Title Page

Skilled Nursing Facility Infection Prevention & Control Observation Rounds

  • Name of Facility:

  • Conducted on

  • OBSERVER IP:

  • UCLA Health System

  • Other members of IP Team present:

    NURSING

GENERAL UNIT OBSERVATION

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

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

  • AIR VENT: Rm #1

  • Paper towels are available at all sinks

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

  • 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.)

  • Soap and Lotion dispensers are filled and functional

  • Taped posters/fliers on the wall are laminated

  • Rooms are maintained CLOSED and not propped open

  • Biohazard Room

  • Clean Utility Room

  • EVS Closet

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

  • Area that needs dusting

  • Area that needs dusting

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

  • Orgqnization - approved disinfectants are available and accessible

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

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

EQUIPMENT

  • IV Poles are CLEAN.

  • Weighing Scale is CLEAN.<br>

  • Lift Equipment is CLEAN

  • Computers / Computer Keyboards are CLEAN.

  • CRASH CART is CLEAN

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

  • Isolation Cart is CLEAN

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

CLEAN UTILITY/ SUPPLY ROOM

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

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

  • All equipment in the room are clean

  • Supplies are 10" above the floor

  • Supplies are 18" below the ceiling

  • All items are within their expiration dates (no outdated items)

DIRTY UTILITY/ BIOHAZARD ROOM

  • Only DIRTY supplies and equipment are in the room

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

  • Full sharps containers are closed and locked

  • Open sharps container is less than 2/3 full

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

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

  • Chemo waste placed in yellow container with liner,

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

  • Broken glass (BLACK) container identified, where applicable

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

ISOLATION ROOM/S

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

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

  • PPE available and accessible

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

  • 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.

OCCUPIED PATIENT ROOMS. Indicate Rm #

  • Overall appearance: CLEAN, NEAT & FREE OF CLUTTER

  • Hand Hygiene supplies readily available and accessible

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

  • Privacy curtain clean (if applicable)

  • Shower curtain is clean (if applicable)

  • Shower Stall / Tub clean (if applicable)

SHOWER ROOM / TUB ROOM

  • Shower stall / tub is CLEAN

  • Shower curtain is not visibly soiled

  • There are no visible evidences of mold growth

UNOCCUPIED PATIENT ROOM. Indicate the Rm #

  • Overall appearance: CLEAN, NEAT & FREE OF CLUTTER

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

  • Shower curtain is clean (if applicable)

  • Shower Stall / Tub clean (if applicable)

  • Privacy curtain clean (if applicable)

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

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

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

  • Linens/Pillows on the floor

  • Linen Room is kept closed at all times

  • Linens/pillows are kept 10" above the floor

  • Bottom shelf of linen carts have splash guards

  • Linens/pillows are 18" below the ceiling

CUSTODIAN / EVS CLOSET

  • Door kept locked at all times

  • Mop sitting in water (Desired answer is NO)

  • EVS cart with equipment and chemicals is kept locked

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

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

PROCESS OBSERVATIONS

  • Patient Care Team performing hand hygiene upon room ENTRY

  • Patient Care Team performing hand hygiene upon room ENTRY

  • Patient Care Team performing hand hygiene upon room EXIT

  • Patient Care Team performing hand hygiene upon room EXIT

  • Patient Care Team wearing appropriate PPE in an isolation room

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

CATHETER ASSOCIATED UTI PREVENTION

  • No dependent loops or kinks observed

  • Urinary bag not touching the floor.

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

  • Indication for urinary catheter reviewed and documented for the day

CENTRAL LINE ASSOCIATED - BSI PREVENTION

  • CVC dressing appears CLEAN, DRY & INTACT

  • CVC dressing changed according to organization's policy

  • Indication for CVC reviewed and documented for the day

ADDITIONAL COMMENTS

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

  • COMMENT #2: Does it need follow up?

  • COMMENT #3: Does it need follow up?

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