Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

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

  • Number of deficiencies found during this Inspection:

  • 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. Alcohol hand rubs are available in patient's rooms?

  • 1.5. Placement of alcohol hand rubs is compliant with safety?

  • 1.6. Hand washing / hand hygiene is performed between patients?

  • 1.7. Hand Hygiene reminder posters present?

  • 1.8. Hand soap is available in all hand washing stations / bathrooms?

2.0. Clean Utility / Central Supply / Storage

  • 2.1. Clean linen cart is covered?

  • 2.2. Clean linen cart has solid surface on bottom shelf?

  • 2.3. Sink storage area empty and clean?

  • 2.4. Thrash cans or waste basket are not overfilled or overflowing?

  • 2.5. Ceiling tiles are not stained or wet?

  • 2.6. Floors are clean?

  • 2.7. Supplies are stored at least 6 inches off of the floor?

  • 2.8. Air intake vents and diffusers are clean?

  • 2.9 Is this section free of additional findings?

3.0 Patient Rooms

  • 3.1. Horizontal surfaces are clean?

  • 3.2 Thrash cans or waste basket are not overfilled or overflowing?

  • 3.3. Bathrooms are clean?

  • 3.4. Hand hygiene products are available?

  • 3.5. Soap and paper towels are available in each bathroom?

  • 3.6. PPE's are available as needed?

  • 3.7. Patient equipment is clean?

  • 3.8. No visible soil on vertical surfaces?

  • 3.9. Ceiling tiles are not discolored, wet, missing, or damaged?

  • 3.10. Air intake vents and diffusers are clean?

  • 3.11. Furniture (chairs, sleepers) are without tears or wear?

  • 3.12. Mattress pad is without tears or puncture holes?

  • 3.13. Floors are clean?

  • 3.14. Sharp containers are no more than 3/4 full?

  • 3.15. Dust not found in high places?

  • 3.16. General area is dust free?

  • 3.18. IV pumps and poles, feeding pumps etc. are clean?

  • 3.19. There is no evidence of pest present?

  • 3.20. Clean / dirty linen handled appropropriatly?

  • 3.21. No needles, syringes, medications within reach of the patient?

  • 3.22. No signs of mildew or mold present?

  • 3.23 Is this section free of additional findings?

5.0. Employee Kitchen / Breakroom

  • 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. Under sink clean and without storage?

  • 5.6. Employee food labeled and dated?

  • 5.8 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. Unused patient equipment/supplies are stored and handled appropriately?

  • 6.3. Medication, specimens, and food are handled appropriately?

  • 6.4. Biohazard trash is segregated from regular trash?

  • 6.5. Clean linen is handled appropriately?

  • 6.7. Dirty linen is handled appropriately?

  • 6.8. All clean linen carts are covered?

  • 6.7. Linen carts have a solid bottom shelf?

  • 6.8. Needles and syringes are disposed of properly?

  • 6.9. Out of date supplies are not present?

  • 6.10. Infectious waste in red bag or container?

  • 6.11. Clean items are not stored in soiled utility room?

  • 6.12 Ceiling tiles are not discolored/ wet/ missing / damaged?

  • 6.13. Lab supplies are not expired?

  • 6.14. Nothing is stored under the sink and there is no sign of leaks?

  • 6.15. Halls are uncluttered?

  • 6.16. Respiratory hygiene available?

  • 6.17 Restrooms clean?

  • 6.18. Trash basket are not overflowing?

  • 6.19. Biohazard symbol on door of biomedical waste storage?

  • 6.20. Medication cart locked?

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

  • 6.22. No personal lotion use.

  • 6.23. Medication Room refrigerator is clean and without ice?

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

  • 6.25. Is this section free of additional findings?

7.0 Logs

  • 7.1. Crash cart checked daily?

  • 7.2. Defibrillator checked daily

  • 7.3. Narcotic counts documented every shift?

  • 7.4. Temperature checked BID for vaccine / medication storage?

  • 7.5. Daily refrigerators checks with corrective actions as needed?

  • 7.7. Glucose meter strips dated

  • 7.8. Cidex monitoring Log complete?

  • 7.9. 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 Manual?

  • 9.3. Personnel can locate their Exposure Control Plan?

  • 9.4. Personnel can locate the blood spill kit?

  • 9.5. Personnel can locate their spill kit for Cidex?

  • 9.6. Employees can state the WHO's 5 moments of Hand Hygiene.

  • 9.7 Dust not found in high places?

  • 9.8. Is this section free of additional findings?

10.0. Soiled Linen / Dirty Utility Room

  • 10.1 Biohazard symbol on door of biomedical waste storage?

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

  • 10.3. Walls / floors are clean

  • 10.4. Ceiling tiles are not discolored/ wet/ missing / damaged?

  • 10.5 Dust not found in high places?

  • 10.6 Is this section free of additional findings?

Additional Comments

  • Additional Comments

  • Surveyor's Signature

Untitled page

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. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.