Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Nursing Stations
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1. Clean and free of clutter
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2. No food present, Only drinks with a lid.
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3. Use of hospital-approved hand lotion.
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4. No patient care supplies left open on tables.
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5. Trash is not overflowing.
Staff
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1. Hand hygiene is being performed correctly.
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2. No fingernail polish or artificial nails. (If providing patient care)
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3. Appropriate fingernail length. (1/4")
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4. Staff understands isolation precaution protocol and needlestick protocol.
Waiting Room, Public Bathrooms, and Hallways
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1. All horizontal surfaces are clean
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2. Areas/hallways are not cluttered.
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3. Trash is not overflowing.
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4. Bathrooms are clean.
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5. Handwashing supplies are available.
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6. No stained ceiling tiles.
Hand Hygiene
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1. Sinks for handwashing are appropriately stocked with soap, paper towels, and trash cans.
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2. Alcohol hand-rubs are available near patient rooms/in patient rooms and other areas as needed.
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3. Hand Hygiene is monitored for staff compliance.
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4. Gloves are stocked in patient's room for staff use when needed.
Precautions
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1. PPE supplies are available.
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2. Appropriate signage in place.
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3. Trash and linen handled per policy.
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4. Patient and family given appropriate education.
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5. If Airborne precautions, is the door closed.
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6. Appropriate PPE being used by staff.
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7. Isolation stations being utilized and are stocked.
Soiled Utility
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1. Door to room is labeled.
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2. Biohazard symbol on door if biomedical waste in room.
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3. Soiled linen in hamper with impervious liner.
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4. Clean supplies not in room.
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5. Appropriate PPE available.
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6. Soiled linen covered for transport.
Storage Room
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1. Is there a clear walk way.
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2. All equipment is clean and stored off the ground.
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3. Equipment bins (blue bins) are clean.
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4. No tape peeling on the floor.
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5. Equipment/supplies are not out of date.
Clean Utility
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1. Door to room is labeled.
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2. Environment is clean.
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3. Clean equipment is tagged/bagged and ready for use.
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4. No supplies stored under sink.
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5. All supplies off the floor.
Clean Linens
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1. Linens are in good condition.
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2. Stored on covered cart or in linen room where shelf is covered.
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3. Clean linen covered during transport.
Refrigerators
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1. Daily temperature checks are documented appropriately.
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2. Items are appropriately labeled and nothing out of date.
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3. Refrigerator is clean.
Patient care equipment
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1. Equipment is cleaned according to policy/company recommendations.
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2. Glucometer wiped down and using Super Sani-Cloths (purple top) and left to dry for at least 2 minutes before being used again.
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3. Vital sign machines are cleaned using the disinfectant wipes before being used.
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4. Equipment that has expiration dates have not expired.
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5. Telemetry electrodes are dated when they are opened. If expired they are thrown away.
Hazardous Materials and Medical Waste
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1. Appropriate sharps container in use.
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2. Sharps containers no more than 3/4 full.
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3. Sharps containers secured for transport.
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4. Appropriate biomedical waste manifests maintained.
EOC
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1. All cylinders (oxygen , other compressed gas) are secured
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2. Empty oxygen tanks are kept separate from full oxygen tanks
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3. Fire extinguishers not obstructed from easy access
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4. No electrical panels are blocked
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5. Hospital furnishings/equipment are kept in good repair (No torn or soiled furniture, wheelchairs, mattresses)
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6. Countertops/doors are in good condition with no chipping to laminate
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7. No supplies stored under sinks
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8. Paper is not present on fire-rated doors
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9. Maintains the integrity of egress throughout unit
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10. No space heaters present in patient care areas
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11. There is at least 18" of open space maintained below a sprinkler deflector to the top of storage
