UCLA Health Clinical Epidemiology and Infection Prevention v072016: SKILLED NURSING FACILITY

Skilled Nursing Facility Infection Prevention & Control Observation Rounds

• Name of Facility:

• Initial Site Visit

  Follow Up Site Visit

• Conducted on

  Date

• OBSERVER IP:

• UCLA Health System

  UCLA Santa Monica Medical Center & Orthopaedic Hospital

  Ronald Reagan UCLA Medical Center

• Other members of IP Team present:

NURSING

GENERAL UNIT OBSERVATION

• Overall appearance: HALLWAYs ARE CLEAN, NEAT & FREE OF CLUTTER

  CLEAN & NEAT

  DIRTY

  CLUTTERED

• Air vents are CLEAN. Indicate 2 rooms to be inspected. If DIRTY, attach a photo.

• AIR VENT: Rm #1

  Yes

  No

  N/A

• Paper towels are available at all sinks

  Yes

  No

  N/A

• Alcohol-Based Hand Rub (ABHR) dispensers are filled and functional

  Yes

  No

  N/A

• Are there any boxes out in the hallway in direct contact with the floor? (Desired answer is NO). If boxes are noted, attach a photo.)

  YES

  NO

• Soap and Lotion dispensers are filled and functional

  Yes

  No

  N/A

• Taped posters/fliers on the wall are laminated

  Yes

  No

  N/A

• Rooms are maintained CLOSED and not propped open

• Biohazard Room

  Yes

  No

  N/A

• Clean Utility Room

  Yes

  No

  N/A

• EVS Closet

  Yes

  No

  N/A

• High / Low Dusting Done (Indicate below areas that need dusting)

  Yes

  No

  N/A

• Area that needs dusting

• Area that needs dusting

• Floor CLEAN, POLISHED & FREE OF CLUTTER. If noted otherwise, attach a photo

  Yes

  No

  N/A

• Orgqnization - approved disinfectants are available and accessible

  Yes

  No

  N/A

• Patient Care Team Member observed eating or drinking in areas other than the lounge.

  Select NO Physician Department Staff (RN, CP) Ancillary

  • NO
  • Physician
  • Department Staff (RN, CP)
  • Ancillary

• Food / Beverages observed in the unit (other than the lounge)

  YES

  NO

EQUIPMENT

• IV Poles are CLEAN.

  Yes

  No

  N/A

• Weighing Scale is CLEAN.<br>

  Yes

  No

  N/A

• Lift Equipment is CLEAN

  Yes

  No

  N/A

• Computers / Computer Keyboards are CLEAN.

  Yes

  No

  N/A

• CRASH CART is CLEAN

  Yes

  No

  N/A

• Toy / Activity Supplies Cart is CLEAN (if applicable)

  Yes

  No

  N/A

• Isolation Cart is CLEAN

  Yes

  No

  N/A

• Patient Medication Refrigerator overall appearance: CLEAN. (if applicable)

  Yes

  No

  N/A

CLEAN UTILITY/ SUPPLY ROOM

• Overall appearance: CLEAN & NOT OVERSTOCKED. If noted otherwise, attach a photo.

  Yes

  No

  N/A

• Boxes of items/supplies in direct contact with the floor. (Desired answer is NO)

  YES

  NO

• All equipment in the room are clean

  Yes

  No

  N/A

• Supplies are 10" above the floor

  Yes

  No

  N/A

• Supplies are 18" below the ceiling

  Yes

  No

  N/A

• All items are within their expiration dates (no outdated items)

  Yes

  No

  N/A

DIRTY UTILITY/ BIOHAZARD ROOM

• Only DIRTY supplies and equipment are in the room

  Yes

  No

  N/A

• Needles & sharps are all disposed safely inside the sharps container

  Yes

  No

  N/A

• Full sharps containers are closed and locked

  Yes

  No

  N/A

• Open sharps container is less than 2/3 full

  Yes

  No

  N/A

• Trash bins/ barrels/carts not overflowing with trash. (Desired answer is NO) If observed otherwise, attach photo

  YES

  NO

• Trash bins/ barrels/ carts are clean and covered.

  Yes

  No

  N/A

• Chemo waste placed in yellow container with liner,

  Yes

  No

  N/A

• Infectious (RED BAG) waste container is clean & covered. <br>(Only items "dripping" in blood or bodily fluids in the container)

  Yes

  No

  N/A

• Broken glass (BLACK) container identified, where applicable

  Yes

  No

  N/A

• Hand Washing sink nearby with filled and functional soap dispenser.

  Yes

  No

  N/A

ISOLATION ROOM/S

• Appropriate Isolation Precaution sign posted. Indicate Rm # & Required Isolation

  Yes

  No

  N/A

• Hand Hygiene supplies (ABHR / soap & water) readily available

  Yes

  No

  N/A

• PPE available and accessible

  Yes

  No

  N/A

• Door is kept closed at all times for Airborne Isolation Precautions

  Yes

  No

  N/A

• Isolation Carts / Supply Box ONLY have isolation precaution supplies inside which may include Unused Protective Eye Wear and Disposable Stethoscopes. If observed otherwise, attach photo.

  Yes

  No

  N/A

OCCUPIED PATIENT ROOMS. Indicate Rm #

• Overall appearance: CLEAN, NEAT & FREE OF CLUTTER

  CLEAN & NEAT

  DIRTY

  CLUTTERED

• Hand Hygiene supplies readily available and accessible

  Yes

  No

  N/A

• High Dusting NOT needed. If observe otherwise, Indicate areas needing high dusting and attach a photo.

  Yes

  No

  N/A

• Privacy curtain clean (if applicable)

  Yes

  No

  N/A

• Shower curtain is clean (if applicable)

  Yes

  No

  N/A

• Shower Stall / Tub clean (if applicable)

  Yes

  No

  N/A

SHOWER ROOM / TUB ROOM

• Shower stall / tub is CLEAN

  Yes

  No

  N/A

• Shower curtain is not visibly soiled

  Yes

  No

  N/A

• There are no visible evidences of mold growth

  Yes

  No

  N/A

UNOCCUPIED PATIENT ROOM. Indicate the Rm #

• Overall appearance: CLEAN, NEAT & FREE OF CLUTTER

  CLEAN & NEAT

  DIRTY

  CLUTTERED

• High Dusting NOT needed. If observe otherwise, Indicate areas needing high dusting and attach a photo.

  YES

  NO

• Shower curtain is clean (if applicable)

  Yes

  No

  N/A

• Shower Stall / Tub clean (if applicable)

  Yes

  No

  N/A

• Privacy curtain clean (if applicable)

  Yes

  No

  N/A

LINEN ROOM/ CARTS (If separate from the Clean Utility/ Supply Room)

• Overall all appearance: CLEAN, NEAT & FREE OF CLUTTER

  Yes

  No

  N/A

• Linen at the bottom shelf is hanging out. (Desired answer is NO) If observed otherwise, attach photo

  YES

  NO

• Linens/Pillows on the floor

  YES

  NO

• Linen Room is kept closed at all times

  Yes

  No

  N/A

• Linens/pillows are kept 10" above the floor

  Yes

  No

  N/A

• Bottom shelf of linen carts have splash guards

  Yes

  No

  N/A

• Linens/pillows are 18" below the ceiling

  Yes

  No

  N/A

CUSTODIAN / EVS CLOSET

• Door kept locked at all times

  Yes

  No

  N/A

• Mop sitting in water (Desired answer is NO)

  YES

  NO

• EVS cart with equipment and chemicals is kept locked

  Yes

  No

  N/A

• Personal belongings inside the EVS closet (Desired answer is NO)

  YES

  NO

• Food & Beverage in the EVS closet (Desired answer is NO)

  YES

  NO

PROCESS OBSERVATIONS

• Patient Care Team performing hand hygiene upon room ENTRY

  Yes

  No

  N/A

• Patient Care Team performing hand hygiene upon room ENTRY

  Yes

  No

  N/A

• Patient Care Team performing hand hygiene upon room EXIT

  Yes

  No

  N/A

• Patient Care Team performing hand hygiene upon room EXIT

  Yes

  No

  N/A

• Patient Care Team wearing appropriate PPE in an isolation room

  Yes

  No

  N/A

• Cleaning & Disinfection of noncritical equipment using hospital approved disinfectants in between patient care

  Yes

  No

  N/A

CATHETER ASSOCIATED UTI PREVENTION

• No dependent loops or kinks observed

  Yes

  No

  N/A

• Urinary bag not touching the floor.

  Yes

  No

  N/A

• Urinary bag not overfilled (not more than 2/3 of the bag full)

  Yes

  No

  N/A

• Indication for urinary catheter reviewed and documented for the day

  Yes

  No

  N/A

CENTRAL LINE ASSOCIATED - BSI PREVENTION

• CVC dressing appears CLEAN, DRY & INTACT

  Yes

  No

  N/A

• CVC dressing changed according to organization's policy

  Yes

  No

  N/A

• Indication for CVC reviewed and documented for the day

  Yes

  No

  N/A

ADDITIONAL COMMENTS

• COMMENT #1: Does it need follow up?<br>

  YES

  NO

• COMMENT #2: Does it need follow up?

  Yes

  No

  N/A

• COMMENT #3: Does it need follow up?

  Yes

  No

  N/A