Title Page

  • Conducted on

  • Prepared by

  • Location

STANDARD PRECAUTIONS

  • Proper PPE use (gloves, mask, gown, etc)?

  • Personal Hygiene no artificial nails, hair pulled back, jewelry appropriate)?

  • STAFF KNOWLEDGE CHECK-What is the process if BBP exposure (splash, needlestick) occurs? (1-STIX/OHS)?

ISOLATION

  • Review Isolation list/Possible SSI's with charge RN or Resource RN

  • Isolation Signage/PPE/MD order in EPIC align and correctly applied?

  • Staff wearing PPE? (tally mark if multiple observations done)

  • How many observations performed while in unit?

  • Families and visitors wearing appropriate isolation PPE?

  • STAFF KNOWLEDGE CHECK: Ambulating patient on isolation?

  • STAFF KNOWLEDGE CHECK: Family/visitor PPE requirements?

PREVENTION BUNDLES

  • Conduct one visual bundle round (CLABSI, CAUTI, Ventilator, SSI)

HAND HYGIENE

  • 1 Hand Hygiene Observation

  • 1 Hand Hygiene Coaching

ENVIRONMENTAL CLEANLINESS

  • CLEAN and DIRTY items clearly separated?

  • NO food or drink outside of approved designated areas; hydration stations identified and utilized?

  • Nutrition room has labeled, non-expired foods in the refrigerator?

  • Nutrition room has no staff or family food stored in refrigerator?<br>

  • Human milk room has appropriate PPE and disinfectant wipes available for use?

  • Staff using PPE and disinfectants appropriately while entering/exiting human milk room?

  • Soiled Utility Room check (waste stream, soiled instrument process)?

  • STAFF KNOWLEDGE CHECK-How do you know this equipment has been cleaned and it is safe to use?

  • STAFF KNOWLEDGE CHECK-How often do you clean high touch areas?

  • STAFF KNOWLEDGE CHECK-Can staff identify high touch areas?

  • STAFF KNOWLEDGE CHECK-Contact time Purple Sani-wipes (2 min) and Clorox bleach disinfectant wipes (3 min)?

ENVIRONMENTAL CLEANING CHECK: ATP

  • Patient Room

  • Room #
  • Isolation Room?

  • Swab #/Location

  • Location
  • RUL?

  • Re-test RUL?

ADDITIONAL FINDINGS

  • Add media

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