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Infection Control

  • Type of isolation precaution displayed before each patient’s room and practiced appropriately

  • There are sufficient PPEs ready for use for each patient’s room.

  • PPEs used and disposed appropriately.

  • Range of negative and positive pressure for the isolation rooms regularly monitored and documented.

  • Hand rub dispenser available in ever patient’s room, toilet and nurse’s station.


  • Each bedside call bell is functioning

  • No obstructions to (a) fire exits, (b) fire extinguishers, (c) fire boxes

  • Shut off valves are: (a) not obstructed, (b) labeled, (c) inspected (inspection card up-to-date)

  • Signs for emergency/fire exits are present, clear, working and leads path to exit.

  • Signs for “no smoking” and “wet floor” are clearly seen

  • Each patient’s bathroom has a non-slipping floor surface and handrails/bars.

  • Each patient bathroom has an emergency pull cord long enough for a patient in low position to reach (at least 20 cm from the floor level).

  • All Primary Nurses are able to demonstrate how to open the bathroom if it is locked from the inside.

  • Fire extinguisher and fire blanket available inside the patient and/or staff pantry.

  • Separate utility areas for clean and dirty equipment.

  • Fire equipment have been inspected and up-to-date.

  • Each room is with label or signage and functioning according to its signage.

  • Childproof outlet caps are in place in pediatric units or in areas where children may be present.

  • Only hospital provided extension cords used

  • Plugs and receptacles in good condition.

Stock Room

  • Stock room locked when not in use

  • Protective clothing and equipment for hazardous materials available

  • Hazardous materials stored in its original container and labelled clearly.

  • Hazardous materials are placed in a separate container on the lowest shelf with ‘Hazardous Materials’ signage on the shelf.

  • Blood and chemical spill kits available as required in the area

  • List of hazardous materials is up-to-date, contains information on how to use the material, its purpose, type, where it’s located, responsible person and quantities permitted to the stored

  • There is a list of required stock items inside the unit/ward stock room indicating the maximum, minimum and critical number required per week.

  • Stocks are stored and organized in an accessible manner that permits easy identification of supplies

  • Sterile items separated from non-sterile items.

  • Top items are 50 cm from the ceiling.

  • There is a heat/smoke detector and sprinkler.

  • Separate items kept in separate labelled containers or shelf space.

  • Heavy items at waist height.

  • Fluids are stored in lower shelves

  • Room temperature and humidity monitored and recorded if IV fluids are kept in the stock room

  • No boxes/items stored on the floor

  • Shelves and containers are clean and dust-free.

  • Items in the shelves arranged in a first-in first-out order.

  • No items that are expired or have an expiry date of less than 3 months.

Linen Room

  • Linen room is locked when not in use

  • Clean laundry covered in lockable linen room.

  • Clean linens stored separately from dirty/used linens

  • Problems with amounts, availability or quality are documented on a Linen Problem log and followed-up.

  • A minimum/maximum/critical quantity of linens required per day is maintained and recorded.

  • Laundry hampers are covered

  • No linen on the floor

Medication Room

  • Narcotic cupboard double locked.

  • Multi-use vials/bottles are labeled with expiration date with the date of opening, name and signature of Primary Nurse upon opening.

  • Medication storage areas (room and cart) locked (except when in use).

  • Medication cassettes labeled with the patient’s MRN and complete name.

  • No expired medications

  • Stock medication list updated regularly

  • KFMC Formulary and List of Approved/Not Approved Abbreviations available in the medication room.

  • Externally and internally used products separated in the medication cassette.

  • Medication room temperature and humidity monitored and recorded every shift.<br>a. Medication room temperature maintained between 15 to 25oC.<br>b. Medication room humidity is maintained between 35-60 RH

  • Medication refrigerator temp is maintained bet 2-8 C and is recorded every shift.

  • In the event when the refrigerator temp goes beyond or below prescribed temp:<br>a. An action was taken to correct the malfunction (notify pharmacy and Biomed)<br>b. Medications transferred to another refrigerator.<br>

  • Refrigerator PPM is up-to-date

Medical Equipment

  • There is an inventory of all medical equipment and their location in the unit/ward.

  • With up-to-date PPM stickers (testing date and due date).

  • Broken equipment removed or labeled/tagged if out-of-order.

  • Treatment trolleys clean and organized.

  • Stretchers with straps or side rails; wheelchairs with straps.

  • Oxygen tanks are stored in appropriate holders, out of entranceways and walkways – empty cylinders are separated from full

Notice Boards

  • KFMC Mission and Vision

  • Emergency disaster color codes

  • Fire response

  • Patient’s rights and responsibilities

Waste Disposal

  • Regular and infectious wastes disposed in appropriate containers. Not overfilled.

  • Sharps’ container lids must be fixed and no more than ¾ full at any given time.

  • Sharps containers present in appropriate locations.

Other Findings

  • Other findings not covered by the above criteria

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