Page 537 - eBook Version 8 Book 1 of 2 JUL 2022

The One Clean Sweep
Y es=Compliance present No= Compliance not present NA=Does not apply to area/unit Patient Care
Date:
Department or Accounting Code Title:
Sweep completed by:
Number of People Surveyed:
Number of Charts Reviewed:
Nominal Scale Yes/No/ NA
#
The Right Thing
Why is this the right thing to do? (Rationale)
1.
No expired patient care supplies or medications
MM 03.01.01 EP 8 – The hospital removes all expired, damages, and/or contaminated medications and stores them separately from medications available for administration.
2.
Omnicell is working appropriately and without broken bar/clips. Items are labeled. Staff able to verbalize how to report Omnicell malfunction.
All medication drawers work properly and all doors locked appropriately. MM 03.01.01: The organization safely stores medications. Remember that items touching inside door can cause door to remain open. Report any Omnicell issues to HelpDesk via HEAT.
3.
No PHI unattended on printer or counter or in regular trash and/or unlocked computers.
Reference Administrative Policy 8.04 – Protected Health Information Use, Disclosure, and Request
4.
Staff can articulate their right to report concerns about safety or the quality of care to The Joint Commission without fear of retaliatory action from the organization.
APR 09.02.01 – Any individual who provides care, treatment, and services can report concerns about safety or the quality of care to The Joint Commission without retaliatory action from the organization. Reference NPSG Badge Buddy.
5.
Clinical staff can articulate the steps required for appropriate specimen labeling:
a. Patient Identification using two identifiers will
be done
b. All specimens will be labeled in the presence
of the patient
c. The collector of the specimen must write the date and time of collection and his/her electronic health record (EHR)login ID on the outside of the specimen in non-smearing blue or black ink.
To provide information required for the proper labeling of specimens being sent to the laboratory or Blood Bank
Please see CPP 1.29 and 6.64 for further details
Environment of Care
Nominal Scale Yes/No/ NA
#
The Right Thing
Why is the right thing to do? (Rationale)
1.
Floors are free of dirt and debris. Walls are clean and not damaged. Furniture is clean and surface intact (no cuts/tears).
Keep areas clean at all times. Contact Facilities Services if assistance is needed.
2.
Nothing blocking doorways, paths of egress or fire safety equipment (extinguishers, pull stations, alarms).
Risk of impeding egress during fire or evacuation. Minimize equipment in hallways. At least 8’ wide path open at all times. EOC. Policy Tracker.
3.
All patient accessible restrooms must have an emergency switch/ call light with a pull cord that reaches the floor.
In the event of a patient fall while in the restroom, they must be able to notify staff for help.
4.
Ceiling tiles are clean and intact without staining or open holes in the ceiling.
Hospital Safety Policy 5.11 - Fire and Smoke Protection
5.
All Alcohol Based Hand Gel dispensers are located at least 6 inches from a light switch and/or an electrical outlet. See pictures at the end of this form.
This is considered a fire hazard as the liquid is flammable. – Per the Life Safety Code
Clean Sweep Tool 4th Quarter 2009 Please fax to Accreditation and Regulatory Readiness at x61622