Infection Prevention Rounds

• Site conducted

• Conducted on

  Date

• Prepared by

• Location

• Floors clean and in good repair

  Yes

  No

  N/A

• Ceiling tiles unstained.

  Yes

  No

  N/A

• Only allowable supplies stored under sinks.

  Yes

  No

  N/A

• No external shipping containers where clean/sterile supplies are present.

  Yes

  No

  N/A

• Sharps containers not more than 2/3 full

  Yes

  No

  N/A

• Hand Hygiene performed before and after room entry/exit.

  Yes

  No

  N/A

• Isolation signs posted appropriately

  Yes

  No

  N/A

• Isolation cart/supplies available

  Yes

  No

  N/A

• Staff wearing appropriate PPE

  Yes

  No

  N/A

• Proper disinfectant available

  Yes

  No

  N/A

• Shower hose hanging without loops (empty patient rooms)

  Yes

  No

  N/A

• Horizontal surfaces are clean

  Yes

  No

  N/A

• No visible soil on vertical surfaces

  Yes

  No

  N/A

• Hallways uncluttered

  Yes

  No

  N/A

• Clean linen covered

  Yes

  No

  N/A

• Solid bottom present on bottom supply storage shelf

  Yes

  No

  N/A

• Clean supplies separate from dirty

  Yes

  No

  N/A

• All supplies within expiration date

  Yes

  No

  N/A

• Reusable instruments sprayed/soaked in enzymatic solution

  Yes

  No

  N/A

• No instrument cleaning in hand-washing sinks

  Yes

  No

  N/A

• Soiled instruments transported in bio-hazard-labeled covered container

  Yes

  No

  N/A

• Supplies are at least 18 inches from ceiling and 6 inches from floor

  Yes

  No

  N/A

• Medications are within expiration date

  Yes

  No

  N/A

• Open, multi-dose vials are labeled with expiration date

  Yes

  No

  N/A

• High-Level Disinfection processes compliant

  Yes

  No

  N/A

OTHER FINDINGS

• undefined

• Add media

  Media

• # of carts compliant ____<br># carts observed ____

  Compliiant

  Observed

• # Instrument totes compliant _____<br># Instrument totes Observed _____

  Compliiant

  Observed