Information

  • Conducted on

  • Prepared by

  • Location

Patient Room

  • Enter room number in field below

  • Is the room occupied?

  • Ceiling tiles free from staining

  • Add media

  • ABHR available/working

  • Add media

  • Soap, water and paper towels available

  • Add media

  • Sharps container is less than 3/4 full

  • Add media

  • No supplies stored under sink

  • Add media

  • Soiled linen in bag; not overfilled,mhamper covered

  • Add media

  • Refrigerator labeled to identify the approved use

  • Add media

  • Items within refrigerator according to label

  • Add media

Isolation Room

  • Correct sign in place (right sign, right reason)<br>Enter the room number and isolation type in the field below.

  • Supplies and PPE available

  • Add media

  • Staff compliant with policy

  • Add media

  • Airborne precaution: Patient placed in negative airflow room according to policy

  • Add media

  • Airborne precautions: Door closed and negative airflow functioning properly

  • Add media

  • Airborne Precautions: Inquire with Charge Nurse re:RNs on unit who are fit tested. List names of employees below.

  • Add media

  • Airborne Precaution: trash can located outside door

  • Add media

Unit

  • Non offensive odor

  • Add media

  • General appearance of cleanliness

  • Add media

  • Ceiling tiles free from staining

  • Add media

  • Flooring free from dust and dirt

  • Add media

  • Vents free from dust

  • Add media

  • Sprinkler heads free from dust

  • Add media

  • Firelight alarm free from dust

  • Add media

  • Linen carts covered

  • Add media

  • Soiled linen bag not overfilled

  • Add media

  • Mediagenic keyboards cleaned

  • Add media

  • Refrigerator labeled to identify the approved use

  • Add media

  • Items within according to label

  • Add media

  • Ice machine visibly clean

  • Add media

  • Unit furniture and textiles intact and able to be effectively cleaned and/or disinfected

  • Add media

  • Medication storage area clean

  • Add media

Standard Precautions

  • HCWs food/beverages permitted in designated areas per policy<br>(excluding areas where specimens may be present)

  • Add media

  • PPE per policy

  • Add media

Clean Utility

  • Designed to meet basic IC compliance

  • Add media

  • Clean items stored appropriately

  • Add media

  • Review for outdated items

  • Add media

Soiled Utility

  • Room appropriately labeled with name and biohazard symbol

  • Add media

  • Appears clean and disinfected on a regular basis (including floors)

  • Add media

  • Mounted sharps container less than 3/4 full

  • Add media

  • Gloves available

  • Add media

  • Splash PPE by hopper

  • Add media

  • Area for hand cleansing

  • Add media

  • Negative airflow functioning properly

  • Add media

EVS Closet/Cart

  • Clean in appearance

  • Add media

  • Free from safety concerns

  • Add media

  • Cleaning supplies appropriately labeled

  • Add media

  • Appropriate PPE available

  • Add media

  • Cart organized

  • Add media

Public Use Restroom

  • All surfaces appear clean

  • Add media

  • Hand-washing supplies available

  • Add media

  • Free from trash/debris

  • Add media

ICRA

  • ICRA permit posted

  • Add media

  • ICRA within date range

  • Add media

  • ICRA being followed

  • Add media

Waiting Area/Entry

  • If appropriate, supplies for respiratory hygiene available and posted instructions in place

  • Add media

Additional Comments and Photos

  • Add media

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