Title Page
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Riceland Medical Center
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Conducted on
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Prepared by C.Pate RN
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Location
Rounds
ER Department & Rooms:
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Appropriate sign(s) posted, including EMTALA signage
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Floors & walls clean
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Walls are free of breaks and penetrations
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Bathroom clean
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Sink Clean
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Furniture clean and in good condition
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Windows and windowsills clean
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Irrigation & sterile solutions labeled as per policy
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Peripheral IVs, CVC, arterial lines labeled as per policy
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Foley catheters hanging appropriately
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IV pumps, feeding pumps, etc. clean (while in use)
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Gloves, PPE, available as per policy
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Barriers used appropriately
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Cubicle curtains clean and free of tears, etc.
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Other Issues and/or Problems:
NURSING FLOOR ROOMS:
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Floors & walls clean
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Walls are free of breaks and penetrations
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Bathrooms clean
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Sinks Clean
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Furniture clean and in good condition
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Windows and windowsills clean
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Irrigation & sterile solutions labeled as per policy
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Peripheral IVs, CVC, arterial lines labeled as per policy
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Foley catheters hanging appropriately
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IV pumps, feeding pumps, etc. clean (while in use)
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Gloves, PPE, available as per policy
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Barriers used appropriately
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Cubicle curtains clean and free of tears, etc.
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Other Issues and/or Problems:
Isolation Rooms:
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Isolation equipment available
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PPE available
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Doors of Isolation patients closed as appropriate
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Negative pressure being supplied (305)
- Compliant
- Non-Compliant
- N/A
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Patients are instructed on isolation requirements
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Patient with proper attire when being transported
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Other Issues and/or Problems
Clinic (Treatment & Examination Rooms):
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Floors & walls clean
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Countertops clean
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Exam tables clean
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Furniture clean and in good condition
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Other Issues and/or Problems
Utility & Storage Rooms:
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Adequate separation of clean & soiled
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Floors & walls clean
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No supplies stored 6" from floor
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Supplies stored 18" from ceiling
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No supplies stored under sinks
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No supplies stored in bathrooms, soiled utility rooms
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Supplies stored away from windows, vents
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Shelving/ drawers/ cabinets clean
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Patient supplies within expiration dates
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Sterilized trays free of dust, unopened, free of tears
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Event-related sterile items labeled appropriately
Soiled Utility Rooms:
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Floors and walls clean
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Area is free of patient supplies and sterilized trays
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Soiled linen is bagged & placed in storage shed outside the back door
Hallways:
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Floors and walls are clean
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Free of obstruction and equipment
Equipment & Non-Critical Items:
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Equipment in patient use is clean
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Equipment stored is clean
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Equipment handled as per policy
Linen:
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Clean linen is distributed to units on clean, covered carts
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Separation of clean & soiled linen
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Clean linen stored in required area, on shelves or carts
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Soiled linen is not placed on the floor, furniture, windowsills, etc.
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Soiled linen is collected per policy
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Soiled linen is contained in bags, not overfilled
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Linen hampers & carts are covered
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Linen hampers & carts are clean and in good condition
Offices, Work Stations, & Reception Areas:
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Carpeting Clean
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Desks clean and free from unnecessary clutter & food items
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Office equipment clean & free from clutter
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Floors free of clutter & trash
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Food only in designated areas
Meeting Areas:
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Empty cups & food items placed in trash
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Furniture clean & in good condition
Waiting Areas & Staff Lounges:
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Furniture clean & in good condition
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Empty cups & food items placed in trash
Waste Management:
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Waste containers not overfilled
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Waste containers clean, operational, & in good condition
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Waste containers covered as required
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Containers located appropriately
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Appropriate number of containers available
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Containers labeled as required
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Red bag available in each regulated medical waste container
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Regulated medical waste discarded appropriately
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Items in regulated medical containers are appropriate
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Sharps containers available
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Sharps containers not overfilled
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Sharps containers secured appropriately
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Sharps appropriately discarded
Other Housekeeping Issues
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Handwashing sink is available
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Hand towels are available
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Hand towel dispenser available/ operable
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Handwashing solution available
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Soap is appropriate for area/ unit
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Handwashing solution dispenser available/ operable
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Alcohol Based Hand Sanitizer available to the staff
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No bar soap
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Area free of roaches, flies, mice, & other vermin
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Blood spill kits available
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Tubs/ showers are clean
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Vent grills are clean
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High-level dusting performed
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Porter's closet clean
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Housekeeping staff aware of cleaning solution admixing policy
Kitchen:
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Floors & walls clean
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No expired juice/ milk, etc.
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Ice Machine clean
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Microwave clean
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Storage closet clean and organized
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Large open area under 3 compartment sink is clean with no holes
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Freezers with labeled food
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Dry goods with labeled food
Refrigerators:
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Daily checklist completed for temperatures
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Correct temp observed: Food & drink, 36-45 degrees F
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Correct temp observed: Medications, 36-46 degrees F
- Compliant
- Non-Compliant
- N/A
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Correct temp observed: Specimens, 36-46 degrees F
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Correct temp observed: Blood, 34-43 degrees F
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Correct temp observed: Freezers, > or equal to 32 degrees F
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Only medications in medication refrigerator
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Only food in food refrigerator
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Only specimens in specimen refrigerator
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Patient food & staff food not mixed
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Refrigerators clean
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Items labeled as per policy
Medications:
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No outdated IV solution or medications
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Open vials dated and timed as per policy
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Medication carts clean and organized
Miscellaneous:
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Handwashing observed when appropriate
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Ceiling tiles are clean and in good condition
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Ceiling is free of holes and penetrations
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Disaster, evacuation, fire, infection control, & MSDS documents are available
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Storage closets and shelves area clean
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Sinks are clean
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Free of leaks or spills
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Specimens are being bagged, handled, and labeled as per policy
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Safety devices available
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Safety devices used appropriately
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Appropriate patient/ visitor signage up and visible
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Other Issues and/or Problems:
Grounds:
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Clean & free of trash
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Building walls free of penetrations
Disinfection
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Appropriate solutions available for soaking
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Appropriate containers available
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Containers clean, covered, labeled as required
Survey Readiness
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Pharmacy locked when pharmacy staff not available
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Review Fire Drill results and ensure drills are current 1/ shift/ qtr
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Review dietary logs to ensure that high risk patients are seen by Dietician
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Review glucometer logs for completion
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Review crash cart check signatures
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Fall patients with demonstrative identification (signage, etc)
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Linen storage room: clean with no other furniture etc in room
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Housekeeping closet in Outpatient area is clean
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Secondary CS room is clean with no boxes on the floor
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Respiratory equipment storage in appropriate room storage
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CORRECTIVE ACTIONS:
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REPORT SENT TO:
SIGNATURES:
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Risk/ Quality Manager
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Assistant Administrator
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Infection Control Nurse
