Infection Control Safety Rounds

• Conducted on

  Date

• Prepared by

• Location
  Address

Patient Room

• Room Number:

• Is patient room occupied?

  Yes

  No

• Ceiling tiles free from staining?

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• ABHR available/working

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• Soap, water and paper towel available

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• Sharps container < 3/4 full

  Meets expectation

  At risk

  Not Applicable

• No supplies stored under sink

  Meets expectation

  At risk

  Not Applicable

• Soiled linen in bag; not overfilled, hamper covered

  Meets expectation

  At risk

  Not Applicable

• Medication storage area clean

  Meets expectation

  At risk

  Not Applicable

• Refrigerator labeled to identify the approved use

  Meets expectation

  At risk

  Not Applicable

• Items within according to label

  Meets expectation

  At risk

  Not Applicable

Isolation Rooms(s)

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

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• Supplies and PPE available

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• Staff compliant with policy

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• Airborne Precautions: Door closed

  Meets expectation

  At risk

  Not Applicable

• Airborne Precautions: Passes tissue test

  Meets expectation

  At risk

  Not Applicable

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

  Yes

  No

  N/A

Unit

Standard precautions

Clean Utility

Soiled Utility

EVS Closet/Cart

Public Use Restroom

ICRA

• ICRA posted

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• ICRA posted within date range<br><br>

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• ICRA being followed

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

Waiting Area/Entry

• Are appropriate supplies for respiratory hygiene available and posted instructions in place?

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

Patient Room

• Enter room number in field below

• Is the room occupied?

  Yes

  No

• Ceiling tiles free from staining

  Meets expectation

  At risk

  Not Applicable

• ABHR available/working

  Meets expectation

  At risk

  Not Applicable

• Soap, water and paper towels available

  Meets expectation

  At risk

  Not Applicable

• Sharps container is less than 3/4 full

  Meets expectation

  At risk

  Not Applicable

• No supplies stored under sink

  Meets expectation

  At risk

  Not Applicable

• Soiled linen in bag; not overfilled,mhamper covered

  Yes

  No

  N/A

• Medication storage area clean

  Meets expectation

  At risk

  Not Applicable

• Refrigerator labeled to identify the approved use

  Meets expectation

  At risk

  Not Applicable

• Items within refrigerator according to label

  Meets expectation

  At risk

  Not Applicable

Isolation Room

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

Unit

Standard precautions

clean Utility

Soiled Utility

EVS Closet/Cart

• Clean in appearance

  Meets expectation

  At risk

  Not Applicable

• Free from safety concerns

  Yes

  No

  N/A

• Container labeled

  Yes

  No

  N/A

• Appropriate PPE available

  Meets expectation

  At risk

  Not Applicable

• Cart organized

  Meets expectation

  At risk

  Not Applicable

Public Use Restroom

• All surfaces appear clean

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• Hand-washing supplies available

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• Free from trash/debris

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

ICRA

• ICRA posted

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• ICRA within date range

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

• ICRA being followed

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media

Waiting Area/Entry

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

  Meets expectation

  At risk

  Not Applicable

• Add media

  Media