Infection Prevention Environmental Audit - duplicate

• Audit Title infection Environmental Audit

• Conducted on

  Date

• Clinical

  Off

  On

• CCU

• ER

• South

• North

• Cardiopulmonary

• Laboratory

• OR/PACU/Anesthesia

• Radiology

• Non Clinical

  Off

  On

• Environmental Services

• Employee Health/Wellness

• Food Services

• HIM

• Materials Management

• Physicians Offices

  Off

  On

• CFP

• CFP Liberty

• CFP Eastside

• Cannon Surgical

• Cannon Orthopedic

• Prepared by S Stark, D DeRossett

• Sharon Stark, RN, MSM Infection Prevention

  Sign

QSF-ICS-1501 Rev 2

• * Staff verbally states or demonstrates

Physical Environment

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

  Yes

  No

  N/A

• Drinks are covered with lids

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• No multi serving food items in patient care/preparation areas

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Soap dispensers filled, not expired, and functioning properly

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Paper towel dispensers filled and functioning

  Yes

  No

  N/A

• No high dust and area dust free

  Yes

  No

  N/A

• Floors are clean

  Yes

  No

  N/A

• Surfaces and furnishings are clean

  Yes

  No

  N/A

• Bathrooms are clean

  Yes

  No

  N/A

• No missing or stained ceiling tiles

  Yes

  No

  N/A

• Area under sink is free from stored items

  Yes

  No

  N/A

• Computer keyboards/WOWs are clean without dust

  Yes

  No

  N/A

• Employee refrigerator free of unlabeled and expired food

  Yes

  No

  N/A

• Other:

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Hospital approved lotion available

  Yes

  No

  N/A

• No commercial lotion in use

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Other:

Standard Precautions and Transmissions Based Precautions

• * Staff defines Standard Precautions

  Yes

  No

  N/A

• Appropriate PPE available on unit

  Yes

  No

  N/A

• Sharps containers secured & not overfilled

  Yes

  No

  N/A

• * Staff locates Exposure Control Plan

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• * Staff states how to clean a blood spill

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• * Staff defines Contact Precautions

  Yes

  No

  N/A

• * Staff defines Droplet Precautions

  Yes

  No

  N/A

• * Staff defines Enteric Precations

  Yes

  No

  N/A

• * Staff defines Airborne Precautions

  Yes

  No

  N/A

• * Staff locates TB Control Plan

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Other:

Equipment and Supplies

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

  Yes

  No

  N/A

• No expired supplies noted

  Yes

  No

  N/A

• No cardboard shipping boxes in supply storage

  Yes

  No

  N/A

• No dirty items in clean supply/designated area

  Yes

  No

  N/A

• No clean supplies in dirty utility/designated area

  Yes

  No

  N/A

• Equipment is clean

  Yes

  No

  N/A

• Equipment with biomedical or engineering tags are clean

  Yes

  No

  N/A

• Clean linen is covered and properly stored

  Yes

  No

  N/A

• Dirty linen is bagged in blue bag and covered

  Yes

  No

  N/A

• * Staff states or locates kill time for cleaning products

  Yes

  No

  N/A

• Other:

Department Specific

• ER, CCU, South, North

  Off

  On

• Medication refrigerator free of expired medicine

  Yes

  No

  N/A

• Medication refrigerator free of other items

  Yes

  No

  N/A

• Patient refrigerator free of other items than patient food

  Yes

  No

  N/A

• Multi patient medication vials are dated and within expiration date

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Physician Practices

  Off

  On

• Medication refrigerator free of expired medicine

  Yes

  No

  N/A

• Medication refrigerator free of other items

  Yes

  No

  N/A

• Multi patient medication vials are dated and within expiration date

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Employee break/ kitchen area clean

  Yes

  No

  N/A

• Main Lab & OP Lab

  Off

  On

• Refrigerator free of expired supplies

  Yes

  No

  N/A

• Refrigerator logs up to date

  Yes

  No

  N/A

• Eyewash station functioning & log up to date

  Yes

  No

  N/A

• Horizontal & vertical surfaces are clean

  Yes

  No

  N/A

• Biomedical waste is handled per policy

  Yes

  No

  N/A

• Pharmacy<br><br><br><br>

  Off

  On

• Hoods are maintained per policy

  Yes

  No

  N/A

• Food Services

  Off

  On

• Temperature logs up to date

  Yes

  No

  N/A

• Refrigerator & Freezer clean

  Yes

  No

  N/A

• Refrigerator free from other items other than food

  Yes

  No

  N/A

• Refrigerator free from expired food

  Yes

  No

  N/A

• Ice machine clean

  Yes

  No

  N/A

• Dishwasher room clean

  Yes

  No

  N/A

• Hood clean and log up to date

  Yes

  No

  N/A

• Cleaning supplies labeled

  Yes

  No

  N/A

• Eyewash station functioning & log up to date

  Yes

  No

  N/A

• Shower functioning & log up to date

  Yes

  No

  N/A

• Microwave clean

  Yes

  No

  N/A

• Trash receptacles not overfilled & exterior clean

  Yes

  No

  N/A

• Dishwasher room clean

  Yes

  No

  N/A

• CP, PT, Radiology

  Off

  On

• Cleaning supplies labeled

  Yes

  No

  N/A

• Eyewash station functioning & log up to date

  Yes

  No

  N/A

• Shower functioning & log up to date

  Yes

  No

  N/A

• Other

  Off

  On

• Temperature logs up to date

  Yes

  No

  N/A

• Microwave clean

  Yes

  No

  N/A