Bed / Rails / 2 Pillows / Linen / Privacy Curtain meet standards? Tape Residue removed?

2. Over bed table / bedside Table / nurse call / Telephone / Cords clean and Organized? Tape / Residue removed?

3. Dusting: Vents / Over Bed Lights / Ceiling Lights / Pictures / Ledges Clean?

4. Television / Information Board clean?

5. Trash Cans / Bio-Hazardous Waste Receptacles Labeled?

6. Sharps Container < 3/4 Full?

7. Patient Chair and Visitor Chair Clean and in Place? Sleep Chair cleaned? Isolate / Bassinette Cleaned?

8. HC Cart Keyboard / Scanner / Mouse / Monitor / Cart Surface /Wheels Cleaned? (If In The Room During Cleaning)

9. Linen Hamper Empty and Cleaned? " Soiled Linen Only " Sign Present?

10. Isolation Room Signs Removed, and Returned? (Discharged Only)


11. Toilet Bowl /Flush Handle /Seat / Bedpan Cleaner / Grab Bars Clean? Chemicals Flushed?

12. Shower Clean and Free of Mildew? Shower doors/Curtain Clean?

13. Sink / Mirror / Vents / Light Switch & Door Handle Meet Standards?

14. Floor Thoroughly Clean? No Debris? Corners Clean? Behind & Under Toilet Clean?

15. Commode Cleaned and in Shower?

16. Toilet Paper, Paper Towels and Soap Adequate?


17. I'VE Pole clean? Cables Clean?
Cables Clean? Cords Neatly Secured?

18. Bed Plugged into Specified Bed Power Outlet? Communication Cable Plugged In?

19. Bed Pump & Cords Clean?
Cords Neatly Secured?

20. Compression Pump & Cords Clean?
Cords Neatly Secured?

21. Employee Able to Demonstrate High-Touch Points? (e g light switches, phone , bed rails, handles, etc)

23. Personal Items Removed? Left Over Nursing Supplies Removed? Closet Empty & Clean?

24. Window Blinds Clean? Room & Overbed lights Turned Off?

Patient knows who their housekeeper for the day is?

26. EVS Service Placard on Table?



28. Employee Utilizing Proper Linen handling Procedures.

29. Employee Can Articulate What to do if Full Linen is Found?
(I.e. ask for help, break down load)

30. Employee States they have Stretched at the beginning and During their shift.

31. Employee Utilizing Proper PPE.

(# yes & NA / 27) x 100 / = % (Acceptable cleaning is > 90%)

Individual teaching provided to employee, DATE__________________________________________
In service needed for department DATE__________________________________________
Share at upcoming huddle. DATE__________________________________________
Revive or revise policy & procedure. DATE__________________________________________

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.