Information

  • Conducted on

  • Prepared by

  • Personnel Conducting inspection

Clinical Unit Performed On

  • Select unit by tapping icon on the right of this box.

Coffee Station; solarium; hallway

Coffee station

  • Coffee area stocked; cup dispenser filled

  • Sink cleaned and polished

  • Counters wiped, machine dusted

  • Trash emptied, can cleaned

  • Floors need:

Solarium

  • Floors clean

  • Chairs dusted/wiped/vacuumed

  • Glass and blinds clean

  • Vending machines dusted

  • Floors need:

Linen room

  • Linen covered properly

  • Floors clean, free of dust bunnies

  • No linen, pillows, etc on top of carts without being bagged

  • Floors need:

Med room

  • Trash cans emptied and cleaned

  • Floors cleaned and mopped

  • Floors need:

Soiled utility

  • No trash or linen on floor

  • Trash and linen segregated

  • Floors clean and mopped

  • Floors need:

Hallway

  • Hall dust free, floors clean

  • Free of dust bunnies behind doorways

  • Baseboards are clean

  • Floors need:

Room 341

Room 341

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment tagged clean

  • All equipment plugged in

  • Floors need:

  • Work orders needed:

Room 342

Room 342

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 343

Room 343

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 344

Room 344

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 345

Room 345

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 346

Room 346

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 347

Room 347

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 348

Room 348

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 349

Room 349

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 350

Room 350

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • All equipment tagged clean

  • Work orders needed:

  • Floors need:

  • Work orders needed:

Room 351

Room 351

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 352

Room 352

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 353

Room 353

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 354

Room 354

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment tagged clean

  • All equipment plugged in

  • Floors need:

  • Work orders needed:

Room 355

Room 355

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 356

Room 356

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 357

Room 358

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Floors need:

  • Work orders needed:

Room 358

Room 359

  • Floor dust/dirt free corners/edges

  • Floor under furniture dust/dirt free

  • Walls dust/dirt free including corners

  • Window ledges dust/dirt free

  • 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

  • Bedside cabinet clean

  • Over bed table clean

  • Cubicle curtain clean

  • Air vents clean

  • Waste containers clean

  • Room is odor free

  • Restroom floor corners/edges clean

  • Restroom walls dust/dirt free

  • Toilet cleaned including around and on the bottom

  • Sink cleaned including bottom

  • Paper towel dispenser supplied

  • Soap dispenser supplied

  • Toilet paper dispenser filled

  • Hand Sanitizer is in working order and filled

  • Sharp Container is less than 3/4 full and clean

  • All equipment plugged in

  • All equipment tagged clean

  • Work orders needed:

  • Floors need:

Engineering

Engineering issues

  • Lighting is in good condition

  • Light Pull Chord in working condition

  • Plumbing in working condition

  • Ceiling tiles and tbar are clean with no stains, cracks, or missing

  • Paint is in good condition

  • Doors are in working condition including all hinges

  • Bathroom door in working order

  • Shower door in working order

  • Patient Room door in working order

  • All outlets in working order

  • Vents are in working order and are clean of debris and dust

  • Nurse Call working properly?

  • TV working properly in correlation to the Nurse Call System?

  • Are there any holes in the walls?

  • No Penetrations in the corridors or stairwell

  • All fire doors latch and close properly

  • All exit signs are properly working

  • All stairwell passage lights are working properly?

  • Are all means of egress free of obstruction both internal and external?

  • Is flooring in good condition?

  • Work orders needed:

Approval

  • Approval of these rounds are accepted by:

  • EVS Representative:

  • Clinical Unit Director/CSM

  • Engineering Representative:

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