What populations are served at this location:
Do you know how to contact infection prevention?
Staff know how to access Institutional Infection Prevention Policies?
Do you have any departmental infection prevention policies?
When was the last time departmental policies were reviewed?
Staff know the location of the Exposure Control Plan / Tuberculosis Control Plan
Influenza vaccination status is known (ex. appropriate colored heart)
Non-vaccinated staff wear mask appropriately
Staff know how to access IFU
Manager uses the Sick Call log
What is done when you identify an empty hand sanitizer dispenser
What is done when you identify a full sharp disposal container
How is water taken from the ice/water machine to the patient's room
Staff can explain what is "biohazardous waste"
What items are disposed of in the red biohazard containers
Staff know how to transport clean/dirty reusable items
Staff can describe process for pre-cleaning items to be sent for sterilization or HLD
State communicable disease list available. Staff can verbalize how to report.
Observations done and recorded each month
Competency validation done every other year
Hand hygiene education done annually
Able to show individual's compliance
No artificial nails, bracelets, thumb-hole tops, hand splints or braces
Hand hygiene is done prior to donning gloves
Hand hygiene is done after removing gloves
Hand hygiene is done prior to having contact with the patient even if not wearing gloves
Waiting areas neat and clean.
Patient scheduling: illness triage? What is response if positive for illness?
Potentially infectious patient (PIP) is moved into exam room/procedure room/patient room asap
Communication to provider about PIP?
Horizontal and high-touch surfaces of exam rooms cleaned between patients.
What procedures are done at this location?
Appropriate procedures in place for patient and staff safety (i.e. PPE, smoke evacuation, positive pressure procedure room?)
Cough etiquette supplies available at entrance to location?
Employee can verbalize when hand hygiene is expected.
Stretchers and wheel chairs are cleaned after use with appropriate disinfectant
No non-intact stretchers, wheel chairs, beds, chairs, etc.
Clean linen is covered and maintained in a clean/dry area
Disposable blood pressure cuffs not re-used for routine patient care
Reusable blood pressure cuffs cleaned between patients
No under sink storage except for cleaning products
Environment and equipment is clean and dust free
All storage containers are cleanable (i.e. no wicker, cardboard boxes etc.)
Emergency supplies - high level disinfected items intact packages, no outdates
No food or drink in the patient care area. Labeled hydration station.
Clean equipment is covered with a clear bag/clean tag is present
Alcohol dispensers readily available
General appearance of the area is clean and uncluttered
Ceiling tiles are clean and dry
Cleaning supplies are labeled (if in secondary container) and approved for use in the hospital
IV bags are not pre-spiked
When are refrigerator(s) defrosted/cleaned
Refrigerator is labeled as "medication" refrigerator
Thermometer present - temps are tracked
Staff can describe what to do if temperature out of range
Multi-dose vials are dated when they are first opened and discarded within 28 days.
Multi-dose vials that are used for more than one patient are stored appropriately and do not enter the immediate patient zone.
What is the process for expired medication?
Safety devices are used for all injections, phelbotomy, venipuncture, & IV therapy. Describe any exceptions to safety devices and rationale.
Sharps containers are accessible, secured to wall/counter and emptied when reach "full" line
Glass is disposed of in rigid sharps containers
Hands are washed prior to preparing medications
Aseptic technique used to enter medication vials
Single use medication vials discarded
Staff can verbalize vaccine storage policy
There is a 3 foot splash zone from the sink where medications are not prepared or stored or splash guard is available
Staff use and can explain standard precautions
Staff use and can explain transmission based precautions
Gloves not worn in the hallway
Communication to ancillary departments or clinicians about potentially communicable patient (Ticket/tag to ride, verbal report, etc.)
Appropriate mouth, nose, and eye protection is worn for aerosol-generating procedures
Inspect patient rooms and bathrooms for inappropriate supplies or outdated supplies
Staff understand cohorting
Appropriate skin disinfection prior to injection/blood draw
Scrub the hub prior to accessing IVs
All medications are prepared in a clean preparation area
All point of care devices are cleaned and disinfected after every use according to IFU.
PPE available gloves, gowns, eye protection, masks
Staff know how to don and doff PPE - competency validated?
Transmission based precaution signs available?
Appropriate use of transmission based precaution signs?
Appropriate order entered into EMR?
Sharps container less than 3/4 full
Sterile irrigation fluid is opened for same day use only (<24hr). Date noted.
Soiled linen is placed in designated covered hampers and is marked with biohazard symbol
Ultrasound gel is single use packets or bottle is dated.
Hampers used appropriately- ie. no bags on the floor, no overflowing linen
If bed is unmade- mattress intact?
Staff know wet contact time for disinfectants
Staff know which disinfectant to use for each item
Precaution bag is present or cubby is stocked with supplies
Correct sign on door
Adequate amount of supplies available
Hand sanitizer available and full
Hand sanitizer covered in Enteric Precaution room
Soap and water is used to disinfect hands as leaving Enteric Precaution room
Wastebasket inside doorway - not overflowing
Hamper available inside room - not overflowing
PPE worn correctly
PPE removed prior to leaving patient room
If negative pressure- PAPR hood or N95 utilized
If negative pressure- check logbook in maintenance- when needed, pressure to be checked/documented every shift
Temperatures logs maintained
Food/ containers dated
No expired food
Clean utility is separate from dirty utility
Outer shipping boxes not stored with supplies/ removed from clean areas
Clean items only
Bottom of storage racks must have solid surface shelving
No medical supplies on floor
Storage of sterile supplies 8-10" above the floor, 2" away from exterior walls
All sterile supplies are dry with intact packaging, not stored on the floor
Nothing stored under the sinks
18 inches of clearance from ceiling in clean utility room or other clean areas
No outdated supplies
Temperature and humidity monitored if MMC processed sterile supplies are stored
Staff can explain even related sterility
Dirty items only
Door closed on soiled utility room
No storage of drinking cups, tissues, paper towels, toilet tissue
Negative pressure maintained and monitored
Items waiting for processing are stored open and remain wet
Room appropriate temperature, humidity and pressurization
Sterile trays are not set up ahead of time and covered for future use
All hair covered when sterile field is open and during procedure
No unattended sterile field
Lead aprons cleaned between uses
Masks worn covering nose and mouth - both ties tied
Appropriate surgical scrub is done prior to sterile procedure
All surfaces appropriately cleaned between cases
Principles of asepsis are maintained for the sterile field and surgical incision
Reprocessing onsite or transport?
Visible bioburden removed at point of use
Items are kept moist
Appropriate temperature, humidity and pressure?
Appropriate PPE worn?
Staff can speak to IFU
Instruments not visibly dry prior to manual cleaning
Instruments unhinged and open
No processing of single use items
Biologicals used appropriately
Area is clean and dust free
Separation of clean and dirty, function and workflow
Endoscopes logged to trace to patient
Endoscopes manual cleaning begins within 1 hour of end of use
Endoscope reprocessing competency validated
Flexible endoscopes are inspected for damage and leak tested as part of each reprocessing cycle
After high-level disinfection, devices are stored in a manner to protect from damage or contamination (Note endoscopes must be hung in a vertical position)
All high level disinfection processes have competency
All cleaning brushes are single-use, disposable or if, reusable, cleaned and either high-level disinfected or sterilized (per IFU).
Chemical and biological indicators are used as required.