IPC Observations/Rounds - L&D

• Site conducted
  Address

• Conducted on

  Date

• Conducted by

• Prepared by

• Yes

  No

  N/A

Equipment

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

  Yes

  No

  N/A

• Proper wipes available to clean glucometer or urine dipstick machine (purple top)

  Yes

  No

  N/A

• Isolation cart stocked and clean

  Yes

  No

  N/A

• Code cart properly stored and log updated

  Yes

  No

  N/A

• Unopened electrode package on defibulator

  Yes

  No

  N/A

• Wheelchairs & other patient equipment clean

  Yes

  No

  N/A

• Eyewash stations clean (no calcification) & Logs up-to-date

  Yes

  No

  N/A

Staff Area

• Food & drink in appropriate areas

  Yes

  No

  N/A

• General cleanliness of nursing stations

  Yes

  No

  N/A

Patient Nourishment Area

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

  Yes

  No

  N/A

• No expired items in fridge

  Yes

  No

  N/A

• Fridge temp checked and logged daily

  Yes

  No

  N/A

• No staff food in patient fridge

  Yes

  No

  N/A

• General cleanliness of patient fridge

  Yes

  No

  N/A

• Ice machine is clean

  Yes

  No

  N/A

• General cleanliness of nourishment room

  Yes

  No

  N/A

Clean Utility Room

• All linens covered

  Yes

  No

  N/A

• No storage on floor

  Yes

  No

  N/A

• No dirty items stored

  Yes

  No

  N/A

• All storage 18in from sprinkler heads

  Yes

  No

  N/A

• No external/shipping boxes

  Yes

  No

  N/A

Dirty Utility Room

• Doors kept closed / not propped open

  Yes

  No

  N/A

• No clean items/equipment/patient items stored here

  Yes

  No

  N/A

• Room is clutterfree

  Yes

  No

  N/A

• Red biohazard containers are covered and not overflowing

  Yes

  No

  N/A

Med Room/Area

• Clean and meds secured

  Yes

  No

  N/A

• Fridge clean and temps checked and logged daily

  Yes

  No

  N/A

• No expired vials/meds or med supplies in use

  Yes

  No

  N/A

• Expiration date noted on packaging

  Date

Environment

• No medications, IVs, or syringes left unsecured or unattended

  Yes

  No

  N/A

• No tape/label adhesive on floor or anywhere else

  Yes

  No

  N/A

• No shipping/external or corrugated boxes

  Yes

  No

  N/A

• No dust/dirt noted (high dusting done)

  Yes

  No

  N/A

• Floors/Walls clean, no dust, trash noted

  Yes

  No

  N/A

• Bedside curtains are clean, free of stains <br> (changed per schedule & when visibly contaminated)

  Yes

  No

  N/A

• Yes

  No

  N/A

Patient Rooms

• No patient supplies found on window sills

  Yes

  No

  N/A

• No syringes/meds left unattended

  Yes

  No

  N/A

• No reuseable gait belts found in rooms

  Yes

  No

  N/A

I.P. General

• No Items are kept in the original shipping boxes, especially in the clinical areas

  Yes

  No

  N/A

• Clean supply rooms & Dirty utility rooms do not have doors propped open

  Yes

  No

  N/A

• Yes

  No

  N/A

Misc

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A