Discharge Cleaning

• Employee Name

• EID #

• Date

  Date

• Facility

  Broadway

  SMCF

  South University

• Prepared by

HAND HYGIENE

• hand hygiene done properly

  Yes

  No

WASTE & RESTOCK DISPOSABLES

• carry the right pager

  Yes

  No

  N/A

• Notify nurse to remove items from room

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

LINEN & HIGH DUSTING

• Remove all used linen - take to soiled utility

  Yes

  No

  N/A

• hand hygiene done properly

  Yes

  No

  N/A

• high dust ROOM (sprinklers, corners, vents, top of doors, top of windows, lights)

  Yes

  No

  N/A

• high dust BATHROOM (sprinklers, vents, lights)

  Yes

  No

  N/A

GENERAL CLEANING PATHWAY

• doorknob, door frame, hinges

  Yes

  No

  N/A

• light switches

  Yes

  No

  N/A

• over the bed light

  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

• shelves

  Yes

  No

  N/A

• chair(s)

  Yes

  No

  N/A

• IV pole

  Yes

  No

  N/A

• window blinds, curtains, & shower curtains per policy

  Yes

  No

  N/A

• window sills

  Yes

  No

  N/A

• windows

  Yes

  No

  N/A

• mirror

  Yes

  No

  N/A

• spot clean walls (behind and under furnishings)

  Yes

  No

  N/A

BED

• pillow

  Yes

  No

  N/A

• footboard

  Yes

  No

  N/A

• side rails & controls

  Yes

  No

  N/A

• headboard

  Yes

  No

  N/A

• mattress

  Yes

  No

  N/A

• bed frame

  Yes

  No

  N/A

• wheels & brakes

  Yes

  No

  N/A

BATHROOM

• doorknob, door frame, hinges

  Yes

  No

  N/A

• light switches

  Yes

  No

  N/A

• sink & fixtures

  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

• spot clean walls as needed

  Yes

  No

  N/A

• clean all garbage cans inside then outside

  Yes

  No

  N/A

• toilet (bottom to top)

  Yes

  No

  N/A

HAND HYGIENE

• hand hygiene done properly

  Yes

  No

RAG CHANGES

• rag changes sufficient

  Yes

  No

CLEANING PATHWAY CONTINUED

• remake bed

  Yes

  No

  N/A

• double DAZO wipe all HTO in patient/bathroom

  Yes

  No

  N/A

• place signature card

  Yes

  No

  N/A

• place gait belt

  Yes

  No

  N/A

• place purell

  Yes

  No

  N/A

• reline garbage cans with 2-3 extra in bottom

  Yes

  No

  N/A

FLOORS & SERVICE

• dust mop PATIENT room floor

  Yes

  No

  N/A

• dust mop BATHROOM floor

  Yes

  No

  N/A

• wet floor sign placed

  Yes

  No

  N/A

• clean bathroom floor with deck brush

  Yes

  No

  N/A

• hand hygiene done properly

  Yes

  No

• spray cubicle & shower curtain with Clorox Hydrogen Peroxide Cleaner (if applicable)

  Yes

  No

  N/A

• wet mop patient room floor

  Yes

  No

  N/A

• lock brake on bed

  Yes

  No

  N/A

• wet mop bathroom floor

  Yes

  No

  N/A

• look over room (blinds all open or closed, bed parked straight, waste cans placed properly, etc)

  Yes

  No

  N/A

• work orders

  Yes

  No

  N/A

• enter bed as clean in ONE Chart

  Yes

  No

  N/A

General Comments

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