IPC Observations/Rounds- NNH

• Site conducted
  Address

• Conducted on

  Date

• Conducted by

• Prepared by

• Yes

  No

  N/A

Equipment

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

  Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A

Clean Storge Room

• General cleanliness of floor/walls

  Yes

  No

  N/A

• Any linens present, 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

• Clean and sterile equipment/supplies kept separate

  Yes

  No

  N/A

• Doors kept closed / not propped open

  Yes

  No

  N/A

• No patient items stored here

  Yes

  No

  N/A

• No red biohazard waste/containers here

  Yes

  No

  N/A

• No shipping/external or corrugated boxes

  Yes

  No

  N/A

Environment

• No external/shipping boxes

  Yes

  No

  N/A

• Room is clutterfree

  Yes

  No

  N/A

• No dust/dirt noted (high dusting done)

  Yes

  No

  N/A

• No tape/label adhesive on floor or anywhere else

  Yes

  No

  N/A

• Floors/Walls clean, no dust, no trash noted

  Yes

  No

  N/A

I.P. General

• Yes

  No

  N/A

• 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

• Yes

  No

  N/A

• Yes

  No

  N/A

• Yes

  No

  N/A