Audit

Managers - Infection Control performed an inspection of your unit. Please review your survey and document your Plan of Correction next to each deficiency.
Return this form to me by:
Summary of Survey
Score - Total Survey Score %
Employee Hand Hygiene Compliance

Employees Monitored

1.0 Hand Hygiene

1.1. Sinks for hand hygiene are well stocked?

1.2. Alcohol hand rubs are well stocked?

1.3. Sinks are available in all areas as needed?

1.4 washing / hand hygiene is performed between patients?

1.5 Employee knows how to document hand hygiene observations?

2.0. Clean Utility / Central Supply / Storage

2.1 Ceiling tiles are not stained or wet?

2.2 Air intake vents and diffusers are clean?

2.3 Walls/Floors are clean?

2.4. Trash cans or waste basket are not overfilled or overflowing?

2.5 Clean supply storage containers are clean and free of dust?

2.6 Clean linen cart is covered?

2.7 Clean linen cart has solid surface on bottom shelf?

2.8 Supplies are stored at least 6 inches off of the floor?

2.9 Supplies are not expired?

2.10 Is this section free of additional findings?

3.0 Patient Rooms

Room evaluated

3.1 Sinks for hand hygiene are well stocked?

3.2 General area is dust free?

3.3 Nothing stored under sinks?

3.4 Dust not found in high places?

3.5 Horizontal surfaces are clean?

3.6 No visible soil on vertical surfaces?

3.7 Ceiling tiles are not discolored, wet, missing, or damaged?

3.8 Air intake vents and diffusers are clean?

3.9 No signs of mildew or mold present?

3.10 Patient equipment is clean?

3.11 Mattress pad is without tears or puncture holes?

3.12 Walls/ Floors are clean?

3.13 Furniture (chairs, sleepers) are without tears or wear?

3.14 There is no evidence of pest present?

3.15 Trash cans or waste basket are not overfilled or overflowing?

3.16 PPE's are available as needed?

3.17 Sharp containers are no more than 3/4 full?

3.18 Foley catheters hanging and secured appropriately?

3.19 Clean / dirty linen handled appropriately?

3.20 Is this section free of additional findings?

4.0 Patient Shower Room

4.1 Shower room clean and orderly?

4.2 Shower curtain clean?

4.3 Sinks for hand hygiene are well stocked?

4.4 Walls/floor are clean?

4.5 Ceiling tiles are not discolored/ wet/ missing / damaged?

4.6 Dust not found in high places?

4.7 Soap and paper towels are available in each bathroom?

4.8 Is this section free of additional findings?

5.0 Patient Nourishment Area

5.1 Floors and walls clean?

5.2 Horizontal and vertical surfaces are clean?

5.3 Microwave oven clean?

5.4 Refrigerator clean and thawed of ice?

5.5 Sinks for hand hygiene are well stocked?

5.6 Under sink clean and without storage?

5.7 Patient refrigerator labeled for patient use only?

5.8 Temperature checks are documented with corrective action when temp is out of range?

5.9 Patient food is labeled appropriately with no expired food found?

5.10 Ice machine is clean?

5.11 Ice machine cleaning date / time stamped?

5.12 There is no evidence of pest present?

5.13 Is this section free of additional findings?

6.0 General Unit / Nurses Station / Medication Room

6.1 Unit / area generally clean (without dust, clutter or debris)?

6.2 Ceiling tiles are not discolored/ wet/ missing / damaged?

6.3 General area is dust free?

6.4 General area is dust free?

6.5 Trash basket are not overflowing?

6.6 Food located in designated areas only?

6.7 Sinks for hand hygiene are well stocked?

6.8 Under sink clean and without storage?

6.9 Unused patient equipment/supplies are stored and handled appropriately?

6.10 Medication, specimens, and food are handled appropriately?

6.11 Needles and syringes are disposed of properly?

6.12 Infectious waste in red bag or container?

6.13 Nothing is stored under the sink and there is no sign of leaks?

6.14 Halls are uncluttered?

6.15 Respiratory hygiene available?

6.16 Biohazard symbol on door of biomedical waste storage?

6.17 Medication cart locked?

6.18 No artificial / acrylic nails use. Nails are no more than 1/4 inch above finger?

6.19 No personal lotion use.

6.20 Medication Room refrigerator is clean and without ice?

6.21 There are no expired products found(IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)

6.22 Is this section free of additional findings?

7.0 Soiled Linen / Dirty Utility Room

7.1 Biohazard symbol on door of biomedical waste storage?

7.2 Biohazard trash is segregated from regular trash?

7.3 Dirty tray cart clean?

7.4 Boxes are stored at least 6 inches off of the floor?

7.5 Clean items are not stored in soiled utility room?

7.6 Walls / floors are clean

7.7 Ceiling tiles are not discolored/ wet/ missing / damaged?

7.8 Is this section free of additional findings?

8.0. Isolation Rooms

8.1. Appropriate signage in place?

8.2. Supplies and PPE's available?

8.3. Trash and linen handled per policy?

8.4. Appropriate PPE's used by staff?

8.5. Door closed as appropriate?

8.6. Negative pressure is being supplied as required?

8.7 Patient and family instructed on isolation requirements?

8.8. Patient with proper attire when being transported?

8.9. Is this section free of additional findings?

9.0. Employee General Knowledge

9.1. Employees know the procedure for blood exposure?

9.2. Personnel can locate their Infection Control Policy?

9.3 Is this section free of additional findings?

Additional Comments

Additional Comments

Surveyor's Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.