• Department Surveyed

  • Department Type

  • Inspection Frequency

  • Conducted on

  • Survey Team



  • I29 - Respiratory etiquette stations are stocked and available with appropriate items? (masks, Kleenex, alcohol rub, etc.)


  • I30 - Cord clamps are disposable / single use?

  • I31 - Laryngoscopes packed individually?

  • I32 - Breast milk refrigerators labeled and monitored appropriately?

  • I33 - Staff verbalizes proper procedure for formula mixing?


  • I34 - No expired formula?


  • I35 - Disinfectant wipes available in patient bathrooms?


  • I39 - Patient urinal / bedpan labeled correctly?

  • I42 - No open irrigation solutions at bedside?

  • I38 - Linen is stored away from supplies?


  • I45 - Documentation is thorough, per policy?

  • I46 - Items are stored correctly, post disinfection?

  • I43 - Ventilation is appropriate?

  • I44 - Procedure is verbalized and per policy?


  • I47 - Laryngoscope blades and handles are sent to SPD - not processed on unit?


  • I01 - Accu-checks are clean & stored appropriately?

  • I02 - Pill cruchers & slicers are clean and sanitary?

  • I03 - Clean equipment is stored in designated areas?

  • I04 - Soiled equipment is stored in designated areas and labeled as 'SPD'?

  • I05 - Unit based equipment is clean and kept in appropriate conditions

  • I06 - Cubical curtains are clean and odor / stain free

  • I13 - Staff can verbalize the location of the Infection Control manual (available online) and know how to access it?

  • I14 - Staff can verbalize where to find the BBP and TB Exposure Control Plans?

  • I15 - Temporary ICE has clean cart and wall-mounted scoop?

  • I17 - Isolation signage appropriate for type of isolation?

  • I18 - Staff is utilizing proper PPE for isolation?

  • I19 - Standard precautions are observed and practiced by staff?

  • I20 - Clean linen is stored in closet or covered shelving - if pillows are stored on top, are they clean and in plastic?

  • I21 - Linen carts have a solid bottom?

  • I24 - Sterile supplies are stored appropriately?

  • I26 - Supply carts have a solid bottom?

  • I27 - Razors are not used for procedure preparation - Electric clippers available?

  • I28 - Sharps safety products are available and utilized by staff? Safety lancets for glucose monitoring, safety needles, etc.


  • A07 - All patient rooms are uncluttered and ready for service?

  • A10 - No under-sink storage? All sinks must have cabinets below secure to prevent burns and hazardous storage conditions.

  • A09 - All supply items stored off the floor? No patient care supplies are allowed to be kept directly on the floor.

  • A11 - All furniture is in good repair? No torn cushions, broken casters, broken arms, etc.

  • A12 - Kitchen area in department is clean, uncluttered, and safe for usage? No toaster ovens, refrigerator is kept in a clean manner, and no crumbs or food is left out to attract scavengers.

  • A13 - No expired food or drinks in department? All patient food must be labeled with expiration date. All staff food must be checked regularly to prevent spoilage and smells.

  • A14 - Medication refrigerator is clean and tidy? No stickers or access codes are attached.

  • A15 - No expired medications in department? Medication refrigerator, crash/code carts, respiratory supplies, and other items are to be checked to ensure no items is outside of expiration range.

  • A16 - Temperature logs on all refrigerators are current, in range, and action is documented when a discrepancy is noted? All dates must be filled out and signed. Ensure the department follows what instructions are indicated on the temperature log form.Check medication, patient food, blood, and other refrigerators in department. Ensure wireless temperature monitoring system is working, accurate, and document action that takes place.

  • A17 - Are all refrigerators properly labeled for their usage? Medication, patient food, and staff food labels must be present on ALL refrigerators.

  • A19 - Other


  • C07 - Are protective supplies and equipment available? Are all PPE carts in appropriate locations and stocked with sufficient items? Are the supplies current? Are staff donning PPE appropriately?

  • C08 - Is all waste in appropriate container? Are all waste containers emptied in a timely manner? Red bins are not overfilled. Medication blue bins are big enough to handle waste load. Paper bins are not overflowing.

  • C14 - Are all soaps in department appropriate for their intended usage? Is all antibacterial soap in appropriate locations? Are soaps expired? Are all dispensers working as intended?

  • C15 - Are all hand sanitizing stations in appropriate locations (>6" from any ignition source)? Are all hand sanitizers labeled with expiration dates and within their range?

  • C11 - Other


  • H01 - Is the department clean? Ensure floor, sinks, all working surfaces, tables (top and bottom), bathrooms, and closets are clean and free of debris.

  • H04 - Is the department dusty? Are all high ledges and ceilings, walls and vents clear or dust and debris?

  • H05 - Other


  • M01 - Paint and Patch

  • M02 - Stained ceiling tiles

  • M04 - Signage issue

  • M06 - All surfaces are solid and able to be clean/disinfected? No cloth/torn materials in patient care areas. Pull cords are not of cloth material.

  • M03 - Other

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.