Hospital Emergency Department Safety and Compliance Inspection Checklist
This checklist ensures hospital emergency departments meet CMS Conditions of Participation (42 CFR Part 482), The Joint Commission Emergency Department standards, and EMTALA (Emergency Medical Treatment and Labor Act) requirements. Designed for ED nurse managers and compliance officers.
- Industry: Healthcare
- Frequency: Daily / Each shift
- Estimated Time: 20-30 minutes
- Role: ED Charge Nurse / Department Manager
- Total Items: 23
- Compliance: CMS 42 CFR Part 482 Conditions of Participation, The Joint Commission Emergency Department Standards, EMTALA 42 CFR Part 489.24, OSHA 29 CFR 1910.1030 Bloodborne Pathogen Standard
EMTALA Compliance
EMTALA medical screening examination and stabilization compliance.
- Dedicated emergency department open and providing care to all presenting patients?
- Triage process operational and all presenting patients logged?
- Transfer log current for all patients transferred out?
- No delays in medical screening due to insurance or financial status?
Crash Cart and Resuscitation Equipment
Emergency resuscitation equipment readiness.
- All crash carts have intact security seals (not opened since last check)?
- Defibrillator self-test current and pads/leads in date?
- Suction equipment functional and tubing present?
- Airway equipment (intubation supplies, BVM) present and in-date?
Medications and Pyxis
Controlled substance and medication management.
- Pyxis / automated dispensing cabinets operational?
- Controlled substance discrepancy log current with no unresolved discrepancies?
- High-alert medications (epinephrine, adenosine) available in crash cart?
- Medication reconciliation process followed for all admitted patients?
Infection Control
Infection prevention in the ED.
- PPE (gloves, gowns, N95s, eye protection) available at all nursing stations?
- Hand hygiene dispensers stocked throughout ED?
- Airborne infection isolation rooms available for suspected TB/COVID?
- Sharps containers not overfilled and changed per policy?
Environment of Care
Patient environment safety.
- Ligature risk areas identified and mitigation measures in place?
- Fall prevention equipment (bed alarms, grip socks) available?
- ED exits functioning - no patients or public blocked from egress?
- Safety concerns or events identified this shift
Staffing and Credentialing
ED staffing and provider credentialing compliance.
- Physician coverage in place for all hours (24/7)?
- Nurse-to-patient ratios within safe limits per facility policy?
- All ED staff credentialing and competency documentation current?
Related Clinical Operations Checklists
Why Use This Hospital Emergency Department Safety and Compliance Inspection Checklist?
This hospital emergency department safety and compliance inspection checklist helps healthcare teams maintain compliance and operational excellence. Designed for ed charge nurse / department manager professionals, this checklist covers 23 critical inspection points across 6 sections. Recommended frequency: daily / each shift.
Ensures compliance with CMS 42 CFR Part 482 Conditions of Participation, The Joint Commission Emergency Department Standards, EMTALA 42 CFR Part 489.24, OSHA 29 CFR 1910.1030 Bloodborne Pathogen Standard. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Hospital Emergency Department Safety and Compliance Inspection Checklist cover?
This checklist covers 23 inspection items across 6 sections: EMTALA Compliance, Crash Cart and Resuscitation Equipment, Medications and Pyxis, Infection Control, Environment of Care, Staffing and Credentialing. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed daily / each shift. Each completion takes approximately 20-30 minutes.
Who should use this Hospital Emergency Department Safety and Compliance Inspection Checklist?
This checklist is designed for ED Charge Nurse / Department Manager professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.