Environmental Rounds Inspection for Infection Prevention and Control

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Patient Rooms

• Floors & walls clean

  Yes

  No

  N/A

• Walls free of breaks & penetrations

  Yes

  No

  N/A

• Bathrooms clean/free of odor

  Yes

  No

  N/A

• Sink(s) clean

  Yes

  No

  N/A

• Furniture clean & in good condition

  Yes

  No

  N/A

• Windows & windowsills clean

  Yes

  No

  N/A

• Window coverings clean/without dust

  Yes

  No

  N/A

• No high dust present

  Yes

  No

  N/A

• Ceiling tiles free of visible dampness/damage

  Yes

  No

  N/A

• PPE, gloves available

  Yes

  No

  N/A

• Nothing on top of sharps boxes

  Yes

  No

  N/A

• ONLY sharps in sharps boxes

  Yes

  No

  N/A

• Sharps box < 3/4 full

  Yes

  No

  N/A

• Appropriate use of red bags

  Yes

  No

  N/A

• Bed clean, linen free of tears

  Yes

  No

  N/A

• Alcohol hand hygiene product stocked

  Yes

  No

  N/A

• Soap and paper towels at all sinks

  Yes

  No

  N/A

Clean Utility/Storage Rooms

• Clean storage contains clean items only

  Yes

  No

  N/A

• Ability to determine if equipment is clean

  Yes

  No

  N/A

• Floors and walls clean

  Yes

  No

  N/A

• No dust on supplies or equipment

  Yes

  No

  N/A

• Bins clean & without dust

  Yes

  No

  N/A

• Supplies stored 6" above floor

  Yes

  No

  N/A

• Supplies stored 18" away from ceiling/fire sprinkler

  Yes

  No

  N/A

• No supplies under the sink

  Yes

  No

  N/A

• Counter tops in good condition

  Yes

  No

  N/A

• Shelving/drawers & cabinets clean

  Yes

  No

  N/A

• Sterilized trays free of dust, unopened, no tears

  Yes

  No

  N/A

• No expired supplies or equipment (check for PM tags)

  Yes

  No

  N/A

• Linen covered

  Yes

  No

  N/A

Soiled Utility Rooms

• Floors & walls clean

  Yes

  No

  N/A

• Free of patient supplies (clean) & sterile trays

  Yes

  No

  N/A

• Hopper clean

  Yes

  No

  N/A

• Counter tops clean/in good condition

  Yes

  No

  N/A

• Soiled equipment stored appropriately

  Yes

  No

  N/A

• Linen bagged appropriately

  Yes

  No

  N/A

• Red bag trash appropriate

  Yes

  No

  N/A

• Biohazard trash bins & linen bins clean

  Yes

  No

  N/A

• PPE available in soiled utility

  Yes

  No

  N/A

General Unit

• No food or drinks at station

  Yes

  No

  N/A

• Computers & keyboards free of soil/dust

  Yes

  No

  N/A

• Laboratory samples segregated from food

  Yes

  No

  N/A

• Station free of clutter

  Yes

  No

  N/A

• Trash not overfilled

  Yes

  No

  N/A

• Floors & baseboards clean

  Yes

  No

  N/A

• Desk surfaces in good condition

  Yes

  No

  N/A

• Chairs/furniture clean, operational and in good condition

  Yes

  No

  N/A

• Staff restroom clean with hand washing supplies

  Yes

  No

  N/A

• Alcohol hand rub accessible, full w/in unit (assess if there need to be more locations)

  Yes

  No

  N/A

• Tub/shower room clean

  Yes

  No

  N/A

• Ceiling tiles are clean, in good condition

  Yes

  No

  N/A

• Sink areas are clean, stocked with soap and paper towels

  Yes

  No

  N/A

• Ice machine clean, no leaks

  Yes

  No

  N/A

• Walls clean, no holes

  Yes

  No

  N/A

• Cleaning products available for use

  Yes

  No

  N/A

Patient Kitchen

• General area clean

  Yes

  No

  N/A

• Refrigerator & freezer clean, no odor

  Yes

  No

  N/A

• Daily temperature log complete

  Yes

  No

  N/A

• Refrigerator temp 0-41 degrees, freezer less than 0 (to -30) degrees

  Yes

  No

  N/A

• All food is labeled w/name, date

  Yes

  No

  N/A

• Food containers are closed

  Yes

  No

  N/A

Medications

• No expired IV solutions or medications

  Yes

  No

  N/A

• No unattended medications

  Yes

  No

  N/A

• Medication prep areas are clean, alcohol prep is present

  Yes

  No

  N/A

Safety

• Observed hand hygiene

  Yes

  No

  N/A

• Staff know how to access IC policies

  Yes

  No

  N/A

• Specimens bagged/labeled/handled appropriately

  Yes

  No

  N/A

• Safety devices available

  Yes

  No

  N/A

• Safety devices are being used appropriately

  Yes

  No

  N/A

• Staff can demonstrate use of safety devices

  Yes

  No

  N/A

Other

Action Plan

• Due to Infection Control by: Actions by Department Director or designee:

Signatures of Inspectors

• Infection Control Director

  Sign

• Environmental Services Director

  Sign

• Engineering

  Sign

• Security

  Sign

• Unit Director or their designee

  Sign