MONTHLY EOC/ INFECTION CONTROL ROUNDS

• Conducted on

  Date

• Prepared by

• Location
  Address

ER DEPARTMENT- General

• Appropriate signs posted, including EMTALA signage

  Yes

  No

  N/A

• PPE Available

  Yes

  No

  N/A

• Irrigation & sterile solutions labeled as per policy

  Yes

  No

  N/A

ER #1

• Floors & walls clean

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, Vital sign machine, etc clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand Sanitizer Available

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• Vent Grills are clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ER # 2

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, Vital sign machine, etc clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Hand Sanitizer Available

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• Vent Grills are clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ER # 3

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Bathroom clean

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand Sanitizer Available

  Yes

  No

  N/A

• Vent Grills are clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

PUBLIC RESTROOMS:

• Men's Restroom Clean

  Yes

  No

  N/A

• (Men's) Hand Soap Available

  Yes

  No

  N/A

• (Men's) Paper towels available

  Yes

  No

  N/A

• (Men's) Toilet Paper available

  Yes

  No

  N/A

• (Men's) Appropriate signage (Employees must wash hands)

  Yes

  No

  N/A

• Women's Restroom Clean

  Yes

  No

  N/A

• (Women's) Hand Soap Available

  Yes

  No

  N/A

• (Women's) Paper towels available

  Yes

  No

  N/A

• (Women's) Toilet Paper available

  Yes

  No

  N/A

• (Women's) Appropriate signage (Employees must wash hands)

  Yes

  No

  N/A

ROOM # 301

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves availabe

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand Sanitizer Available

  Yes

  No

  N/A

• Vent Grills are Clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

301/303 BATHROOM

• Bathroom Clean

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 303

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condiiton

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Select Yes No N/A

  • Yes
  • No
  • N/A

• IV pumps, feeding pumps, vital sign machine, etc clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand Sanitizer available

  Yes

  No

  N/A

• Vent Grills Clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 302

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand Sanitizer Available

  Yes

  No

  N/A

• Vent grills are clean

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

302/304 BATHROOM

• Bathroom clean

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 304

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine etc clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand sanitizer available

  Yes

  No

  N/A

• Vent grills are clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 305

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machines, etc. clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand sanitizer available

  Yes

  No

  N/A

• Vent grills clean

  Yes

  No

  N/A

• Area free from roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

305 Bathroom

• Bathroom clean

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 306

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc. clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand Sanitizer Available

  Yes

  No

  N/A

• Vent Grills Clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, and other vermin

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

306/308 Bathroom

• Bathroom clean

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 308

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc. clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand Sanitizer Available

  Yes

  No

  N/A

• Vent Grills clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 307

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc. clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand sanitizer available

  Yes

  No

  N/A

• Vent Grills clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

307/309 Bathroom

• Bathroom clean

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

  Yes

  No

  N/A

ROOM # 309

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc. clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand Sanitizer available

  Yes

  No

  N/A

• Vent Grills are clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 310

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc. clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand Sanitizer available

  Yes

  No

  N/A

• Vent Grills are clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

310/312 Bathroom

• Bathroom clean

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 312

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc. clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand sanitizer available

  Yes

  No

  N/A

• Vent Grills are clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 311

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc. clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand sanitizer available

  Yes

  No

  N/A

• Vent Grills are clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

311/ 313 Bathroom

• Bathroom clean

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

ROOM # 313

• Floors & walls clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Sink Clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Windows and windowsills clean

  Yes

  No

  N/A

• Peripheral IVs, Midlines, and CVCs are labeled per policy

  Yes

  No

  N/A

• Foley catheter/s hanging appropriately

  Yes

  No

  N/A

• IV pumps, feeding pumps, vital sign machine, etc. clean and covered with clean bag if not in use and clean if in use

  Yes

  No

  N/A

• Gloves available

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Cubicle curtains clean and free of tears, etc.

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand sanitizer available

  Yes

  No

  N/A

• Vent grills are clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

Isolation Rooms:

• Doors closed as appropriate

  Yes

  No

  N/A

• Patient and/or family instructed on isolation requirements

  Yes

  No

  N/A

• Patient wearing proper attire when being transported

  Yes

  No

  N/A

• Negative Pressure being supplied as required

  Yes

  No

  N/A

Clinic Treatment Rooms

• Floors & walls clean

  Yes

  No

  N/A

• Countertops clean

  Yes

  No

  N/A

• Exam tables clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Hand soap and paper towels available

  Yes

  No

  N/A

• Hand sanitizer available

  Yes

  No

  N/A

• PPE available

  Yes

  No

  N/A

• Refrigerators clean

  Yes

  No

  N/A

• Medications within date

  Yes

  No

  N/A

• Ceiling Tiles are clean and in good condition

  Yes

  No

  N/A

• Vent Grills clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• OTHER repairs needed/ etc.

Clinic Lobby

• Furniture clean and in good condition

  Yes

  No

  N/A

• Hand sanitizer available

  Yes

  No

  N/A

• Masks available

  Yes

  No

  N/A

Utility & Storage Rooms:

• Adequate separation of clean & soiled

  Yes

  No

  N/A

• Floors and walls clean

  Yes

  No

  N/A

• No supplies stored on the floor

  Yes

  No

  N/A

• Supplies stored 6" from the floor

  Yes

  No

  N/A

• Supplies stored 18" from ceiling

  Yes

  No

  N/A

• No supplies stored under sinks

  Yes

  No

  N/A

• No supplies stored in bathrooms, soiled utility rooms

  Yes

  No

  N/A

• Supplies stored away from windows, vents

  Yes

  No

  N/A

• Shelving/ drawers/ cabinets clean

  Yes

  No

  N/A

• Patient supplies within expiration dates

  Yes

  No

  N/A

• Sterilized trays free of dust, unopened, tears

  Yes

  No

  N/A

• Event- related sterile items labeled appropriately

  Yes

  No

  N/A

Soiled Utility Rooms:

• Floors and walls clean

  Yes

  No

  N/A

• Free of patient supplies and sterilized trays

  Yes

  No

  N/A

• Soiled linen is bagged & placed outside in building by back door

  Yes

  No

  N/A

Hallways:

• Floors & walls clean

  Yes

  No

  N/A

• Free of obstruction and equipment

  Yes

  No

  N/A

• OTHER: repairs needed/ etc.

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

Equipment & Non-Critical Items:

• Equipment in patient use clean

  Yes

  No

  N/A

• Equipment stored is clean

  Yes

  No

  N/A

• Equipment handled as per policy

  Yes

  No

  N/A

Linen:

• Clean linen distributed to units on clean, covered carts

  Yes

  No

  N/A

• Separation of clean & soiled linen

  Yes

  No

  N/A

• Clean linen stored in required area, on shelves or carts

  Yes

  No

  N/A

• Soiled linen not placed on floor, furniture, windowsills, etc.

  Yes

  No

  N/A

• Soiled linen collected as per policy

  Yes

  No

  N/A

• Soiled linen contained in bags, not overfilled

  Yes

  No

  N/A

• Linen hampers & carts covered

  Yes

  No

  N/A

• Linen hampers & carts clean & in good condition

  Yes

  No

  N/A

Offices, Work Stations, & Reception Areas:

• Carpeting clean

  Yes

  No

  N/A

• Desks clean and free from unnecessary clutter & food items

  Yes

  No

  N/A

• Office equipment clean & clutter free

  Yes

  No

  N/A

• Floors free of clutter & trash

  Yes

  No

  N/A

• Food only in designated areas

  Yes

  No

  N/A

Meeting Rooms:

• Carpeting clean

  Yes

  No

  N/A

• Empty cups & food items placed in trash

  Yes

  No

  N/A

• Furniture clean & in good condition

  Yes

  No

  N/A

Waiting Areas & Staff Lounges:

• Carpeting clean

  Yes

  No

  N/A

• Furniture clean & in good condition

  Yes

  No

  N/A

• Empty cups & food items placed in trash

  Yes

  No

  N/A

Radiology Department

• Furniture in good condition

  Yes

  No

  N/A

• Bathroom clean

  Yes

  No

  N/A

• Waiting area clean

  Yes

  No

  N/A

• Other:

Waste Management

• Waste containers not overfilled

  Yes

  No

  N/A

• Waste container clean, operational, & in good condition

  Yes

  No

  N/A

• Waste container covered as required

  Yes

  No

  N/A

• Containers located appropriately

  Yes

  No

  N/A

• Appropriate number of containers available

  Yes

  No

  N/A

• Containers labeled as required

  Yes

  No

  N/A

• Red bags available in each regulated medical waster container

  Yes

  No

  N/A

• Regulated medical waste discarded appropriately

  Yes

  No

  N/A

• Items in regulated medical waste containers are appropriate

  Yes

  No

  N/A

• Sharps containers available

  Yes

  No

  N/A

• Sharps containers not overfilled

  Yes

  No

  N/A

• Sharps containers secured appropriately

  Yes

  No

  N/A

• Sharps appropriately discarded

  Yes

  No

  N/A

OTHER Housekeeping Issues:

• Blood Spill Kits Available

  Yes

  No

  N/A

• Housekeeping staff aware of cleaning solution admixing policy

  Yes

  No

  N/A

• High-level dusting performed

  Yes

  No

  N/A

• Porter's closet clean

  Yes

  No

  N/A

Kitchen:

• Sinks Clean

  Yes

  No

  N/A

• Countertops are clean

  Yes

  No

  N/A

• Floors & Walls Clean

  Yes

  No

  N/A

• Hand Soap Available

  Yes

  No

  N/A

• Paper Towels Available

  Yes

  No

  N/A

• Hand Sanitizer Available

  Yes

  No

  N/A

• No expired juice/ milk, etc.

  Yes

  No

  N/A

• Ice Machine is clean

  Yes

  No

  N/A

• Microwave Clean

  Yes

  No

  N/A

• Storage closet clean and organized

  Yes

  No

  N/A

• Large open area under 3 compartment sink is clean with no holes

  Yes

  No

  N/A

• Freezers with labeled food

  Yes

  No

  N/A

• Dry goods with labeled food

  Yes

  No

  N/A

• OTHER:

Refrigerators:

• Daily checklists completed for temperatures

  Yes

  No

  N/A

• Correct temp observed: Food & Drink 36-45 degrees F

  Yes

  No

  N/A

• Correct temp observed: Medications, 36-46 degrees F

  Yes

  No

  N/A

• Correct temp observed: Specimens, 36-46 degrees F

  Yes

  No

  N/A

• Correct temp observed: Blood, 34-43 degrees F

  Yes

  No

  N/A

• Correct temp observed: Freezers, > or equal to 32 degrees F

  Yes

  No

  N/A

• Only medications in medication refrigerator

  Yes

  No

  N/A

• Only food in food refrigerator

  Yes

  No

  N/A

• Only Specimens in specimen refrigerator

  Yes

  No

  N/A

• Patient food & staff food not mixed

  Yes

  No

  N/A

• Refrigerators clean

  Yes

  No

  N/A

• Items labeled as per policy

  Yes

  No

  N/A

Medications:

• No outdated IV solutions or medications

  Yes

  No

  N/A

• Open vials dated and timed per policy

  Yes

  No

  N/A

• Medication carts clean and organized

  Yes

  No

  N/A

MISCELLANEOUS:

• Handwashing observed when appropriate

  Yes

  No

  N/A

• Disaster, evacuation, fire, infection control, & MSDS documents are available

  Yes

  No

  N/A

• Storage closets and shelves are clean

  Yes

  No

  N/A

• Sinks are clean

  Yes

  No

  N/A

• Free of leaks and spills

  Yes

  No

  N/A

• Specimens are being bagged, handled, and labeled as per policy

  Yes

  No

  N/A

• Safety devices available

  Yes

  No

  N/A

• Safety devices used appropriately

  Yes

  No

  N/A

• Appropriate patient/ visitor signage up and visible

  Yes

  No

  N/A

• OTHER Issues and/or Problems

Grounds:

• Clean & free of trash

  Yes

  No

  N/A

• Building walls free of penetrations

  Yes

  No

  N/A

• OTHER

Disinfection:

• Appropriate solutions available for soaking

  Yes

  No

  N/A

• Appropriate containers available

  Yes

  No

  N/A

• Containers clean, covered, labeled as required

  Yes

  No

  N/A

Survey Readiness:

• Pharmacy locked when pharmacy staff not available

  Yes

  No

  N/A

• Fire drills are current 1/shift/ qtr

  Yes

  No

  N/A

• Glucometer logs completed (ER)

  Yes

  No

  N/A

• Glucometer logs completed (Floor)

  Yes

  No

  N/A

• Crash Cart logs completed (ER)

  Yes

  No

  N/A

• Crash Cart logs completed (Floor)

  Yes

  No

  N/A

• Fall patients with demonstrative identifications (signage, etc)

  Yes

  No

  N/A

• Linen storage room: Clean with no other furniture etc in room

  Yes

  No

  N/A

• Secondary CS room is clean with no boxes on the floor

  Yes

  No

  N/A

• Respiratory equipment stored in appropriate storage room (covered and clean)

  Yes

  No

  N/A

Behavior Health:

• Floors & walls are clean

  Yes

  No

  N/A

• Walls are free of breaks and penetrations

  Yes

  No

  N/A

• Bathrooms clean

  Yes

  No

  N/A

• Sinks clean

  Yes

  No

  N/A

• Furniture clean and in good condition

  Yes

  No

  N/A

• Gloves & PPE available as per policy

  Yes

  No

  N/A

• Barriers used appropriately

  Yes

  No

  N/A

• Bed pans & urinals labeled as appropriate

  Yes

  No

  N/A

• Hand soap available

  Yes

  No

  N/A

• Hand sanitizer available

  Yes

  No

  N/A

• Ceiling tiles are clean and in good condition

  Yes

  No

  N/A

• Vent Grills clean

  Yes

  No

  N/A

• Area free of roaches, flies, mice, & other vermin

  Yes

  No

  N/A

• OTHER repairs needed/ etc

• CORRECTIVE ACTIONS:

• REPORT SENT TO:

SIGNATURES:

• Risk/ Quality Manager

• Assistant Administrator

• Infection Control Nurse