETS BEING USED FOR CRITICAL EQUIPMENT ONLY? YES     NO     N/A    
  IS THERE ANY EXPOSED WIRING OR ELECTRICAL PANELS? YES     NO     N/A    
  ARE BREAKERS LABELED? YES     NO     N/A    
  ARE PANELS KEPT LOCKED? YES     NO     N/A    
  ARE ANY OUTLETS/ELECTRICAL BOX COVERPLATES DAMAGED OR MISSING? YES     NO     N/A    
  ARE MEDICAL GAS ZONE VALVES AND MAIN VALVES MARKED WITH IDENTITY AND LOCATIONS SERVED? YES     NO     N/A    
  ARE MEDICAL GAS ZONE VALVES AND MAIN VALVES ACCESSIBLE AND NOT BLOCKED? YES     NO     N/A    
  DO STAFF MEMBERS UNDERSTAND WHO SHOULD CLOSE OXYGEN VALVES IN THE CASE OF A FIRE EMERGENCY? YES     NO     N/A    
SECURITY
  ARE ALL EMPLOYEES WEARING ID BADGES IN PLAIN VIEW? YES     NO     N/A    
  CAN STAFF EXPLAIN HOW TO GET HELP IN A SECURITY EMERGENCY? YES     NO     N/A    
  ARE PROTECTIVE MEASURES IN SENSITIVE AREAS ACTIVE AND ARE STAFF MEMBERS ABLE TO EXPLAIN THEIR ROLE IN PROTECTING THE PATIENTS? YES     NO     N/A    
ASK THREE (3) STAFF MEMBERS TO DESCRIBE "CODE PINK" PROCEDURES & THEIR ROLE.
  HOW MANY OF THE 3 ACCURATELY DESCRIBED THE CODE PINK PROCESS?
EMERGENCY MANAGEMENT
  IS THERE A CURRENT COPY OF THE EMERGENCY MANAGEMENT PLAN ON THE UNIT? YES     NO     N/A    
  CAN STAFF EXPLAIN THEIR ROLE IN THE VARIOUS EMERGENCY OPERATION PLANS? YES     NO     N/A    
  COMMENTS/CONCERNS