Information
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Conducted on
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Prepared by
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Personnel Conducting inspection
Clinical Unit Performed On
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Select unit by tapping icon on the right of this box.
Coffee Station; solarium; hallway
Coffee station
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Coffee area stocked; cup dispenser filled
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Sink cleaned and polished
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Counters wiped, machine dusted
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Trash emptied, can cleaned
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Floors need:
Solarium
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Floors clean
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Chairs dusted/wiped/vacuumed
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Glass and blinds clean
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Vending machines dusted
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Floors need:
Linen room
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Linen covered properly
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Floors clean, free of dust bunnies
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No linen, pillows, etc on top of carts without being bagged
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Floors need:
Med room
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Trash cans emptied and cleaned
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Floors cleaned and mopped
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Floors need:
Soiled utility
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No trash or linen on floor
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Trash and linen segregated
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Floors clean and mopped
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Floors need:
Hallway
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Hall dust free, floors clean
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Free of dust bunnies behind doorways
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Baseboards are clean
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Floors need:
Room 341
Room 341
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment tagged clean
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All equipment plugged in
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Floors need:
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Work orders needed:
Room 342
Room 342
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 343
Room 343
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 344
Room 344
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 345
Room 345
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 346
Room 346
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 347
Room 347
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 348
Room 348
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 349
Room 349
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 350
Room 350
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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All equipment tagged clean
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Work orders needed:
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Floors need:
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Work orders needed:
Room 351
Room 351
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 352
Room 352
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 353
Room 353
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 354
Room 354
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
-
Closets are dust/dirt free
-
Call light control dust/dirt free
-
Patient bed rails cleaned
-
TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
-
Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment tagged clean
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All equipment plugged in
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Floors need:
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Work orders needed:
Room 355
Room 355
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
-
Closets are dust/dirt free
-
Call light control dust/dirt free
-
Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 356
Room 356
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 357
Room 358
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
-
Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Floors need:
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Work orders needed:
Room 358
Room 359
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Floor dust/dirt free corners/edges
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Floor under furniture dust/dirt free
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Walls dust/dirt free including corners
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Window ledges dust/dirt free
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Overbed light dust/dirt free
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Closets are dust/dirt free
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Call light control dust/dirt free
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Patient bed rails cleaned
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TV set dust/dirt free
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Bedside cabinet clean
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Over bed table clean
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Cubicle curtain clean
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Air vents clean
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Waste containers clean
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Room is odor free
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Restroom floor corners/edges clean
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Restroom walls dust/dirt free
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Toilet cleaned including around and on the bottom
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Sink cleaned including bottom
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Paper towel dispenser supplied
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Soap dispenser supplied
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Toilet paper dispenser filled
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Hand Sanitizer is in working order and filled
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Sharp Container is less than 3/4 full and clean
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All equipment plugged in
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All equipment tagged clean
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Work orders needed:
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Floors need:
Engineering
Engineering issues
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Lighting is in good condition
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Light Pull Chord in working condition
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Plumbing in working condition
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Ceiling tiles and tbar are clean with no stains, cracks, or missing
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Paint is in good condition
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Doors are in working condition including all hinges
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Bathroom door in working order
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Shower door in working order
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Patient Room door in working order
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All outlets in working order
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Vents are in working order and are clean of debris and dust
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Nurse Call working properly?
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TV working properly in correlation to the Nurse Call System?
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Are there any holes in the walls?
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No Penetrations in the corridors or stairwell
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All fire doors latch and close properly
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All exit signs are properly working
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All stairwell passage lights are working properly?
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Are all means of egress free of obstruction both internal and external?
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Is flooring in good condition?
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Work orders needed:
Approval
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Approval of these rounds are accepted by:
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EVS Representative:
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Clinical Unit Director/CSM
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Engineering Representative:
