Information

  • Hospital Name

  • Conducted on

  • Prepared by

  • Location

Employee Hand Hygiene Compliance

  • Employees Monitored

Hand Hygiene

  • Sinks for hand hygiene are well stocked?

  • Sinks are available in all areas as needed?

  • Alcohol hand rubs are well stocked?

  • Alcohol hand rubs are available in patient's rooms?

  • Placement of alcohol hand rubs is compliant with safety?

  • Hand washing/hand hygiene is performed between patients?

  • Hand Hygiene reminder posters present?

  • Hand soap is available in all hand washing stations/bathrooms?

Clean Utility / Central Supply / Storage

  • Clean linen cart is covered?

  • Clean linen cart has solid surface on bottom shelf?

  • Sink storage area empty and clean?

  • Thrash cans or waste basket are not overfilled or overflowing?

  • Ceiling tiles are not stained or wet?

  • Floors are clean?

  • Supplies are stored at least 6 inches off of the floor?

  • Air intake vents and diffusers are clean?

  • Is this section free of additional findings?

  • Please describe other findings:

Patient Rooms

  • Horizontal surfaces are clean?

  • Thrash cans or waste basket are not overfilled or overflowing?

  • Bathrooms are clean?

  • Hand hygiene products are available?

  • Soap and paper towels are available in each bathroom?

  • PPE's are available as needed?

  • Patient equipment is clean?

  • No visible soil on vertical surfaces?

  • Ceiling tiles are not discolored, wet, missing, or damaged?

  • Air intake vents and diffusers are clean?

  • Furniture (chairs, sleepers) are without tears or wear?

  • Mattress pad is without tears or puncture holes?

  • Floors are clean?

  • Sharp containers are no more than 3/4 full?

  • Dust not found in high places?

  • General area is dust free?

  • REFERENCE: General area is dust free
    [This is an example of how you can use iAuditor to include best practice reference images in your templates to assist with inspections]

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  • Foley catheters hanging and secured appropriately?

  • IV pumps and poles, feeding pumps etc. are clean?

  • There is no evidence of pest present?

  • Clean / dirty linen handled appropropriatly?

  • No needles, syringes, medications within reach of the patient?

  • No signs of mildew or mold present?

  • Is this section free of additional findings?

  • Please describe other findings:

Patient Kitchen / Breakroom

  • Floors and walls clean?

  • Horizontal and vertical surfaces are clean?

  • Microwave oven clean?

  • Refrigerator clean and thawed of ice?

  • Under sink clean and without storage?

  • Patient refrigerator labeled for patient use only?

  • Temperature checks are documented with corrective action when temp is out of range?

  • Patient food is labeled appropriately with no expired food found?

  • Ice machine is clean?

  • There is no evidence of pest present?

  • Is this section free of additional findings?

  • Please describe other findings:

Employee Kitchen / Breakroom

  • Floors and walls clean?

  • Horizontal and vertical surfaces are clean?

  • Microwave oven clean?

  • Refrigerator clean and thawed of ice?

  • Under sink clean and without storage?

  • Employee food labeled and dated?

  • Temperature checks are documented with corrective action when temp is out of range?

  • Is this section free of additional findings?

  • Please describe other findings:

General Unit / Nurses Station / Medication Room

  • Unit/area generally clean (without dust, clutter or debris)?

  • Unused patient equipment/supplies are stored and handled appropriately?

  • Medication, specimens, and food are handled appropriately?

  • Biohazard trash is segregated from regular trash?

  • Clean linen is handled appropriately?

  • Dirty linen is handled appropriately?

  • All clean linen carts are covered?

  • Linen carts have a solid bottom shelf?

  • Needles and syringes are disposed of properly?

  • Out of date supplies are not present?

  • Infectious waste in red bag or container?

  • Clean items are not stored in soiled utility room?

  • Ceiling tiles are not discolored/ wet/ missing / damaged?

  • Lab supplies are not expired?

  • Nothing is stored under the sink and there is no sign of leaks?

  • Halls are uncluttered?

  • Respiratory hygiene available?

  • Restrooms clean?

  • Trash basket are not overflowing?

  • Biohazard symbol on door of biomedical waste storage?

  • Medication cart locked?

  • No artificial/acrylic nails use. Nails are no more than 1/4 inch above finger?

  • No personal lotion use.

  • Medication Room refrigerator is clean and without ice?

  • There are no expired products found(IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)

  • Is this section free of additional findings?

  • Please describe other findings:

Logs

  • Crash cart checked daily?

  • Defibrillator checked daily

  • Narcotic counts documented every shift?

  • Temperature checked BID for vaccine / medication storage?

  • Daily refrigerators checks with corrective actions as needed?

  • Ice machine cleaning date / time stamped?

  • Glucose meter strips dated

  • Cidex monitoring Log complete?

  • Is this section free of additional findings.

  • Please describe other findings:

Isolation Rooms

  • Appropriate signage in place?

  • Supplies and PPE's available?

  • Trash and linen handled per policy?

  • Appropriate PPE's used by staff?

  • Door closed as appropriate?

  • Negative pressure is being supplied as required?

  • Patient and family instructed on isolation requirements?

  • Patient with proper attire when being transported?

  • Is this section free of additional findings?

  • Please describe other findings:

Employee General Knowledge

  • Employees know the procedure for blood exposure?

  • Personnel can locate their Infection Control Manual?

  • Personnel can locate their Exposure Control Plan?

  • Personnel can locate the blood spill kit?

  • Personnel can locate their spill kit for Cidex?

  • Employees can state the WHO's 5 moments of Hand Hygiene.

  • Dust not found in high places?

  • Is this section free of additional findings?

  • Please describe other findings:

Soiled Linen / Dirty Utility Room

  • Biohazard symbol on door of biomedical waste storage?

  • Boxes are stored at least 6 inches off of the floor?

  • Walls / floors are clean

  • Ceiling tiles are not discolored/ wet/ missing / damaged?

  • Dust not found in high places?

  • Is this section free of additional findings?

  • Please describe other findings:

Patient Shower Room

  • Shower clean?

  • Shower room clean and orderly?

  • Walls and floor are clean?

  • Ceiling tiles are not discolored/ wet/ missing / damaged?

  • Dust not found in high places?

  • Is this section free of additional findings?

  • Please describe other findings:

Completion

  • Additional Comments

  • Surveyor's Name and Signature

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