Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

CLEANING OBSERVATIONS

  • 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)

BATHROOM

  • 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?

EQUIPMENR OBSERVATION

  • 17. I'VE Pole clean? Cables Clean? <br>Cables Clean? Cords Neatly Secured?

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

  • 19. Bed Pump & Cords Clean?<br>Cords Neatly Secured?

  • 20. Compression Pump & Cords Clean? <br> 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?

  • 25. "RIGHT WORDS AT THE RIGHT TIME" Observed? <br> Patient knows who their housekeeper for the day is?

  • 26. EVS Service Placard on Table?

  • 27.

SAFETY OBSERVATION

  • 28. Employee Utilizing Proper Linen handling Procedures.

  • 29. Employee Can Articulate What to do if Full Linen is Found? <br>(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%)

FOLLOW UP ACTION

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

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