ICU Room HRO - Revised*

• Campus Location

• Conducted on

  Date

• Prepared by

• Employee Name:

• Room Location:

• Date Marked:

  Date

• Time Marked:

  Date

• Cleaning Type

  Daily

  Discharge

• Date Inspected:

  Date

• Time Inspected:

  Date

Yes = Completely Removed / No = Appeared Untouched

• 1. Bathroom Light Switch

  Yes

  No

  N/A

• 2. Bathroom Door Knobs

  Yes

  No

  N/A

• 3. Toilet Faucet/handrail/handhold

  Yes

  No

  N/A

• 4. Head Wall Control (Discharge Only)

  Yes

  No

  N/A

• 5. Toilet Seat/ Porta Pottie

  Yes

  No

  N/A

• 6. Handle / Glass door

  Yes

  No

  N/A

• 7. Bedside Table/Cart/Tray (Discharge Only)

  Yes

  No

  N/A

• 8. Exam light / Monitor (Discharge Only)

  Yes

  No

  N/A

• 9. Telephone / Call light (Discharge Only)

  Yes

  No

  N/A

• 10. Chair in room

  Yes

  No

  N/A