Infection Prevention Rounds

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Participants

• Location
  Address

• Area Rounded

Temperature Documentation

• Dietary

  Yes

  No

  N/A

• Sage CHG within 84hr window, is it on the right setting “C”

  Yes

  No

  N/A

• Blanket Warmers

  Yes

  No

  N/A

• Medication Fridge

  Yes

  No

  N/A

Patient Nourishment Area

• all patient food is labeled w/name & date (nothing older than 3 days)

  Yes

  No

• no expired items in fridge

  Yes

  No

• no staff food in patient fridge

  Yes

  No

• ice machine is clean

  Yes

  No

• Bread (7 days) and thickening powder (30 days) are within days of opening

  Yes

  No

• general cleanliness of patient fridge

  Yes

  No

• general cleanliness of nourishment room

  Yes

  No

Staff Area

• food & drink in appropriate areas

  Yes

  No

• general cleanliness of nursing stations

  Yes

  No

• general cleanliness of break room

  Yes

  No

Linen Storage

• Linens stored appropriately? No items on top of cart, no excess linen out of cart, pillows covered

  Yes

  No

• linens covered

  Yes

  No

• Soiled linen <2/3 full

  Yes

  No

Supplies & Equipment

• Clean equipment placed in clean storage area or designated areas (labeled)

  Yes

  No

• Code cart free of dust and expired items

  Yes

  No

• Wheelchairs & other patient equipment clean

  Yes

  No

• No expired items

  Yes

  No

• No patient supplies found on window sills

  Yes

  No

Pharmaceuticals & POU

• Med Room: Clean and meds secured

  Yes

  No

• Med fridge clean

  Yes

  No

• No expired vials/meds or med supplies in use

  Yes

  No

• Around Unit: No medications, IVs, or syringes left unsecured or unattended

  Yes

  No

• Patient Rooms: No syringes/meds left unattended

  Yes

  No

• Proper wipes available to clean glucometer

  Yes

  No

Clean Utility Room

• Bottom shelves are solid

  Yes

  No

• Proper storage under sinks/ice machines

  Yes

  No

• appropriate waste disposal

  Yes

  No

• no storage on floor

  Yes

  No

• No dirty items stored

  Yes

  No

• storage is compliant sprinkler heads

  Yes

  No

• no external/shipping boxes

  Yes

  No

Dirty Utility Room

• doors kept closed / not propped open

  Yes

  No

• no clean items/equipment/patient items stored here

  Yes

  No

• room is clutter free

  Yes

  No

• red biohazard containers are covered and not overflowing

  Yes

  No

Isolation and Hand Hygiene

• Isolation cart stocked and clean

  Yes

  No

• Appropriate hand hygiene stations available

  Yes

  No

• Hand hygiene available and stocked

  Yes

  No

• Observed Hand Hygiene Compliance

  Compliant

  Non-Compliant

  N/A

Environment Cleanliness

• Fans are clean and appropriately located

  Yes

  No

• No tape/label adhesive on floor or anywhere else

  Yes

  No

• No shipping/external or corrugated boxes

  Yes

  No

• No dust/dirt noted (high dusting done)

  Yes

  No

• Floors/Walls clean, no dust, trash noted

  Yes

  No

I.P. General

• No artificial or gel nails

  Yes

  No

• Sharps containers <3/4 full

  Yes

  No

• Drywall intact

  Yes

  No

• Floors are cleanable

  Yes

  No

• Ceiling tiles free of stains, crack, gaps

  Yes

  No