Daily Patient Room Cleaning

• Employee Name

• EID #

• Date

  Date

• Facility

  Broadway

  SMCF

  South University

• Prepared by

ISIT

• Introduce self

  Yes

  No

  N/A

• state purpose

  Yes

  No

  N/A

• ask if there's anything else

  Yes

  No

  N/A

• thank guest

  Yes

  No

  N/A

HAND HYGIENE

• hand hygiene done properly

  Yes

  No

Waste & Restock Disposables

• soap

  Yes

  No

  N/A

• lotion

  Yes

  No

  N/A

• sharps - change when 2/3 full

  Yes

  No

  N/A

• toilet paper

  Yes

  No

  N/A

• paper towels

  Yes

  No

  N/A

• wastebaskets emptied, wiped and the liners replaced (2-3 left in bottom)

  Yes

  No

  N/A

General Cleaning Pathway

• doorknob, door frame, hinges

  Yes

  No

  N/A

• light switches

  Yes

  No

  N/A

• nurse call light & cord

  Yes

  No

  N/A

• telephone & cord

  Yes

  No

  N/A

• Computer, keyboard, mouse, scanner

  Yes

  No

  N/A

• bedside table

  Yes

  No

  N/A

• night stand/handles

  Yes

  No

  N/A

• counter tops, desks

  Yes

  No

  N/A

• sink/faucet/handles/vanity

  Yes

  No

  N/A

• window sills

  Yes

  No

  N/A

• shelves

  Yes

  No

  N/A

• chair(s)

  Yes

  No

  N/A

• windows

  Yes

  No

  N/A

• mirrors

  Yes

  No

  N/A

• spot clean walls and under furniture as able

  Yes

  No

  N/A

• side rails & controls (ask for permission)

  Yes

  No

  N/A

• footboard

  Yes

  No

  N/A

• headboard

  Yes

  No

  N/A

RAG CHANGES

• rag changes sufficient

  Yes

  No

HAND HYGIENE

• hand hygiene done properly

  Yes

  No

Bathroom

• doorknob, door frame, hinges

  Yes

  No

  N/A

• light switches

  Yes

  No

  N/A

• spot clean walls as needed

  Yes

  No

  N/A

• sink

  Yes

  No

  N/A

• tub/shower & shower walls

  Yes

  No

  N/A

• pull cord

  Yes

  No

  N/A

• handrails

  Yes

  No

  N/A

• mirror

  Yes

  No

  N/A

• toilet (bottom to top)

  Yes

  No

  N/A

HAND HYGIENE

• hand hygiene done properly

  Yes

  No

Floors & Service

• clean room card

  Yes

  No

  N/A

• dust mop floor

  Yes

  No

  N/A

• wet floor sign placed

  Yes

  No

  N/A

• clean bathroom floor with deck brush

  Yes

  No

  N/A

• wet mop patient room floor

  Yes

  No

  N/A

• wet mop bathroom floor

  Yes

  No

  N/A

HAND HYGIENE

• hand hygiene done properly

  Yes

  No

• look over room

  Yes

  No

  N/A

• work orders

  Yes

  No

  N/A

General Comments

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