Northside Forsyth Hospital

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

I. INFECTION PREVENTION

1. Hand Hygiene

• a. Towel dispensers full

  Yes

  No

  N/A

• b. Soap dispensers full

  Yes

  No

  N/A

• 1) product within expiration

  Yes

  No

  N/A

• 2) Soap dispensers damaged

  Yes

  No

  N/A

• c. Antiseptic gel dispensers full and functioning

  Yes

  No

  N/A

• 2) product within expiration date

  Yes

  No

  N/A

• Observe staff going in and out of rooms to see if hand hygiene is performed

  Yes

  No

  N/A

2. Personal Protective Equipment

• a. Readily available (gloves, masks, gowns, eye protection)

  Yes

  No

  N/A

• 1) appropriate and hospital approved masks available

  Yes

  No

  N/A

• b. Employee wearing appropriate barrier protection for patient (standard precautions)

  Yes

  No

  N/A

• c. Gloves are worn appropriately (worn only for direct patient care or while handling contaminated items)

  Yes

  No

  N/A

• d. Isolation Caddies Present

  Yes

  No

  N/A

• 1) isolation caddies stocked

  Yes

  No

  N/A

• 2) signage for isolation rooms appropriate

  Yes

  No

  N/A

• 3) employee using appropriate transmission based barrier precautions

  Yes

  No

  N/A

• 4) isolation education left on caddies

  Yes

  No

  N/A

• 5) caddies clean and free of inappropriate items

  Yes

  No

  N/A

3. Sharps Container

• a. Located in all areas where sharps are used, easily accessible

  Yes

  No

  N/A

• 1) appropriate height (no lower than 52 and no higher than 56)

  Yes

  No

  N/A

• b. Needles NOT recapped (check @ least 3 needle boxes)

  Yes

  No

  N/A

• C. Less than 3/4 full

  Yes

  No

  N/A

4. Red Bags: Biomedical Waste Containers

• a. Red bags or biomedical waste containers readily available

  Yes

  No

  N/A

• b. Only biomedical trash is placed in red bags or biomedical waste containers

  Yes

  No

  N/A

• c. Red bag/waste containers covered

  Yes

  No

  N/A

5. General Information

• a. Nurses station - counters un-cluttered, neat & clean

  Yes

  No

  N/A

• 1) drinks covered

  Yes

  No

  N/A

• 2) employee food on or in nurses station

  Yes

  No

  N/A

• 3) pneumatic tube station free of dust/dirt

  Yes

  No

  N/A

• 4) free of personal items bags, purses, jackets, coats

  Yes

  No

  N/A

• b. Underneath sink areas (not in pt. rooms) clear of any patient related supplies

  Yes

  No

  N/A

• c. Staff locker room floor clean, free of clutter, lockers dust free on top

  Yes

  No

  N/A

• d. Ceiling tiles are free of stained and intact

  Yes

  No

  N/A

• e. Storage units have solid bottoms

  Yes

  No

  N/A

6. Linen Storage

• a. Stored appropriately (in covered cart or enclosed cabinet)

  Yes

  No

  N/A

• b. Linen in hallway for distribution to patient rooms

  Yes

  No

  N/A

• 1) cart covered

  Yes

  No

  N/A

• 2) carts have solid bottoms

  Yes

  No

  N/A

7. Soiled Linen

• a. In appropriate blue bag linen hamper with lid closed (no more than 3/4 full)

  Yes

  No

  N/A

8. Refrigerator (Medication & Pt. Nourishment)

• a. Pt. food and medications stored in separate refrigerators

  Yes

  No

  N/A

• b. Pt. nourishments wrapped, dated, and labeled

  Yes

  No

  N/A

• c. Medications within expiration date, labeled

  Yes

  No

  N/A

• d. Pt. nourishments within expiration date

  Yes

  No

  N/A

• e. Refrigerator is clean/defrosted, and rubber seals are intact

  Yes

  No

  N/A

• f. No employee food in refrigerator

  Yes

  No

  N/A

9. Refrigerator Log: (Medication & Pt. Nourishment)

• a. Temperature recorded daily

  Yes

  No

  N/A

• b. If unit closed-noted per policy

  Yes

  No

  N/A

10. Ice Machines

• a. Drain, chute & exterior clean

  Yes

  No

  N/A

• b. Filter/fan exhaust clean-filter changed per policy

  Yes

  No

  N/A

11. Code Carts

• a. Clean

  Yes

  No

  N/A

• 1) storage bins free of dust

  Yes

  No

  N/A

• b. Locked

  Yes

  No

  N/A

• c. Checked daily

  Yes

  No

  N/A

• 1) noted when unit closed

  Yes

  No

  N/A

• d. Resuscitation bag/mask available

  Yes

  No

  N/A

• 1) stored in plastic dust cover

  Yes

  No

  N/A

12. Medication Carts

• a. Locked when unattended

  Yes

  No

  N/A

• b. Clean/uncluttered

  Yes

  No

  N/A

• 1) patient information on unattended cart

  Yes

  No

  N/A

• c. Free of personal items (food/drink/lipstick/etc.)

  Yes

  No

  N/A

13. Corridors

• a. Clear from equipment not immediately being used

  Yes

  No

  N/A

• b. Equipment being used is placed to one side (Pt. Care units - outside corridor)

  Yes

  No

  N/A

II. PROCEDURE/TREATMENT/EXAM ROOMS

14. Exam Rooms

• a. Rooms clean and uncluttered

  Yes

  No

  N/A

• b. Counters clear of patient care items

  Yes

  No

  N/A

• c. Linen stored in cabinets

  Yes

  No

  N/A

• d. Patient care items > 12" from sink

  Yes

  No

  N/A

III. Storage/Utility/Supply

15. Storage/Utility/Supply Room Doors Come To A Positive Latch

• a. Utility/storage/pantry/ locker rooms kept closed

  Yes

  No

  N/A

• b. Clean utility room is clean and labeled

  Yes

  No

  N/A

• c. Dirty/ Soiled utility room is clean and labeled

  Yes

  No

  N/A

16. Clean Supply/Storage/Utility Room

• a. Sterile supplies intact & within expiration date

  Yes

  No

  N/A

• b. Patient supplies & stock at least "18 from ceiling

  Yes

  No

  N/A

• c. Patient supplies & stock at least "4 off floor

  Yes

  No

  N/A

• d. Clean storage/supply/utility area free of cardboard boxes and outside shipping cases/crates (checked locked areas/closets)

  Yes

  No

  N/A

• e. Common equipment cleaned and indicated (bagged & tagged)

  Yes

  No

  N/A

• f. Floors and bins clean and free of spills/stains/dust

  Yes

  No

  N/A

IV. Medication Room

17. Medication Rooms

• a. Clean and uncluttered

  Yes

  No

  N/A

• b. Patient supplies secured away from potential for contamination (sinks, floors)

  Yes

  No

  N/A

• c. Blood glucose/flex meter stored >12" from sink

  Yes

  No

  N/A

• d. Blood glucose/flex meter strips and reagent labeled with open date

  Yes

  No

  N/A

• e. Eyewash stations labeled and log present

  Yes

  No

  N/A

V. General IP Practices/Staff Knowledge

Hand Hygiene

• a. When should you wash your hands?

  Yes

  No

  N/A

• b. Are direct patient care givers allowed to wear nail enhancers? (Observe staff to see if any are)

  Yes

  No

  N/A

• 1) Observe for gel or chipped polish

  Yes

  No

  N/A

• c. What are two reasons you would use soap and water to wash your hands?

  Yes

  No

  N/A

• d. When can you use alcohol based gel to disinfect hands?

  Yes

  No

  N/A

Isolation Patients

• a. How do you know to place your patient on transmission based precautions?

  Yes

  No

  N/A

• b. When do you use standard-plus precautions?

  Yes

  No

  N/A

• c. How are you notified that your patient has a (+) culture with an MDRO?

  Yes

  No

  N/A

• d. What is the type of isolation you place your patient in if they have an MDRO?

  Yes

  No

  N/A

• e. Is a doctor's order needed to place a patient on isolation?

  Yes

  No

  N/A

• f. When do you educate pt., family, or significant others about the process of isolation?

  Yes

  No

  N/A

• g. What tool is used when education of pt., family, and significant others?

  Yes

  No

  N/A

• h. What 3 places should you document isolation? (1. IPOC 2. Patient Educ. 3. Isolation record)

  Yes

  No

  N/A

• i. How do you know if airborne isolation room is working?

  Yes

  No

  N/A

• j. Staff can verbalize and demonstrate location of isolation signs

  Yes

  No

  N/A

• k. What type of mask is used in airborne isolation room if you are just ruling out TB?

  Yes

  No

  N/A

Infection Prevention General Knowledge

• a. List your infection prevention practitioners

  Yes

  No

  N/A

• b. What can you say about infection prevention program on your unit?

  Yes

  No

  N/A

• c. Staff can locate IP policies

  Yes

  No

  N/A

• d. Staff can explain procedure for blood/body fluid exposure

  Yes

  No

  N/A

• e. Patient care areas are free of food, drinks, cosmetics

  Yes

  No

  N/A

• f. Unit/area free of personal lotion

  Yes

  No

  N/A

• g. What are standard precautions?

  Yes

  No

  N/A

• h. When do you use standard precautions?

  Yes

  No

  N/A

• i. Where is PPE kept?

  Yes

  No

  N/A

• b. Are direct caregivers allowed to wear nail enhances? (Observe)

  Yes

  No

  N/A

VI. Low Level Disinfection Monitoring

• a. Name a piece of non-critical item, and what would you do with a piece of non-critical equipment after using on a patient and before using on another patient?

  Yes

  No

  N/A

• b. How do you know if a bedside commode is "clean" or "dirty"?

  Yes

  No

  N/A

• c. What is the process of cleaning storage cabinets?

  Yes

  No

  N/A

• d. (Observe) Are staff cleaning non-critical equipment between patients

  Yes

  No

  N/A

• e. Can you tell me how equipment is cleaned that goes in and out of a patients room that is in isolation? (Also see if there is dedicated patient care equipment is being used)

  Yes

  No

  N/A

• g. Disinfectant contact time

  Yes

  No

  N/A

VII. Environmental Services

• a. General housekeeping closet in order, room/area neat

  Yes

  No

  N/A

• b. Housekeeping equipment clean & in good working condition

  Yes

  No

  N/A

• c. Cleaning supplies properly labeled & stored, closet clean & free of clutter

  Yes

  No

  N/A

• d. Floors clean, free of debris/spills

  Yes

  No

  N/A

• e. Goggles available for chemical admixture

  Yes

  No

  N/A

• f. Trash containers empty

  Yes

  No

  N/A

• g. Plastic liners in all waste containers

  Yes

  No

  N/A

• h. Hazardous waste properly handled

  Yes

  No

  N/A

• i. Furniture/appliances soil free

  Yes

  No

  N/A

• j. Curtains/drapes properly hung & clean

  Yes

  No

  N/A

• k. Mattresses are intact and clean

  Yes

  No

  N/A

• l. Walls free of spots and soil

  Yes

  No

  N/A

• m. Vents are dust free

  Yes

  No

  N/A

• n. No evidence of "high" dust

  Yes

  No

  N/A

VIII. Pt. Rooms

• a. Pt. room clean (bedside table, floor, uncluttered with linen, linen bags and trash < 3/4 full)

  Yes

  No

  N/A

Misc. Items

• a. Misc. Items of Concern

  Yes

  No

  N/A