Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Nursing Station
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1. Clean and free of clutter
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2. No food present, only drinks with a lid.
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3. No patient care supplies left open on tables.
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4. Trash is not overflowing.
Preop-PACU
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1. Area/hallways are not cluttered.
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2. Handwashing supplies are available.
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3. Alcohol hand-rubs are available near patient rooms/in patient rooms and other areas as needed.
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4. Hand Hygiene is monitored for staff compliance.
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5. PPE supplies are available and are being used appropriately.
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6. Trash and linens handled per policy.
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7. No stained ceiling tiles.
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8. Patient care equipment cleaned/disinfected according to policy/company recommendations.
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9. Daily temperatures checks are documented appropriately for refrigerators.
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10. Fluid warming cabinets temperatures checked daily and are documented correctly. (Temp. not to exceed 140°F)
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11. No fluids kept if they are not in their original package.
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12. Sharps containers no more than 3/4 full.
General Infection Prevention
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1. All sterile supplies are dry with intact packaging at least 8" about the floor and 2" away for exterior walls.
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2. Staff has access to and are familiar with the MDRO list
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3. No out of date equipment/supplies present
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4. Humidity logs are filled out daily and are within normal range.
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5. Surgical EVS personnel terminally cleans all OR rooms at the end of the day.
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6. OR staff performs damp dusting in the morning before the first case of the day.
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7. OR staff performs case turnover cleaning in between cases.
Surgical attire
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1. Staff changed into scrubs at the hospital and are wearing clean surgical attire when entering a semi-restricted/ restricted areas.
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2. All hair is covered when entering a semi-restricted/ restricted area.
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3. Beards covered when entering restricted areas.
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4. Head coverings are disposable or are laundered by the facility.
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5. No visible jewelry worn by scrubbed staff.
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6. Mask is worn in the presence of open sterile items and equipment.
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7. Dedicated shoes or shoe covers are worn.
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8. Shoe covers worn as PPE removed and discarded immediately after use.
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9. Scrub Attire is launder after each daily use.
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10. Surgical attire removed before leaving the facility.
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11. Identification badges cleaned with low-level disinfectants.
Surgical Scrubbing
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1. Scrub is performed according to manufacturer's directions and aseptic technique.
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2. Scrubbed personnel do not contaminate themselves while gowning and gloving.
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3. Keeps hands and arms above waist level at all times.
Skin Prep
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1. Patient's received theraworx bath wipes.
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2. Hair is removed using clippers.
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3. Skin prep is performed according to manufacturer's direction.
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4. Sufficient drying time is allowed prior to draping.
Sterile Technique
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1. Sterile field is prepared close to time of surgery (<1hour)
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2. Sterile items are transported in covered/enclosed cases/carts
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3. Sterile packages are inspected for punctures, tears, and expiration dates.
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4. Draping is performed by at least 2 people and drapes are not lifted or moved after placement.
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5. Flash sterilization is only done in emergency situations.
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6. Counts are done accordingly.
Endoscopes
Storage
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1. Flexible Endoscopes are placed in a drying cabinet or a storage cabinet.
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2. Endoscopes are hung up and do not touch the wall or floor of cabinet.
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3. All removeable parts are detached but stored with the endoscope.
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4. Clean gloves are worn when transporting the endoscope to and from the storage cabinet.
Precleaning
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1. Precleaning being performed at the point of use using a fresh cleaning solution.
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2. Exterior surface of endoscope is cleaned and suction is used through the suction and biopsy channels.
Transporting
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1. Contaminated endoscope are transferred to the decontamination room as soon as possible.
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2. Endoscopes are kept moist but not submerged.
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3. A container or cart that is leak proof, puncture resistant, and large enough to contain all contents with the endoscope coiled in large loops.
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4. The cart or container is marked with a biohazard legend.
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5. There is a record of when the procedure is completed and when cleaning is initiated.
EOC
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1. All cylinders (oxygen, other compressed gas) are secured
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2. Empty oxygen tanks are kept separate from full oxygen tanks
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3. Fire extinguisher not obstructed from easy access
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4. No electrical panels are blocked
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5. Hospital furnishings/equipment are kept in good repair (No torn or soiled furniture, wheelchairs, mattresses)
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6. Countertops/doors are in good condition with no chipping to laminate
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7. No supplies stored under sinks
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8. Paper is not present on fire-rated doors
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9. Maintains the integrity of egress throughout the unit
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10. No space heaters present in patient care areas
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11. There is at least 18" of open space maintained below a sprinkler deflector to the top of storage
