Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Nursing Stations
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1. Clean and free of clutter
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2. No food present
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3. Drinks have lids
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4. No patient care supplies left open on tables
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5. Trash is not overflowing
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6. Sharps container below fill line
Staff
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1. Hand hygiene is being performed correctly
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2. No fingernail polish or artificial nails. (if providing patient care)
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3. Appropriate fingernail length (1/4")
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4. Staff understands isolation precaution protocol and needlestick protocol.
Waiting Room, Public Bathrooms, and Hallways
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1. All horizontal surfaces are clean
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2. Areas/hallways are not cluttered
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3. Trash is not overflowing
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4. Bathrooms are clean and have hand washing supplies.
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5. No stained ceiling tiles
Hand Hygiene
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1. Sinks for handwashing are appropriately stocked with soap, paper towel, and trash cans.
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2. Alcohol hand-rubs are available near patient rooms/in patient rooms and other areas as needed.
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3. Hand Hygiene is monitored for staff compliance.
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4. Gloves are stocked in patients' room for staff use when needed.
Precautions
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1. PPE supplies are available
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2. Appropriate signage in place
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3. Trash and linens handled per policy
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4. Patient and family given appropriate education on isolation rooms.
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5. If airborne precautions, is the door closed.
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6. Appropriate PPE being used by staff.
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7. Isolation stations being utilized and are stocked.
Soiled Utility
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1. Door to room is labeled and closed.
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2. Biohazard symbol on door if biomedical waste in room
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3. Soiled linen in hamper with impervious liner
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4.Clean supplies not in room
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5. Appropriate PPE available
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6. Soiled Linen covered for transport.
Storage Room
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1. Is there a clear walk way
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2. All equipment is clean and stored off the ground
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3. Equipment bins are clean
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4. No tape peeling on the floor or tables.
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5. Equipment/supplies are not out of date.
Clean Utility
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1. Door to room is labeled
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2. Environment is clean
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3. Clean equipment is tagged/bagged and ready for use.
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4. No supplies stored under sink
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5. All supplies off the floor.
Clean Linens
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1. Linens are in good condition
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2. Stored on covered cart or in linen room where shelf is covered.
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3. Clean linen covered during transport
Refrigerators
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1. Daily temperature checks are documented appropriately
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2. Items are appropriately labeled and nothing is out of dated
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3. Refrigerator is clean
Patient Care Equipment
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1.Epuipment is cleaned according to policy/company recommendations
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2. Purple top wipes are used to disinfect IV pumps
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3. Vital sign machines are cleaned using disinfectant wipes before being used.
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4. Equipment that has expiration dates have not expired.
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5. Telemetry electrodes are dated when they are opened. If expired they are thrown away.
Hazardous Material and Medical Waste
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1. Appropriate sharps container in use.
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2. Sharps containers no more than 3/4 full
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3. Sharps containers secured for transport
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4. Appropriate biomedical waste manifests maintained
EOC
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1. All cylinders (oxygen, other compressed gases) are secured
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2. Empty oxygen tanks are kept separate from full oxygen tanks
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3. Fire extinguishers not obstructed from easy access
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4. No electrical panels are blocked
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5. Hospital furnishings/equipment are kept in good repair (no torn or soiled furniture, wheelchairs, or mattresses
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6. Countertops/doors are in good condition with no chipping to laminate
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7. No supplies stored under sinks
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8. Paper is not present on fire-rated doors
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9. Maintains the integrity of egress throughout the unit
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10. No space heaters present in patient care areas
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11. there is at least 18" of open space maintained below a sprinkler deflector to the top of storage
