Title Page
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Department audited
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Site audited
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Date audited
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Conducted by
Environment
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No meds, IVs, or syringes left unsecured or unattended
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No tape or label adhesive on floor or anywhere else
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No shipping/external or corrugated boxes
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High dusting done, no dust/dirt noted
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Floors/Walls clean, no dust or trash noted
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Ceiling tiles appropriately placed & free from water stains or holes
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Hand sanitizer dispensers have drip trays
Staff Area
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Food & drink appropriately covered in appropriate areas
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General cleanliness of nursing stations
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Workstations free from patient supply storage
Patient Nourishment Area
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All patient food labeled w/name & date (nothing older than 3 days)
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No expired items in fridge
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Fridge temp checked and logged daily
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No staff food in patient fridge
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General cleanliness of patient fridge
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Ice machine clean and no mold, rust, or calcium buildup noted
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General cleanliness of nourishment room (include fridges/microwaves)
Equipment
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Clean equip placed in clean storage area or designated areas (supplies in drawers/baskets/cubbies removed & discarded as appropriate)
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Proper wipes available to clean glucometer or urine dipstick machine
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Isolation cart appropriately stocked and clean
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Code cart properly stored and log updated
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No open electrode packages noted on crash cart
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POC testing device (e.g., glucometer) is cleaned and disinfected after every use, as per MIFUs
Clean Utility Room
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Linens covered
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No storage on floor
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No dirty items stored
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Storage is 18in from sprinkler heads
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No external/shipping boxes
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Entry door not propped open (kept closed except for entry/exit)
Dirty Utility Room
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No storage on floor
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No clean items, clean equip, or patient care items stored here
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Biohazard containers labeled as such; covered, and not overflowing
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Room is clutter-free
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Entry door not propped open (kept closed except for entry/exit)
Medication Room/Area
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Room clean, clutter-free, and meds secured
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Fridge clean and temps checked/logged daily
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No expired vials/meds or med supplies in use
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Multi-dose vials are dated when first opened and discarded within 28 days unless MIFUs specifies a different beyond-use-date
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No storage under sink
I.P. General
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Hand hygiene upon enter/exit patient room
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No porous or unwipe-able items (e.g., paper, tape, adhesive residue, torn chairs, peeling tape/labels, etc)
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No mixing of clean patient supplies with office supplies
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Sharps containers replaced when the "fill line" is reached
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No storage of patient care items on WOWs
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