I Physical Environment

* Staff verbally states or demonstrates

Physical Environment

Staff states designated clean & dirty areas or flow of work spaces

Drinks are covered with lids

No food/drinks in preparation work areas, specimen areas or WOWs

No multi serving food items in patient care/preparation areas

No personal/food items 12" near sink or splash guard present

No patient care supplies/equipment 12" near sink or splash guard present

Soap dispensers filled, not expired, and functioning properly

Alcohol hand rinse dispensers available, filled, not expired and functioning properly

Paper towel dispensers filled and functioning

No high dust and area dust free

Floors are clean

Surfaces and furnishings are clean

Bathrooms are clean

No missing or stained ceiling tiles

Area under sink is free from stored items

Computer keyboards/WOWs are clean without dust

Employee refrigerator free of unlabeled and expired food

Other:

II Hand Hygiene

* Staff states when to use soap and water for hand hygiene

* Staff states when to use alcohol hand rinse for hand hygiene

Hospital approved lotion available

No commercial lotion in use

Staff without artificial nails or cracked polish and nails less than 1/4 in length

Other:

III Standard and Transmission Base Precautions

Standard Precautions and Transmissions Based Precautions

* Staff defines Standard Precautions

Appropriate PPE available on unit

Sharps containers secured & not overfilled

* Staff locates Exposure Control Plan

* Staff states process if accidental exposure occurs (cleanse, notify, f/u)

* Staff states how to clean a blood spill

* Staff knows when a patient is on Transmission Based Precautions (EMR, signage)

* Staff defines Contact Precautions

* Staff defines Droplet Precautions

* Staff defines Enteric Precations

* Staff defines Airborne Precautions

* Staff locates TB Control Plan

* Staff states who can enter a negative pressure room (fit tested/family)

Other:

IV Equipment and Supplies

Equipment and Supplies

Storage so supplies dust free, 6" off floor, on solid bottom & 18" from ceiling

No expired supplies noted

No cardboard shipping boxes in supply storage

No dirty items in clean supply/designated area

No clean supplies in dirty utility/designated area

Equipment is clean

Equipment with biomedical or engineering tags are clean

Clean linen is covered and properly stored

Dirty linen is bagged in blue bag and covered

* Staff states or locates kill time for cleaning products

Other:

V Department Specific

Department Specific

ER, CCU, South, North

Medication refrigerator free of expired medicine

Medication refrigerator free of other items

Patient refrigerator free of other items than patient food

Multi patient medication vials are dated and within expiration date

Medicine and food refrigerators temperatures recorded daily, in range or documented action

Physician Practices

Medication refrigerator free of expired medicine

Medication refrigerator free of other items

Multi patient medication vials are dated and within expiration date

Medicine and food refrigerators temperatures recorded daily, in range or documented action

Employee break/ kitchen area clean

Main Lab & OP Lab

Refrigerator free of expired supplies

Refrigerator logs up to date

Eyewash station functioning & log up to date

Horizontal & vertical surfaces are clean

Biomedical waste is handled per policy

Pharmacy



Hoods are maintained per policy

Food Services

Temperature logs up to date

Refrigerator & Freezer clean

Refrigerator free from other items other than food

Refrigerator free from expired food

Ice machine clean

Dishwasher room clean

Hood clean and log up to date

Cleaning supplies labeled

Eyewash station functioning & log up to date

Shower functioning & log up to date

Microwave clean

Trash receptacles not overfilled & exterior clean

Dishwasher room clean

CP, PT, Radiology

Cleaning supplies labeled

Eyewash station functioning & log up to date

Shower functioning & log up to date

Other

Temperature logs up to date

Microwave clean

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.