Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

DATE & NAME

  • DATE:

  • NAME:

  • FLOOR:

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. IV 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.

  • 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__________________________________________

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.