Title Page
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Facility
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Department
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Conducted on
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Angela Gray, RN, CIC
Environment of Care
Building / Maintenance
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Ceiling tiles are in place, free from stains and unbroken.
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No penetrations in the walls, floor or ceiling.
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Wall hangings are secured.
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Escutcheons are in place and properly seated.
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Call pull cords are in appropriate locations, length, and unobstructed.
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Exit signs are illuminated and unobstructed.
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Egress route is unobstructed and proper width.
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Stairwells are clear of items.
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Smoke and fire doors latch, operate and close properly.
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Approved surge protectors are used and are secured properly.
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Fire extinguishers are properly labeled and inspected. Mounted between 5 inches from the floor and no more than 5 feet to the top of the extinguisher.
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Furniture is clean and without stains, rips or tears.
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Ice machines are clean. PMs are available.
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Other
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Other
Housekeeping / EVS
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Floors are clean and free of slip hazards.
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Windows and windowsills are clean.
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Sharps containers are secured and less that 2/3rds full.
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Clean linen is stored in a required area on shelves or carts, and is covered. No linen on the floor.
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Clean and soiled linen are separated.
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No excessive trash and linen in soiled utility.
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Hand washing soap and/or sanitizer is available to staff.
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Hand washing soap dispensers are operable and unbroken.
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High level dusting has been preformed.
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Vent grills are clean.
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Area is free of insets, rodents and other vermin.
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Housekeeping staff are aware of contact times for cleaning solutions.
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Housekeeping staff are aware of the differences in patient isolation precautions.
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Other
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Other
Employee Safety / Department
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Unoccupied patient rooms are clean and without used supplies.
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No supplies under the sink.
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Negative pressure rooms have appropriate air exchanges and are monitored.
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Isolation precautions are appropriately posted and appropriate PPE is available.
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Staff are knowledgeable in the differences in isolation precautions.
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Adequate separation of clean and soiled equipment and storage.
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Clean equipment is tagged and bagged according to policy. Process is consistent.
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Soiled linen is bagged and placed in designated area.
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Storage room supplies are 18" from the ceiling and at least 6" off the floor. Solid surfaces on the lower shelf of any shelving.
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No cardboard boxes or supplies on the floor.
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No corrugated boxes in nourishment area.
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No expired items or supplies in the supply room.
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Red biohazard bags/containers are available and only contain regulated waste items.
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Sharps containers are easily accessible and unobstructed.
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Sharps containers are not located above a waste can.
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No capped syringes or medication vials in sharps containers.
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No expired medications or IV solutions.
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Medications are secured and not accessible to the public. Medications carts are locked.
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Temperature logs on medication refrigerators are current and without missing entries.
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Temperature logs on patient nourishment refrigerators are current and without missing entries.
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Appropriate items stored in corresponding refrigerators. Patient and staff food not mixed.
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Crash Cart logs are without missing inspections.
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Medical Gas valves are not blocked.
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Oxygen tank/cylinder storage is designated area. Full and in use cylinders are noted.
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Other
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Other
High Level Disinfection / Sterilization
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Trophon HLD logs are up to date. Failures have action items.
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Staff are knowledgeable on HLD process and process is consistent.
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Ultrasound equipment is cleaned and disinfected according to manufacturers instructions for use.
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Appropriate pre-cleaning or soaking/disinfecting solutions are available and used according to manufacturers guidelines.
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Appropriate transport containers are used.
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Sterilizer is functioning properly.
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Sterilizer is cleaned and inspected regularly.
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Chemical / Biological indicators are appropriate for process and are used per policy.
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Scopes are sterilized according to manufacturers instructions for use.
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Scopes are hung in closed cabinet and logged according to sterilization.
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Appropriate PPE is available and used in decontamination area.
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Decontamination room has separate hand washing sink.
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Other
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Other
Infection Prevention
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Staff are aware of contact times for disinfectant wipes.
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Disinfectant wipes are available and not expired.
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Staff is knowledgeable on hand hygiene techniques. When to use soap and water versus sanitizer, and length of time for hand hygiene.
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Staff is knowledgeable on the transport process of a patient on various isolation precautions.
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PPE boxes are stocked appropriately.
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Invasive lines (central lines, indwelling catheters, ventilation tubes, etc.) are documented appropriately.
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Other
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Other
Miscellaneous
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Work space and desks are free from unnecessary clutter and food items.
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Staff personal items are secured (i.e. purses/wallets).
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Staff refrigerators are clean and labeled appropriately.
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Hospital approved space heaters only are used.
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No candles with fire burning wicks.
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All cables and wires are neatly secured, out of the way of feet under a desk or work area.
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Eye wash stations available in appropriate places and logged per policy.
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Code knowledge (disaster, fire, evacuation, etc.) are demonstrated by staff.
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Other
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Other
