Title Page
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Conducted on
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Prepared by
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Campus Location
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Unit
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Unit
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Unit
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Unit
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Specify unit:
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Specify Clinic:
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Unit
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Clinic
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Units
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Units
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Types of Staff Interviewed (RN, Tech, EVS, Pharmacist, etc.)
AHS Rounds
EOC Exits & Egress; Medication Room
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All Staff must wear name badges with photo ID visible above waist
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Egress is clear. Exit doors are not blocked and clear of clutter
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Hallways clear with all equipment parked on one side or in alcoves
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Fire rated doors must latch & close properly
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No flammable items on fire rated doors
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Nothing in front of medical gas valves, fire extinguishers or pull stations
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Nothing stored under sinks throughout unit
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No doorstops used or doors propped open
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No overfilled sharps containers throughout the unit (replace when ¾ full)
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Pt information (white board, WOWs & Chart) secured to ensure privacy
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No food or beverages in patient care areas or nurse’s stations
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All Pt. equipment labeled with clinical engineering sticker & current PMs
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Overall cleanliness of unit (floors, walls, clutter, dust)
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No unattended meds on Pyxis, WOWs, or throughout the unit
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All insulin or multi-use vials are dated w/discard date in 28 days
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Med Room: Med Room locked with access for authorized personnel only
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Med Room: Med Prep areas are clean, uncluttered and separated from other areas
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Pill cutters are individual use only. Must be labeled with patient name
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Medication refrigerator and freezer temperatures logged and documented daily
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Med Room check for expired medications and supplies
Crash Cart, Waived Testing and Infection Control Practices:
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Crash Cart: Defibrillator is plugged in.
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Crash Cart tidy and clean. No dust or excessive supplies on crash carts
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Crash cart logs and Defibrillator check documented daily. Lock is intact.
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Crash Cart: Check for expired supplies
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Crash Cart leads are closed and sealed in their original packages
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Infection Prevention: Contact Precaution sign posted and isolation cart placed outside of room
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Waived Testing: Glucometer cleaned. Controls and Strips dated w/date opened/expiration date: Toss after 90 days
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Hand gel stocked in all dispensers
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No gloves, booties, hanging face masks while in hallway or public areas
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No open Sani-Cloth containers
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Hand hygiene performed when staff entering & exiting patient rooms
Patient Pantry/Kitchen; Clean and Soiled Utility Rooms ( C and S)
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Patient Pantry: Patient food must be labeled with Pt. name and date
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Patient Pantry: No staff food to be stored in patient refrigerator
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Patient Pantry: Refrigerator temp checked daily & documented daily by dietary services
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C: Linen carts must be covered and have solid bottoms throughout the unit
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C: No supplies stored on the floor. Must be on pallets or wire shelving with solid bottom
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C: No corrugated shipping boxes. Remove immediately
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C: O2 tanks are stored upright in the holder. Full and empty O2 tanks are separated with signage
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C: Check for expired medications and or supplies throughout the unit
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C & S: No supplies stored within 18 inches from the bottom of the sprinkler head
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S: No clean supplies or clean equipment to be stored in the soiled utility room
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S: No storage of patient personal belongings
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S: Floors are clutter free, allowing access to sink, hopper, and door
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S: Approved enzymatic gel/ instrument cleaning supplies in room (if applicable)
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S: All biohazard, pharmaceuticals, garbage containers must be clearly labeled and covered with a lid
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S: Equipment requiring cleaning or services must be clearly marked
Best Practices and Opportunities for Improvement:
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Best Practices Noted on the Unit:
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Opportunities for Improvement Identified on the Unit
Other
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Was any Service Recovery required? If yes, please explain:
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Please share any Staff Recognition:
