• Document No.

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Infection Prevention and Control Related

  • Approved alcohol hand sanitizer not expired

  • No patient care items are stored in the patient room

  • Curtains are clean and in good shape

  • No one time use equipment open in room

  • Only clean equipment in patient room

  • No used supplies

  • Gloves are available in patient room

  • Are all rooms with specific air pressurization requirements correct?

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

General Cleanliness/Housekeeping

  • Floors, walls, vents and light fixtures are clean

  • Cabinets are empty and clean

  • Shower curtains are clean

  • Toilets are clean (top, back, floors)

  • No hair/debris visible on drain

  • Linens are clean and free of tears

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

  • Exterior windows are clean

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

  • Appropriate waste liners

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

  • There are no visible insects

  • Any foul oders

  • No taped signs or tape from previous patients

General Safety

  • Sharps containers are secured

  • Sharp containers are less than 3/4 full

  • Nothing stored above/on top of sharp containers

  • Are any tripping/slipping hazards present?

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

Utilities / Life Safety

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

  • Floors and walls in good condition

  • Curtains are clean and have open mesh tip

  • Floors are clean with no visible markings

  • All light fixtures have working bulbs

  • No plumbing issues (dripping faucet)

  • Temperature is maintained and comfortable

  • Supply and return grilles are clean and free of dust


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

  • Furniture is not stained or in poor condition

  • TV is working properly

  • Nurse call bed remote is clean and works properly

  • Patient lift equipment and slings are readily available

  • Patient equipment inspection updated and labeled with correct sticker

Additional Information

  • Auditor

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.