Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Equipment
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Clean equipment placed in clean storage area or designated areas (labeled)
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Proper wipes available to clean glucometer or urine dipstick machine (purple top)
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Isolation cart stocked and clean
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Code cart properly stored and log updated
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Unopened electrode package on defibulator
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Wheelchairs & other patient equipment clean
Staff Area
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food & drink in appropriate areas
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general cleanliness of nursing stations
Patient Nourishment Area
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all patient food is 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 is clean
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general cleanliness of nourishment room
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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all storage 18in from sprinkler heads
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no external/shipping boxes
Dirty Utility Room
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doors kept closed / not propped open
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no clean items/equipment/patient items stored here
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room is clutterfree
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red biohazard containers are covered and not overflowing
Medication Room/Area
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Clean and meds secured
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fridge clean and temps checked and logged daily
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No expired vials/meds or med supplies in use
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Expiration date noted on packaging
Environment
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No medications, IVs, or syringes left unsecured or unattended
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No tape/label adhesive on floor or anywhere else
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No shipping/external or corrugated boxes
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No dust/dirt noted (high dusting done)
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Floors/Walls clean, no dust, trash noted
Patient Rooms
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No patient supplies found on window sills
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No syringes/meds left unattended
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No reuseable gait belts found in rooms
