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Survey #:
Facility:
(Name, Department)
Dept. Leadership:
S N/I N/A
Date Survey Distributed to Department Leadership
0 0 0
SCORE - Employee Knowledge Compliance
#DIV/0!
# PFI's Required - Total
0 0 2
SCORE - Work Center (Dept) Survey Compliance
#DIV/0!
Date of Final PFI Suspense Date
0 0 0
SCORE - Physical Environment Compliance
#DIV/0!
# PFI's Completed within Appropriate Timeframe
0 0 0
SCORE - Clinical Equipment Compliance
#DIV/0!
# PFI's Completed - Total
0 0 2
SCORE - TOTAL SURVEY COMPLIANCE
#DIV/0!
Date Plan for Improvements Completed
Surveyor Comments
S = Satisfactory, N/I = Needs Improvement; N/A = Not Applicable, Not Questioned or Not Observed, Page 1 of 16, Revised: 03/07/0902/04/09
PFI = Plan for Improvement, POC = Point of Contact Author: Jenny Demaris, (541) 574-4749
Samaritan Pacific Communities Hospital - Survey, Environmental Tour
Survey #:
Facility:
S = Satisfactory, N/I = Needs Improvement; N/A = Not Applicable, Not Questioned or Not Observed, Page 2 of 16, Revised: 03/07/0902/04/09
PFI = Plan for Improvement, POC = Point of Contact Author: Jenny Demaris, (541) 574-4749
Samaritan Pacific Communities Hospital - Survey, Environmental Tour
Survey #:
Facility:
# S N/I N/A Employee General Knowledge # S N/I N/A Clinical/Medical Equipment Management
A Back-up Power, Red Outlets/Flashlights, Battery Lights 8 0 0 0 # of Equip. w/Elec. Safety Check Label Present
B Defective Equipment Labels, Location & Use Of 9 0 0 0 # of Equip. w/Control ID# or Other Label Present
C Emergency Paging Ext. or Phone Number (911 or x No.) 10 0 0 0 # of Equip. w/PMI Expiration Date or N/A Labels Present
D Emergency Quick Reference Guides, Location Of 11 0 0 0 # of Equip. within Appropriate PMI Date Timeframe
E Employee Safety Committee, How to Access/Representative 12 0 0 0 # of Equip. in PMI Database
F Employee Safety Committee, Where Minutes are Posted 13 Other
G Fire/Smoke Compartments - Evac. Routes-Exits, Location of 0 0 0 Total
H 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. Compliance
J Material Safety Data Sheets, Access to 14 Satisfactory Score = 95% or above score
K Reporting/Response of Cardiac Arrest
L Reporting/Response of Code Decon # S N/I N/A Log Sheet, Documentation
M Reporting/Response of Fire, Code Red (RACE) 15 Crash Carts/AED's, Daily
N Reporting/Response of Haz. Material Exposure/Spill 16 1 Dishwashers, Daily
O Reporting/Response of Infant/Child Abduction 17 1 Eye Wash Stations, Weekly
P Reporting/Response of Infectious Waste Exposure/Spill 18 Fire Extinguishers, Monthly
Q Reporting/Response of Injuries (Pt., Visitor, Employee) 19 Refrigeration, Food/Specimens/Meds/Products, Daily
R Reporting/Response of Security Threat/Crime
S Reporting/Response of Utility Failures # S N/I N/A Fire Prevention - Life Safety
T Response of Disaster Code 20 Doors Closed, Soiled/Clean/Hazardous Areas
U SMDA - Safe Medical Device Act - Actions to Take 21 Doors Fire, <1/8 Inch Gaps & < 3/4 Inch Undercut
V Secondary Container Labels, Location & Use of 22 Doors Fire, Appropriate Label Visible
W 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, Clear
1 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, Visible
2 Dept. Disaster Box, Available/Stocked 30 Flammables, Stored Appropriately
3 Dept. First Aid Supplies, Available 31 Penetrations Wall/Ceiling/Floors, None Present
4 Emergency Quick Reference Guides Available (flipcharts) 32 Sprinkler Heads/Smoke Detectors, Clean & Intact
5 Earthquake Mitigation Measures in Place 33 Sprinklers, 18" Ceiling Clearance
6 Flashlights Available, With Extra Charged Batteries 34 Other:
7 Other:
S = Satisfactory, N/I = Needs Improvement; N/A = Not Applicable, Not Questioned or Not Observed, Page 3 of 16, Revised: 03/07/0902/04/09
PFI = Plan for Improvement, POC = Point of Contact Author: Jenny Demaris, (541) 574-4749
Samaritan Pacific Communities Hospital - Survey, Environmental Tour
Survey #:
Facility:
S = Satisfactory, N/I = Needs Improvement; N/A = Not Applicable, Not Questioned or Not Observed, Page 4 of 16, Revised: 03/07/0902/04/09
PFI = Plan for Improvement, POC = Point of Contact Author: Jenny Demaris, (541) 574-4749
Samaritan Pacific Communities Hospital - Survey, Environmental Tour
Survey #:
Facility:
S = Satisfactory, N/I = Needs Improvement; N/A = Not Applicable, Not Questioned or Not Observed, Page 5 of 16, Revised: 03/07/0902/04/09
PFI = Plan for Improvement, POC = Point of Contact Author: Jenny Demaris, (541) 574-4749
Samaritan Pacific Communities Hospital - Survey, Environmental Tour - Plan for Improvement
Survey #: 0 0
Facility: 0 0
Specific
Item Suspense Point of Contact Location or ID
Corrective Action to be Taken Date Comments
#(*) Date - Department No. or Product
Info
Survey #: 0 0
Facility: 0 0
Specific
Item Suspense Point of Contact Location or ID
Corrective Action to be Taken Date Comments
#(*) Date - Department No. or Product
Info
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
B
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
C
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
D
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
E
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.
F 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
G
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
H 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
I 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
J 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
K 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
L 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
M
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,
N
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.
SPCH - Environment of Care Revised: 02/04/09
Survey, Environmental Tour - Reference Information Page 9 of 16
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
Q
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
R 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
S
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
T
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.
U
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.
V Not in Use
W Not in Use
Emergency Management
2 Dept. Disaster Box, Available/Stocked - this indicator will be implemented later this year .
3 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
4
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
5
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
6
complexity of rooms.
7 Not in Use
Clinical/Medical Equipment Management
Elec. Safety Check Label Present - Medical equipment regardless of ownership must be electrical safety checked prior to
8
use. Includes rental, loaner, trial, patient owned, company owned equipment.
SPCH - Environment of Care Revised: 02/04/09
Survey, Environmental Tour - Reference Information Page 10 of 16
46 Products Properly Stored - products should be stored appropriately based on hazard rating, reactivity and flammability
SPCH - Environment of Care Revised: 02/04/09
Survey, Environmental Tour - Reference Information Page 11 of 16
Electrical Outlets Safety Covers, Exam/Waiting Areas - exam and waiting areas should have in place tamper resistant
72
outlets or outlet safety covers. These are to prevent children from risk of injury if they were to tamper with the outlet.
73 Electrical Panels, Accessible (36" Rule) - no items are stored in front of electrical panels
74 Electrical 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
75
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.
76
Any items with expired dates must be removed from use immediate and disposed of appropriately.
77 Forms Available - Employee Injury, Unusual Occurrence - are forms readily available and can employees locate them.
78 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
79
area, if light available is it lit? Did someone respond?
80 Signage Appropriate for Area/Services - are there any signs that need to be moved, deleted, added, revised?
81 Storage/Mechanical Rooms, Clean/Uncluttered
82 Trip Hazards, None Present
83 Walls/Floors/Ceilings/Doors in Safe Condition - No Hazards
84 Not in Use
Security Management
SPCH - Environment of Care Revised: 02/04/09
Survey, Environmental Tour - Reference Information Page 12 of 16
89 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
90
at least quarterly and/or or more frequently if there are personnel changes within the department.
91 Security Doors Operational (Key Pad Doors/Magnets)
Security Wrist (Panic) Alarms Available/Operational - departments with wrist alarms should have alarms readily available
92
and they should be operational.
93 Not in Use
Personnel Identification - all SHS personnel and medical staff are required to have their identification displayed
94
appropriately while on duty at all times. Are personnel wearing their badges? 100% compliance required.
95 Blue Emergency Code Cards Present - Blue cards should be available with badges.
Samaritan Pacific Communities Hospital - Survey, Environmental Tour
Clinical/Medical Equipment Management Survey
Page 13 of 16
Satisfactory 0 0 0 0 0
Unsatisfactory 0 0 0 0 0
N/A 0 0 0 0 0
Page 14 of 16
Employee Name Badges 12/30/1899 0
# of Missing
Yellow Cards
# Expired