Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

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?<br>

  • 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

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