Department Drill - Regulatory Compliance

Audit Form

Department Drill - Regulatory Compliance

Required

Observed Date

Unit

Staff/Nursing Station

All staff are wearing ID badges in appropriate location on uniform?

No food/drinks located in patient care area?

Confidential patient information is secured (charts closed, worksheets face down, WOWs facing away from traffic and not left unsecured)?

Safety alarms and telemetry monitors are on and audible?

Crash/Code Carts

Crash/Code cart log includes documented daily checks (only 1 month of checks on clipboard, previous month in Director's office)?

Crash/Code cart is locked and defibrillator is plugged in?

Crash/Code cart has no expired items?

Medication Management

Medication rooms are locked?

No expired medications identified, including inside refrigerators?

Medication refrigerator temperature log is up to date with documented corrective actions if temperature was out of range?

No prescription pads unsecured?

Syringes and needles are secure (not easily accessible)?

Multi-dose vials are initialed/dated and not expired with expiration date (28 days after opening)?

Glucose control solutions and/or test strips are not expired and labeled with opening date and expiration date according to manufacture IFU's?

Pill crushers are not soiled?

Pill splitters are disposable only and labeled with patient information?

Environment of Care

All areas on unit are free of clutter and equipment is not blocking hallways?

No equipment/carts blocking fire doors, fire pull stations, breaker boxes, or medical gas panels?

All doors securely close?

No doors are propped open?

Fire extinguishers are inspected monthly?

All ceiling tiles are clean/free of stains and no gaps/openings in the ceiling are identified?

All sprinkler heads are free of dust (DO NOT ATTEMPT TO CLEAN IF DUST IS NOTED - NOTIFY MAINTENANCE DEPARTMENT)?

All light fixtures are illuminated with no bulbs out?

Light coverings are free of insects?

All temperature/humidity logs are updated and recordings out of range have corrective action identified (Supply rooms, refrigerators, warming cabinets, eye wash stations, etc)?

Patient food is not stored with employee food?

Hand washing sinks and eye wash stations are easily accessible?

No expired supplies identified in the department?

Clean equipment is segregated from dirty and identified in compliance with facility policy?

Sharps container are secured and not over the fill line?

Nothing stored below sinks?

Nothing is stacked within 18 inches from the ceiling or sprinkler heads and items are at least 6 inches off the floor?

No corrugated cardboard is located within department unless approved through facility risk assessment?

Emergency pull cords in patient bathrooms are available and not restricted?

Personal Protective Equipment (PPE) is readily available with isolation signage posted per facility policy?

No tape located on walls, equipment, counters, etc?

All oxygen tanks are secured and tanks are separated by full or empty?

Point of care testing equipment such as glucometers are clean and no bodily fluids are visible?

Equipment preventative maintenance (PM) inspection sticker is present and not expired?

Ice machine is clean and free of any buildup around dispenser?

Staff can articulate the meaning of RACE and PASS (RACE - Rescue/Alarm/Contain/Extinguish, PASS - Pull/Aim/Squeeze/Sweep)?

Orders/Documentation

Pain scale documented with pain medication administration and pain scale reassessment documented according to facility policy?

Restraints - Physician order current and documentation is present according to facility policy?

Patients at risk for falls have fall designation (yellow gown/socks/armband, sign/light on door, bed alarm activated, etc)?

Suicide screening completed on all patients?

Nursing chart checks are completed each shift?

Patient care plans are individualized and current correlating with the care delivered?

Patient white boards in rooms are updated each shift?

Summary of Immediate Corrective Actions Completed

Do not enter protected health information (PHI)

Reports

This tool provides customizable real-time compliance reports. Here are some of the popular visualizations.

Trend performance over time. Dept_Drill_report 1

Track performance across units, departments, and clinics. Dept_Drill_report 2

Break out performance by checklist field sections. Dept_Drill_report 3

Contact our team or start a free trial to learn more about the many flexible reporting options available.

Resources

Toolkits & Guides

Department Drills for Regulatory Compliance Guide

Department Drill - Regulatory Compliance

Table of Contents

Audit Form

Department Drill - Regulatory Compliance

Department Drill - Regulatory Compliance Checklist

Reports

Resources