This document is a controlled document.

Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

Leadership Environmental Rounds

EXPLANATION.

A. The primary objectives of this checklist are:

1) To provide guidance for leadership to ensure compliance with safety program elements.
2) To provide a guide for leadership team members to follow while conducting Safety rounds on
issues related to environmental and safety.
3) To help facility leadership understand facility-wide hazard identification, reporting, and tracking
system.
B. This checklist will be completed as part of facility Leadership Safety Rounds every three months

LEADERSHIP TEAM PARTICIPANTS:

Name Designation Signature

Facility Director
Medical Director
TQM representative
Maintenance officer
Nursing head
IPC Link
FMS Manager

Safety Officer

Date:

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This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

Area: External Pharmacy, approval section, main reception, laboratory, generator area, admin Yes No NA
building, housekeeping, ER,
A. SAFETY
1) Regular departmental safety surveys conducted and support requested, if needed, from ✓
Safety Committee?
2) Identified hazards corrected or assistance requested? ✓

3) New employees have received safety-related instructions/training prior to ✓

commencement of work?
4) New employees attend New Hire Orientation within 30 days of assignment? ✓

5) Employees who are injured, or become ill, while at work are sent to the Staff clinic and ✓
appropriate forms filed?
6) Employees have read the “Facility Safety Program” and the facility safety plans ✓

7) A unit Safety Liaisons is assigned to the Department Safety Issues. ✓

8) Environment Of Care (Safety) is always discussed at unit communications meetings and ✓

minutes are forwarded to the Department Head.
9) Employees help to keep our unit safety bulletin board current, neat and orderly? ✓

10) Safety-related training material is routinely distributed to employees? ✓

11) Employees have attended all scheduled safety-related training sessions? ✓

13) Employees have attended all scheduled departmental drills? ✓

B. LIFE /FIRE SAFETY

1) My staff knows the basic functions of the fire alarm system. ✓

2) My staff knows not to place items close to sprinkler heads. ✓

3) My staff knows to be alert for fire hazards in maintenance and remodeling areas. ✓

4) My staff takes fire drills seriously. ✓

5) My staff follows the No Smoking policy and is alert for those who do not follow policies. ✓

6) My staff can tell if the fire extinguishers have been inspected. ✓

7) My staff knows how to operate firefighting equipment (extinguishers, FM 200, fire hose) ✓

8) Does the staff knows about smoke/ fire detection equipment in their department? ✓

9) Does the staff knows about safe evacuation techniques and the use of evacuation ✓
equipment?

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This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

Area: External Pharmacy, approval section, main reception, laboratory, generator area, admin Yes No NA
building, housekeeping, ER,

C. SECURITY
1) My staff wears appropriate ID badges. ✓

2) Patient valuables are properly secured. ✓

3) Medications and security sensitive documents/programs are secure. ✓

4) My staff knows that the use of mobile phone is NOT permitted inside the AMG and ✓
advice patients and visitors of this fact.
5) My staff is aware of the necessity to offer briefcases, bags, etc., to the Industrial Security ✓
for inspection, upon entry to the facility.
6) My staff has read the Security Management Program. ✓

7) My Staff Know of the existence of a security. ✓

8) The staff knows about the safety codes that relate to security e.g. code white, Code Black ✓
etc?
D. HAZARDOUS MATERIALS AND WASTE:
1) My staff knows the location of and has read the appropriate MSDS for all hazardous ✓
materials they may handle, store, use or dispose of.
2) My staff knows that Hazardous Materials and Waste Management Program is in place. ✓

3) My staff is aware of the existence of a Hazardous Materials and Waste ✓

4) My staff has received scheduled departmental Hazardous Materials Training? ✓

5) I ensure that those members of my staff who actually handle, store, use or dispose of ✓
hazardous materials receive Hazardous Materials Training.
6) My staff is aware of the potential health hazards related to the hazardous materials, and ✓
use safe procedures and approved personal protective equipment (PPE).
7) I ensure that my new staff attends New Hire Orientation, where they receive orientation ✓
on the general Hazardous Materials/Waste Management Program.
8) My staff knows the emergency response procedures to be followed in the event of a spill ✓
of any hazardous material, and the use of chemical spill kits.
E. INFECTION CONTROL
A. Patient Area
1) I have sharp disposal containers that located at each chair/bed and elsewhere as needed ✓
within the unit.
2) Respirators are used by staff during direct care of patients with M. tuberculosis to ✓
prevent its transmission in the facility. Note: respirators that contain an N-Series filter
with a 95% efficiency (N-95) rating is appropriate for use in accordance with the IPC
guidelines.

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This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

Area: External Pharmacy, approval section, main reception, laboratory, generator area, admin Yes No NA
building, housekeeping, ER,
3) I have antiseptic liquid soap which provided through wall-mounted dispensers and used
in the following areas or situations+ the alcohol rubs:
a. Before invasive procedures. ✓

b. Before and after leaving isolation rooms ✓

d. Specialty care units. ✓

4) Lockers, cabinets and refrigerators are clean. ✓

5) Housekeeping personnel are proficient in cleaning of blood spills. ✓

6) I have a blood spill kit in every patient care unit which includes all necessary equipment. ✓

7) Our infectious waste is sent to waste company (SEPCO) except for body parts. ✓

8) Our clean and sterile items are transported and stored in a sanitary manner. ✓

9) Our endoscopes are properly cleaned prior to disinfections or sterilization. ✓

10) Infectious waste is properly disposed. ✓

12) The surfaces of machines and chairs are disinfected after use with an approved ✓
disinfectant.
13) Equipment such as blood pressure cuffs, stethoscopes, clamps, scissors and ✓
thermometers are allocated to single patient and are disinfected at the conclusion of
each patient treatment.
B. Non-Patient Area
1) Potentially hazardous food meets temperature requirements during storage, ✓
preparation, display, service, transportation (41 °f or below or 140°f or above), (for
kitchen and cafeteria).
2 There is functional separation of clean and soiled linen during storage and transport. ✓

3 Hand washing facilities are located in all areas where un-bagged soiled linen is handled ✓

4 Any linen which is wet from blood, excreta, other body fluids (e.g., from ER) is put into ✓
water-soluble bags, or is otherwise adequately contained, before being put into the
laundry bag to prevent leakage of fluids
5 There is a clear gradient from dirty to clean area i.e.: decontamination area to packing to ✓
sterilization to storage.
F. EXTERNAL EMERGENCY PREPARATIONS:
1) My staff has received emergency preparedness orientation. ✓

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This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

Area: External Pharmacy, approval section, main reception, laboratory, generator area, admin Yes No NA
building, housekeeping, ER,
2) My staff has read “External Disaster plan” ✓

3) Each member of the staff has a role to play in the event of an emergency, and they are ✓
aware of it? How they will be assigned a role.
4) The staff know the code for External Disaster is: Code yellow ✓

5) The last External Emergency drill was held in ✓

6) My staff is aware of how patients are to be handled during a drill in their unique area. ✓

G. INTERNAL EMERGENCY PREPARATIONS:

D My staff has read “the Internal Disaster Plan” ✓

2) My staff knows RACE & PASS procedures. ✓

3) The staff attends scheduled Fire Safety Training? ✓

4) The staff knows evacuation procedures, routes and triage zones & assembly areas? ✓

5) My staff knows Room Check Tagging Procedure. ✓

6) My staff knows how to contain fire. ✓

7) My staff has received fire extinguisher training. ✓

8) My staff knows the Code Red and the emergency number: 2222 ✓

9) My staff has read the No Smoking Policy. ✓

10) My staff is aware of bomb threat procedure. ✓

H. NURSING
D The staff is wearing safe & proper shoes. ✓

2) The staff examines & removes any instruments, pins, needles & other articles from soiled ✓
linen & clothing.
3) Sharps containers are readily available. ✓

4) The staff knows the proper disposition of needles & syringes. ✓

5) The staff know that crash carts should be locked, they check the expiry date of ✓
medications & supplies with in the crash carts every shift check the defibrillator also
6) The staff checks the medication refrigeration temperature, & make sure there is no food ✓
or beverages inside the fridge.

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This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

Area: External Pharmacy, approval section, main reception, laboratory, generator area, admin Yes No NA
building, housekeeping, ER,
7) The staff knows that all drawers & cabinet doors should be closed. ✓
8) The staff knows that all equipment &supplies must be properly stored, & that heavy ✓
items should not be stored on top shelves.
9) The staff know that patient room furnishing should be safely arranged ✓
10) The staff knows that patient’s beds must be at lowest setting whenever possible. ✓
11) The staff know that when breaking an ampoule, they should protect their fingers by using ✓
a file & covering the tips with gauze
12) The staff are careful that stretchers, examining tables, etc. are properly secure, when ✓
assisting patients on to them, by setting breaks on wheels
13) The staff understands & practices good body mechanics. ✓
14) The staff takes all fall precaution measures for vulnerable patients. ✓
15) The staff know that protruding "handles" on beds should be turned in. ✓
16) The staff knows that when transporting patients on wheel chairs, stretchers or wheeled ✓
tables, every precaution shall be taken to ensure the patient's safety.
17) The staff know that they should never use the contents of an unlabeled bottle, & that it ✓
should be discarded.
18) The staff knows that all patients must wear I.D. bracelet at all times. ✓
I. MEDICAL EQUIPMENT AND DEVICES
D The staff has read the Medical Equipment/Devices Policies and Procedures. ✓
2) The electrical equipment in my area is inspected and tested as scheduled. ✓
3) Back-up equipment is available and we are able to obtain it quickly. ✓
4) My staff knows what to do in the event of medical device/ equipment failure. ✓
5) My staff understands the concept of Occurrence Report OVR and how it is related to ✓
medical devices and equipment.
6) My staff knows the tagging procedure in the event of a suspected malfunction of a ✓
medical device or equipment.
7) My staff, on all shifts, knows how to access the Bio-Medical technician on-call. ✓
J. UTILITY SYSTEMS
1) My staff has read the Utility Systems Management Program. ✓
2) My staff knows how to report a utility problem. ✓
3) My staff is aware that back-up power generators are available which, when the main ✓
power fails, should provide power to critical areas within 10 seconds.
4) My staff knows what to do if the back-up power fails. ✓
5) My staff knows that water flooding, i.e. from a malfunctioning sprinkler head, is a serious ✓
event that must be stopped quickly.
6) My staff knows that Hazardous Locations exist where special ventilation equipment is ✓
used.
A. Involved in review of projects in their areas for new construction, renovation and ✓
remodeling in order to ensure fire protection, safety, health, infection control and
environmental issues are addressed?
B. Safety Liaison Officer and alternate have been assigned. ✓
c. All department staff attend required Safety related training? ✓

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This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

Area: External Pharmacy, approval section, main reception, laboratory, generator area, admin Yes No NA
building, housekeeping, ER,
A. PATIENT ROOMS
1) Are all lampshades clean and in good order? ✓
2) Is the floor free from dirt and debris? ✓
3) Have all garbage cans been emptied and cleaned ✓
4) Have all sections of the floor including baseboards and comers been moped ✓
5) Have all surfaces, ledges, fixtures and fittings been dusted ✓
6) Are all sofa/sitters couch upholstery and underneath cushions cleaned? ✓
7) Have all chairs been dusted and upholstery cleaned? ✓
8) Have all tables been dusted and polished? ✓
9) Are the TV's clean and in good order? Is remote control available & clean? ✓
10) Is the refrigerator clean and in good order? ✓
11) Have all over bed tables and patient closet been cleaned? ✓
12) Are curtains cleaned and properly hanged? ✓
13) Is the patient room free of bad odours? ✓
14) Are bedside rails, head/foot boards and frames under mattress clean? ✓
15) Are beddings correctly arranged? ✓
16) Are bedspreads free of rips, holes and stains? ✓
17) Is the room provided with facial tissue box? ✓
18) Are all carpets clean and without stains? ✓
19) Are window glass and glass-fronted cabinet been wiped cleaned? ✓
20) Are A/C vents clean and free of dust? ✓
21) Are the telephone sets been cleaned and in good order? ✓
B. BATHROOMS
D Have all the garbage cans been emptied and cleaned? ✓
2) Is the floor free from dirt and debris? ✓
3) Has the toilet seat both sides been thoroughly cleaned and in good order? ✓
4) Commode flushes working properly? ✓
5) Commode free of lime scale? ✓
6) Has the bed been thoroughly cleaned? ✓
7) Has the sink and its water stopper been thoroughly cleaned? ✓
8) Have all wall tiles been washed down? ✓
9) Walls and floor tiles grouting been scrubbed? ✓
10) Has the shower room area been cleaned and free of moulds? ✓
11) Are all chrome fixtures sparkling? ✓
12) Are all floors drain strainers and cover been cleaned? ✓
13) Have all sections of the floor including baseboards and corners been mopped? ✓
14) Are the mirrors clean? ✓
15) Are all light bulbs working? ✓
16) Are all ceiling tiles clean and without stains? ✓

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This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

Area: External Pharmacy, approval section, main reception, laboratory, generator area, admin Yes No NA
building, housekeeping, ER,
17) Have all surfaces, ledges, fixtures and fittings been dusted? ✓
18) Are all soap dispensers filled and bar soap available? ✓
19) Are paper towels and toilet tissue available in all dispensers? ✓
20) Are bath towel, hand towels and face towel available? ✓
21) Is the bathroom free of bad odors? ✓

MAJOR FINDINGS AND RECOMMENDDED IMPROVEMENT PLAN

S.
RESPONSIBL
NO FINDINGS REQUIRED ACTION TIME LINE REMARKS
E PERSON
.
1. Employees have not read the All employees need to train regarding Safety officer 10-04-2022
Facility Safety Program and the the facility safety program safety and
facility safety plans. the safety plans.
2. Staffs doesn’t know the Need to orient all staffs about the Safety officer 13-02-2022
functioning of fire alarm system functioning of fire alarm system and
and as well as the location of the main fire alarm panel location and
the fire alarm panel board its operations
3. Many things are kept near to Need to inform the staffs not to keep Safety officer 20-02-2022
the ceilings staffs doesn’t know any items close to the sprinkler
the working method of heads. around 40cm height should
sprinkler system free from the ceiling
4. Door closer in handicap room Need to remove the door closer from FMS 18-03-2022
the handicap toilet
5. There is no AC inside Medical Need to install AC in Medical Gas Safety officer 10-05-2022
gas room room
6. Staffs doesn’t know about safe Train the staffs about the safe Safety officer 20-04-2022
evacuation techniques and the evacuation techniques
use of evacuation equipment
7. There is no mechanism for Need to purchase a bag having lock to Nursing 18-04-2022
keeping patient valuable things keep patient valuable things Head/Operati
in departments on/Safety
officer
8. There is no staffs available in Need to change the location of FMS/Operatio 20-04-2022
reception 2 for attending the Emergency telephone and paging n
emergency call and for paging system to the occupied reception
the emergencies
9. Staffs are not wearing ID Security staff needs to be trained to Facility head/ 10-05-2022
badges. check for ID bands when employees admin
enter the clinic. If not then their manager/ HR
supervisor should be informed and an

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 This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

OVR be raised to facility head and HR.

proper actions need to be taken.
10. Staffs are not well aware about Safety officer need to train the staffs Safety Officer 20-05-2022
the security codes like code about all emergency codes used in
white. Silver, Black etc facility
11. Housekeeping staffs are not Need to train them how to use spill IPC link/Safety 12-05-2022
well aware about the proficient kits (biohazard and chemical spill kit) Officer
use of spill kits
12. Staffs don’t know the facility Need to explain them about disaster Safety officer 25-05-2022
disaster plans. plan and all staff need to read the /Nursing Head
plan from the safety file
13. Few staffs are not much Need to train all staffs about RACE Safety Officer 15-05-2022
familiar about RACE and PASS and PASS methods
14. The current IV medication Provide controlled access to only Facility head/ 12-06-2022
room does not have controlled authorized staff HOD nursing
access
15. Generator room is very dirty Need to close all penetration and FMS 20-05-2022
and many hole are available arrange the room properly.
16. Electrical room cables are not Need to arrange the room properly. FMS 10-04-2022
arranged properly
17. Staffs don’t know about the Explain the staffs about medical Safety Officer 20-06-2022
medical management plan equipment plan and procedures /BME
18. Staff are not following the Staff need training on how to report BME 10-03-2022
official policy for reporting failures and the use of OVRs and
equipment failures equipment failure form
19. Tissue boxes are not available Need to keep tissue boxes in each Housekeeping 10-04-2022
in-patient care areas patient care areas
20. Chemical spill kits are not Need to purchase chemical spill kits Safety officer 23-05-2022
available in main departments

SL# OBSERVATION ACTION TO BE TAKEN RESPONSIBILITY TIME LINE COST REMARKS

Ground floor
1. There is no nurse call system for the Need to install nurse call system with FMS/ BMD 25-07-2022
Handicap toilet alarm connected to the ER
2. Ground floor procedure room doesn’t Need to install temperature and FMS/ IPC 15-06-2022
have monitoring humidity monitor and implement the
daily checklist.
3. ER patient flow design is not ER plan to be revised to include triage FMS, IPC, TQM 30-05-2022
appropriate area, CPR room, isolation, medication
preparation room.

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 This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

4. The waste room is not adequate for Need to install metallic racks, air FMS 15-06-2022
proper storage of medical waste. conditioner for proper temperature &
Medical waste room, room humidity maintenance and monitor.
temperature are not monitoring
5. There is no firefighting mechanism in Civil Defense consultant need to FMS 28-05-2022
the medical waste room confirm if automatic system is required
or provision of extinguisher is enough.
6. No firefighting system available in Need to install required firefighting FMS 28-05-2022
medical gas cylinder storage room mechanism as per Civil Defense
requirements.
7. The warning light on the door to X-ray Need to fix warning light in front of x- BMD 16-08-2022
room is not proper. ray room (green, yellow and red)
8. There is only water sprinkler in the X- Need to confirm with firefighting FMS 10-10-2022
ray room which is not the proper one contracted company and consultant to
for machine areas install the proper mechanism e.g.
FM200
9. Inadequate type and numbers of Need to install CO2 extinguisher in US FMS 16-07--
extinguishers in the area and X-ray room 2022
10. The current TLDs are not enough for Need to have one more TLD for each BMD 15-06-2022
the existing staff technician. Need to change the names
on the TLD of the staff who left with the
current one
11. Complete set of lead apron is missing Need to find the complete set of aprons BMD 15-06-2022
in radiology and panorama room with different sizes of thyroid and gonad
shields.
Need proper inventory of the lead
aprons.
Need proper hangers to hang the
aprons in X-ray and panorama rooms.
12. There is no evacuation equipment Need to install one set of sky pad FMS 28-08-2022
physically impaired and bedridden mattress near the fire exit.
patients
13. One room is used for dirty and clean If proper utility room is created in 1st FMS/ IPC 15-07-2022
utilities as well as janitor items. This is floor and housekeeping supply store is
not correct created in 3rd floor then this area can be
used as a janitor room
14. Fire exit near elevator has steps which Need to break the step and install ramp FMS 8-06-2022
is very risk to evacuate the wheelchair and rails on the fire exit.
patients.
First Floor

15. Utility rooms are not available and Need to create a utility room for dirty FMS/ IPC 24-09-2022
dirty utilities are kept in small spaces utilities.
and corridors
16. There are water sprinklers in the lab Need to confirm with Civil Defense FMS 06-08-2022
which are not for machine areas. consultant for requirements of fire

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 This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

suppression systems e.g. FM200 in the

lab
17. Inadequate number and type of Need to add CO2 extinguishers in this FMS 25-05-2022
extinguishers in the lab area (02)
18. Electric kettles are using inside the Remove all heating elements e.g. FMS 10-03-2022
facility electric kettle from the area
19. Medical equipment maintenance and Proper inventory, maintenance BMD 18-04-2022
management needs to be properly schedules, history and reports need to
coordinated be practiced
20. There is inadequate measures for Need to install proper hand washing FMS/ IPC 22-07-2022
hand washing sinks with glass slab to prevent splash
(01)
21. There is no measure to prevent splash Need to install glass slabs in sample FMS/ IPC 26-05-
in case of leaking of sample from receiving areas 20222
vessel or breaking of tube
22. Damaged equipment’s are kept in Need to implement lock out tag out BMD 18-04-2022
laboratory without any tag policy & Place “out of order” tag on the
equipment.
Remove unused equipment from all
areas
23. The sample collection room does not The sample collection room needs to be FMS 30-06-2022
have enough space to accommodate widened to accommodate this function
the full length of the chair. In case of
patient collapse it would not be
possible to put the chair in supine
position and administer life saving
measures
24. No traffic control at the lab entrance. Need to install security mechanism to FMS 12-04-2022
allow only authorized staff in the lab
25. There is no space for the staff to put Need a staff room with lockers for the FMS/ IPC 24-05-2022
their personal belongings and hang staff.
the abayas
26. The microbiology area is not as per The current immunology room will be FMS/ IPC 06-11-2022
requirements swap with microbiology section, both
will be renovated and autoclave room
to be added in microbiology
Lab Store will be renovated as well
beside immunology room
27. Iqama baladiya room will be Iqama baladiya room will be renovated, Operation / HR/ 15-07-2022
renovated racks need to be install, all iqama FMS /LAB
baladiya record which is kept on the
roof top will be stored on the iqama
baladiya room so that other room will
be used for other purposes and need to
install proper firefighting system inside
the room

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 This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

28. The current CSSD is of inadequate As per management decision; the IPC/FMS/Opera 04-07-2022
design and needs to change Shumaisy CSSD has to be redesigned so tion
that it can cater to all branches in the
region.
The design has been approved and
needs to be implemented by FMS team
29. There is improper use of extensions in Remove the extension cable from the FMS 12-04-2022
the panorama room room & provide extra socket if needed
30. There is no warning lights outside the Need to add the lights as required in the BMD 30-06-2022
panorama room X-ray room
31. Inadequate type and numbers of Need to install CO2 extinguisher FMS 25-07-2022
extinguishers in the area
32. The dental x ray films are developed Need to either provide a separate space FMS/ BMD 30-10-2022
in the same area for this purpose or replace with a digital
sensor
33. There is use of amalgam in the clinics The amalgam use needs to be stopped MD/ operations 26-07-2022
with improper disposal and replaced by adequate flowable
material to reduce the load of mercury
in the facility as well as waste disposal
34. first floor passage for AC maintenance Need to fix handrail minimum 1.5 height FMS 24-07-2022
handrails doesn’t have enough height
35. Room temperature is not monitoring, Need to purchase hygrometer for the Operation 16-07-2022
monitor is not available. store and implement proper \Housekeeping/
temperature management and Store in charge
checklists.
36. Need to install smoke detectors in main 06-06-2022
Fire alarm systems are not available in
store need to get civil defense FMS
main store
suggestion
37. There is no ramp to enter wheel chair Need to create ramp and rails for the FMS 20-04-2022
patients to the OPD clinics. area for the easy access of wheel chair
patients

38. Evacuation maps not upgraded Evacuation map need to upgraded in FMS 18-05-2022
each floor zones & evacuation route
maps should include
• You are here.
• Fire extinguishers.
• Fire hose reel/cabinets.
• Fire blankets.
• Escape routes.
• Assembly points.
• Fire exits.
• Call points break glass/pull
station.

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 This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

39. Safety boxes are not available in Need to install safety boxes at least one FMS 23-06-2022
clinics in each floor which include
• Yellow jacket
• Hard hat
• Torch
• Googles
• Gloves
40. No certificate or documents for the Need to get the certificate for FMS 30-07-2022
inflammable cabinet available in inflammable cabinet\ need to purchase
laboratory dpt. new one
41. Fire safety cabinets are not available Provide appropriate cabinets in FMS 30-07-2022
in store and generator area maintenance and store areas
42. There is no evacuation equipment Need to install one set of sky pad FMS 28-08-2022
physically impaired and bedridden mattress & Evacuation chair near the
patients fire exit.
Second floor

43. Inside accounts department files are All wooden shelves in accounts FMS/Operation 16-10-2022
kept on wooden shelves department need to remove and fix
metallic racks for keeping the files.
Third floor

44. Third floor many files are kept on the Passage to the emergency exit should Operation/FMS 12-05-2022
floors which block the emergency exit free from obstacle, need to remove the
passage. files from the area immediately.
The iqama baladya area in near lab need
to be made in to a proper filing room
with racks, safety and environmental
control and all records need to be
placed there.
45. There is no fire safety measure in the Need to install automatic fire FMS 15-10-2022
server room. suppression system e.g., FM200 as per
civil defense consultant advice
46. Server room cables are not channeled All codes need to be channeled FMS 22-05-2022
properly & extension cables are using properly. Remove the extension cable
from the server room and provide
additional socket if needed.
47. There are rooms near server rooms The room needs to be cleaned and can Operations/ 12-05-2022
which are full of old files and garbage. be used for: IPC/ FMS
Store, housekeeping supply room, staff
room, locker room, janitor room etc.
management need to decide as per
need

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 This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

48. Third floor emergency exit door to the It’s not allowed to keep any manual lock FMS 10-04-2022
roof top installed with a manual lock for the fire exit door, need to remove
the lock immediately

ROOF TOP/S

49. Roof top cables are not arranged All cables should arrange properly by FMS 13-06-2022
properly, also unwanted cables, steel piping, labeling and unwanted things
pipes, compressors paper cartons need to remove from the roof
chairs are all around the roof Immediately.
All air conditioner compressors need to
be put on one side and labeled as per
inventory
Cables need to be arranged with the
corners of the roof to prevent any
tripping.
50. Third floor roof top, many old satellite Need to remove the all materials from Operation/FMS 13-06-2022
dishes, antenna, cables are trailing on the roof top. /Housekeeping
floors
51. Lift room temperature is not being Room temperature need to monitor on FMS 26-07-2022
monitored daily basis. repair/ replace the air-
conditioning
52. Beside elevator room there is one Remove all the unwanted materials FMS/Operation 13-06-2022
more room stored with files cartoons from the room and use the spaces as
sharp containers etc. maintenance and BMD workshops
53. Water tank doesn’t have proper Water tank need to be locked. FMS 16-05-2022
locking system
54. Both the Roof tops (2F and 3F) Need to install security access on both FMS 14-04-2022
entrance doesn’t have security access the roof top access points and only
authorized staffs will have an access,
with CCTV surveillance system.
GENERAL FINDINGS

55. Normal lights are not available on 2F Install normal lights on the roof tops FMS 22-05-2022
roof top
56. Emergency Lights are not available on Install Emergency lights on 2F & 3F roof FMS 30-06-2022
both roof tops tops
57. Fire doors are not connected with fire All fire doors need to connect with fire FMS 28-08-2022
alarm alarm
58. Elevator is not connected with fire Elevator should connect with fire alarm FMS 17-06-2022
alarm
59. Generator doesn’t have any AMC Need to create one AMC contract for FMS 13-05-2022
contract Generator.
60. There is no firefighting equipment’s Need to install suitable firefighting FMS 10-06-2022
available in electrical room equipment’s in electrical room

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 This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

61. Ultrasound, Xray and some of the Ultra sound and x ray department need FMS/Operation 18-05-2022
areas in 2F has no generator backup to connect generator backup /MD/BMD
power connections
62. Fire alarm system is conventional Need to change fire alarm system in to FMS 18-10-2022
addressable so that exact location of
fire can be identified
63. Many un wanted materials are kept Need to remove all things from the Housekeeping 12-04-2022
inside of fire pump room room and keep it clean /FMS
64. Fire blankets are not available in main Need to install fire blankets in FMS 26-06-2022
departments departments like
• ER
• Laboratory (2pcs)
• Store
• Pharmacy
• Radiology
65. facility has no fire zones With the help of civil defense consultant FMS 18-08-2022
find out the location of fire zone and
install the fire-resistant doors in the
location.
66. Exit signage’s need to change Need to purchase new illuminating FMS 18-06-2022
directional emergency exit signage’s
67. No master key for the clinic Need to create one master key for all Operation 21-05-2022
rooms.
If it is expensive need to create a key
management cabinet and all staffs after
finishing their duty need to keep the key
on the cabinet.
68. Security rounds are not conducting Security rounds need to be done by Admin/Operati 20-04-2022
admin and security as per daily shift on
69. Employees are not wearing Id cards All employees inside the facility need to Operation/HR 18-05-2022
wear id card.
70. Fire exit door doesn’t have fire rated Need to make certificate or need to FMS 22-10-2022
certificate install new fire doors
71. Few areas Electrical outlet couldn’t All electrical outlets need to be FMS 24-05-2022
identifiable identified and marked as per the
voltage (110 VOLT, 220VOLT,
GENERATOR CONNECTION etc.) and
keep the log book along with FMS dpt.
72. Electrical distribution boards are not Electrical Distribution board need to FMS 30-08-2022
securely covered cover and secure with breakable glass
73. Ramps and stair case doesn’t have Fix anti slipping stickers in all ramps and FMS 15-06-2022
anti slipping stickers chances for slip stairs.
and fall
74. Some sinks & sink tapes are rusted Need to check each room, all rusted FMS 20-07-2022
items need to be repaint or replace

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 This document is a controlled document. Facility reserves the right to amend or terminate any of its content at any time
without prior notice. The information should only be used for internal use.

75. No nurse call system in toilets Install nurse call system inside all FMS /BMD 18-08-2022
patient toilet and need to connect with
the nurse station
76. No sign board for parking area Need to fix sign board for parking area FMS 15-06-2022

77. No designated area /sign board for Need to create handicap parking area FMS 15-06-2022
handicap parking area. sign board.

78. Line diagram is not available for Need to prepare line diagram for FMS 27-08-
showing emergency supply to critical emergency power supply to the critical 2022
areas lab machines fridges etc. areas
79. Line diagram for the electric Need to make line diagram for all the FMS 27-08-2022
connection not available electric connections from the DB
80. Fire alarm and firefighting drawings Need to get fire alarm and firefighting FMS 27-08-2022
are not available layout of the facility
81. Plumping connection drawings are Need to get the drawing for the FMS 14-06-2022
not available plumbing connections
82. Safety boards are not available in the Install safety boards in each FMS 18-07-2022
clinics department(120CMX90CM) 4PCS
83. Some areas emergency lights are not Repair all damaged emergency lights FMS 16-06-2022
working and few areas emergency and Install emergency lights in required
lights are not available. areas.
84. Fire pump and generator are installed Generator and fire pump need to be FMS 28-08-2022
in single room separated
85. Fire suppression system not available Install proper firefighting suppression FMS 15-07-2022
in generator room system in generator room

86. Fire assembly point are not available Need to make main assemble point area FMS 16-06-2022
outside of the building and the areas
need to be isolated by chain. Suggested
location in front of pharmacy and
optical area
87. Triage zone is in front of main Need find any other area having enough FMS 16-06-2022
entrance which is very narrow and space to allocate the patients once the
congested to allocate patients. evacuation is announced. Suggesting
the area in front of pharmacy
88. Transport ventilator is not available in Need to purchase transport ventilator BMD 31-03-21
ER for ER

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