Department Tracer

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Central Station/desk: area clean

• No unlabeled/unattended specimens

  Yes

  No

  N/A

• No food or beverages in undesignated areas

  Yes

  No

  N/A

• No soiled equipment on counters

  Yes

  No

  N/A

• WOWs, desk computers, keyboards clean top to bottom

  Yes

  No

  N/A

• No employee food or drinks on WOWs or outside designated "drink" area

  Yes

  No

  N/A

• No unattended medications or syringes on WOWs

  Yes

  No

  N/A

• No open unlabeled medication vials on WOWs

  Yes

  No

  N/A

• Patient chart covers clean without stick residue

  Yes

  No

  N/A

Clean Supply Storage: clean floors, walls, AC grills, counter tops

• all supplies stored in orderly fashion without danger for contamination

  Yes

  No

  N/A

• solid surface on bottom rack of supply rack

  Yes

  No

  N/A

• packaging not compromised by storage space, esp. sterile packaging

  Yes

  No

  N/A

• supplies not stored within 3 feet of water source or 18 inches from sprinkler head

  Yes

  No

  N/A

• no corrugated boxes in room

  Yes

  No

  N/A

• no expired supplies

  Yes

  No

  N/A

• no storage directly on floor

  Yes

  No

  N/A

• clean equipment marked as clean per policy

  Yes

  No

  N/A

Clean linen storage: all linen covered, clean floors, walls, AC grills

• clean linen carts: linen covered, no items on top of cart, no soiled items

  Yes

  No

  N/A

Patient Nutrition Room: clean floors, walls, AC grills, counter tops

• Patient nutrition refrigerator clean with no unlabeled, outdated perishable food items (not older than 3 days) or expired food items; no meds; no specimens

  Yes

  No

  N/A

• Patient Nutrition refrigerator temp log up to date with daily documentation and with explanations for temps outside normal parameters

  Yes

  No

  N/A

• Patient non-refrigerated nutrition stocked in orderly fashion and without compromise to packaging

  Yes

  No

  N/A

• No corrugated boxes in room

  Yes

  No

  N/A

• no insects

  Yes

  No

  N/A

• ice machine clean

  Yes

  No

  N/A

• coffee makers clean

  Yes

  No

  N/A

Isolation Precautions

• Staff utilizing appropriately with correct signage

  Yes

  No

  N/A

• Hand hygiene and ppe supplies available/stocked

  Yes

  No

  N/A

• Covid 19 Considerations ( shields, space on lunch breaks etc)

  Yes

  No

  N/A

Medication Room: Clean floors, walls, AC grills, counter tops

• Hand Hygiene supplies available

  Yes

  No

  N/A

• multi-dose medication vials: labeled with "beyond use date" once opened (should not be open more than 28 days)

  Yes

  No

  N/A

• only medications in med refrigerator

  Yes

  No

  N/A

• sharps containers not more than 2/3 full

  Yes

  No

  N/A

• accu check strips and solutions labeled appropriately when opened

  Yes

  No

  N/A

• no expired supplies

  Yes

  No

  N/A

• pill crusher clean

  Yes

  No

  N/A

undefined

• Yes

  No

  N/A

Department/Unit: appears generally clean

• Floors clean; wet floor signs placed appropriately

  Yes

  No

  N/A

• Hallway AC grills and returns clean without dust buildup; no horizontal dust

  Yes

  No

  N/A

• No wet ceiling tiles

  Yes

  No

  N/A

• Linen Carts covered

  Yes

  No

  N/A

• Crash cart clean and orderly

  Yes

  No

  N/A