Patient Rooms

Floors & walls clean

Walls free of breaks & penetrations

Bathrooms clean/free of odor

Sink(s) clean

Furniture clean & in good condition

Windows & windowsills clean

Window coverings clean/without dust

No high dust present

Ceiling tiles free of visible dampness/damage

PPE, gloves available

Nothing on top of sharps boxes

ONLY sharps in sharps boxes

Sharps box < 3/4 full

Appropriate use of red bags

Bed clean, linen free of tears

Alcohol hand hygiene product stocked

Soap and paper towels at all sinks

Clean Utility/Storage Rooms

Clean storage contains clean items only

Ability to determine if equipment is clean

Floors and walls clean

No dust on supplies or equipment

Bins clean & without dust

Supplies stored 6" above floor

Supplies stored 18" away from ceiling/fire sprinkler

No supplies under the sink

Counter tops in good condition

Shelving/drawers & cabinets clean

Sterilized trays free of dust, unopened, no tears

No expired supplies or equipment (check for PM tags)

Linen covered

Soiled Utility Rooms

Floors & walls clean

Free of patient supplies (clean) & sterile trays

Hopper clean

Counter tops clean/in good condition

Soiled equipment stored appropriately

Linen bagged appropriately

Red bag trash appropriate

Biohazard trash bins & linen bins clean

PPE available in soiled utility

General Unit

No food or drinks at station

Computers & keyboards free of soil/dust

Laboratory samples segregated from food

Station free of clutter

Trash not overfilled

Floors & baseboards clean

Desk surfaces in good condition

Chairs/furniture clean, operational and in good condition

Staff restroom clean with hand washing supplies

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

Tub/shower room clean

Ceiling tiles are clean, in good condition

Sink areas are clean, stocked with soap and paper towels

Ice machine clean, no leaks

Walls clean, no holes

Cleaning products available for use

Patient Kitchen

General area clean

Refrigerator & freezer clean, no odor

Daily temperature log complete

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

All food is labeled w/name, date

Food containers are closed


No expired IV solutions or medications

No unattended medications

Medication prep areas are clean, alcohol prep is present


Observed hand hygiene

Staff know how to access IC policies

Specimens bagged/labeled/handled appropriately

Safety devices available

Safety devices are being used appropriately

Staff can demonstrate use of safety devices


Action Plan

Due to Safety by: Actions by Department Director or designee:

Signatures of Inspectors
Infection Control
Environmental Services Director
Unit Director or their designee
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.