Patient Room Audit

• Document No.

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Infection Prevention and Control Related

• Approved alcohol hand sanitizer not expired

  Compliant

  Non-Compliant

  N/A

• No patient care items are stored in the patient room

  Compliant

  Non-Compliant

  N/A

• Curtains are clean and in good shape

  Compliant

  Non-Compliant

  N/A

• No one time use equipment open in room

  Compliant

  Non-Compliant

  N/A

• Only clean equipment in patient room

  Compliant

  Non-Compliant

  N/A

• No used supplies

  Compliant

  Non-Compliant

  N/A

• Gloves are available in patient room

  Compliant

  Non-Compliant

  N/A

• Are all rooms with specific air pressurization requirements correct?

  Compliant

  Non-Compliant

  N/A

• Staff knows location, operation and procedures for airborne isolation rooms

  Compliant

  Non-Compliant

  N/A

General Cleanliness/Housekeeping

• Floors, walls, vents and light fixtures are clean

  Compliant

  Non-Compliant

  N/A

• Cabinets are empty and clean

  Compliant

  Non-Compliant

  N/A

• Shower curtains are clean

  Compliant

  Non-Compliant

  N/A

• Toilets are clean (top, back, floors)

  Compliant

  Non-Compliant

  N/A

• No hair/debris visible on drain

  Compliant

  Non-Compliant

  N/A

• Linens are clean and free of tears

  Compliant

  Non-Compliant

  N/A

• Bed handrails, tray, head and foot board are clean

  Compliant

  Non-Compliant

  N/A

• Exterior windows are clean

  Compliant

  Non-Compliant

  N/A

• Area/equipment is dust free, high and low level areas

  Compliant

  Non-Compliant

  N/A

• Appropriate waste liners

  Compliant

  Non-Compliant

  N/A

• Appropriate soap in patient rooms (2% chg w/out lotion)

  Compliant

  Non-Compliant

  N/A

• There are no visible insects

  Compliant

  Non-Compliant

  N/A

• Any foul oders

  Compliant

  Non-Compliant

  N/A

• No taped signs or tape from previous patients

  Compliant

  Non-Compliant

  N/A

General Safety

• Sharps containers are secured

  Compliant

  Non-Compliant

  N/A

• Sharp containers are less than 3/4 full

  Compliant

  Non-Compliant

  N/A

• Nothing stored above/on top of sharp containers

  Compliant

  Non-Compliant

  N/A

• Are any tripping/slipping hazards present?

  Compliant

  Non-Compliant

  N/A

• Nurse call cords are fully accessible and not tied up or touching floor

  Compliant

  Non-Compliant

  N/A

Utilities / Life Safety

• Ceiling tiles are in place, free from stains, cracks, and holes

  Compliant

  Non-Compliant

  N/A

• Floors and walls in good condition

  Compliant

  Non-Compliant

  N/A

• Curtains are clean and have open mesh tip

  Compliant

  Non-Compliant

  N/A

• Floors are clean with no visible markings

  Compliant

  Non-Compliant

  N/A

• All light fixtures have working bulbs

  Compliant

  Non-Compliant

  N/A

• No plumbing issues (dripping faucet)

  Compliant

  Non-Compliant

  N/A

• Temperature is maintained and comfortable

  Compliant

  Non-Compliant

  N/A

• Supply and return grilles are clean and free of dust

  Compliant

  Non-Compliant

  N/A

Miscellaneous

• Appropriate type and amount of furniture and waste receptacles in patient room

  Compliant

  Non-Compliant

  N/A

• Furniture is not stained or in poor condition

  Compliant

  Non-Compliant

  N/A

• TV is working properly

  Compliant

  Non-Compliant

  N/A

• Nurse call bed remote is clean and works properly

  Compliant

  Non-Compliant

  N/A

• Patient lift equipment and slings are readily available

  Compliant

  Non-Compliant

  N/A

• Patient equipment inspection updated and labeled with correct sticker

  Compliant

  Non-Compliant

  N/A

Additional Information

• Auditor

  Sign