Information

  • Audit Title

  • Document No.

  • Unit/Department

  • Unit/Department Director

  • Conducted on

  • Prepared by

Managers, Biannual infection control rounds are made in conjunction with EOC rounds. Below is a list of Infection Control's findings. Please review the findings and correct any deficiencies noted.

1.0 Hand Hygiene

  • 1.1. Hand washing sinks are available in all areas as needed?

  • 1.2. Hand washing sinks are well stocked with soap and paper towels?

  • 1.3. Alcohol-based Hand Rub is available in all areas as needed?

  • 1.4. Alcohol-based Hand Rub dispensers are not empty?

  • 1.5. Placement of Alcohol-based Hand Rub dispensers is compliant with safety regulations?

  • 1.6. Hand Hygiene reminder posters are present?

  • 1.7. Is this area free of additional findings?

2.0. Clean Utility/Clean Supply Storage /Linen Storage

  • 2.1. Clean linen cart is covered?

  • 2.2. Clean linen cart has solid surface on bottom shelf?

  • 2.3. Under sink storage area empty and clean?

  • 2.4. Ceiling tiles are not stained or wet?

  • 2.5. Storage shelving or bins are clean and free of dust?

  • 2.6. Air intake vents and diffusers are clean?

  • 2.7. Supplies are stored at least 6 inches off of the floor and not within 18 inches of the ceiling?

  • 2.8. Out of date supplies are not present?

  • 2.9. Outside shipping boxes are not present?

  • 2.10. No dirty patient care items are stored in this area?

  • 2.11. Is this section is free of additional findings?

3.0. Soiled Linen / Dirty Utility Room

  • 3.1. Biohazard symbol on door of biomedical waste storage?

  • 3.2. Items are stored at least 6 inches off of the floor and 18 inches from the ceiling?

  • 3.3. Walls and floors are clean?

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

  • 3.5. Clean items are not stored in soiled utility room?

  • 3.6 Is this section free of additional findings?

4.0 Patient Nutrition Area

  • 4.1. Floors and walls clean?

  • 4.2. Countertops are clean?

  • 4.3. Microwave oven is clean?

  • 4.4. Refrigerator is clean and thawed of ice?

  • 4.5. Under sink is clean and without storage?

  • 4.6. Patient refrigerator is labeled for patient use only?

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

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

  • 4.9. Ice machine is clean?

  • 4.10. There is no evidence of pest present?

  • 4.11. Is this section free of additional findings?

5.0 Patient Rooms

  • 5.1. Horizontal surfaces are clean?

  • 5.2 Trash cans or waste basket are not overfilled or overflowing?

  • 5.3. Bathrooms are clean?

  • 5.4. Soap and paper towels are available in each bathroom?

  • 5.5. PPE is available as needed?

  • 5.6. Patient equipment is clean?

  • 5.7. No visible soil on vertical surfaces?

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

  • 5.9. Air intake vents and diffusers are clean?

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

  • 5.11. Mattress pad is without tears or puncture holes?

  • 5.12. Floors are clean?

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

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

  • 5.15. There is no evidence of pest present?

  • 5.16. Clean/dirty linen handled is appropropriatly?

  • 5.17. No signs of mildew or mold present?

  • 5.18. Is this area free of additional findings?

6.0. Employee Breakroom

  • 6.1. Floors and walls are clean?

  • 6.2. Countertops and vertical surfaces are clean?

  • 6.3. Microwave oven is clean?

  • 6.4. Refrigerator is clean and thawed of ice?

  • 6.5. Under sink area is clean and without storage?

  • 6.7. Is this section free of additional findings?

7.0 Medication Room

  • 7.1. Floors and walls are clean?

  • 7.2. Countertop and work surfaces are clean?

  • 7.3.. Medication Room refrigerator is clean and without ice?

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

  • 7.5. Is this section free of additional findings?

8.0 Waiting Areas

  • 8.1. Area generally clean (without dust, clutter or debris)?

  • 8.2. Respiratory hygiene products (e.g. masks, tissues, hand gel) are available?

  • 8.3. Are "Cover Your Cough" signs are posted?

  • 8.4. Vistor restrooms are clean?

  • 8.5. Is this section free of additional findings?

9.0 Nurses Station

  • 9.1 Staff are not eating or drinking in areas where lab specimens are located?

  • 9.2. Staff drinks are covered in areas where drinking is permitted outside the breakroom?

  • 9.3. Staff are not using personal hand lotion?

  • 9.4. Is this section free of additional findings?

10. Logs

  • 10.1. Temperature checked BID for vaccine/medication storage?

  • 10.2. Daily refrigerators checks with corrective actions as needed?

  • 10.3. Glucose meter strips dated?

  • 10.4. Smoke testing for negative pressure rooms are documented daily when patient with suspective or active TB is occupying the room?

  • 10.5. Is this section free of additional findings.

11. Isolation Rooms and Precautions

  • 11.1. Appropriate signage in place?

  • 11.2. Supplies and PPE's available?

  • 11.3. Safe zones are appropriately marked with red tape on the floor?

  • 11.4. Doors are closed as appropriate in negative pressure rooms?

  • 11.5. Negative pressure visual monitor is funtioning correctly?

  • 11.6. Staff is wearing appropriate PPE?

  • 11.7. Visitors are wearing appropriate PPE?

  • 11.8. Is this section free of additional findings?

12. Employee General Knowledge

  • 12.1. Employees know the procedure reporting a bloodborn pathogen exposure?

  • 12.2. Personnel can locate their Infection Control Manual?

  • 12.3. Personnel can state the 5 moments of hand hygiene?

  • 12.4. Is this section free of additional findings?

Additional Comments

  • Additional Comments

  • Surveyor's Signature

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