Information
UCLA SMH Infection Prevention Audit - Medical Procedural Areas
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Location
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Conducted on
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Prepared by
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Personnel Attending the Rounds:
General Infection Control Practices & Safety
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Staff can locate Infection Prevention Policies
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Staff can articulate and locate the Bloodborne Pathogen Exposure Policy
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Staff can locate the SDS
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Appropriate PPE available
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Staff is observed using PPE appropriately
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PPE is disposed at point of use
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Sinks properly located and functioning
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Hand washing sinks are stocked with paper towels, soap
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Alcohol-based Hand Sanitizer available
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Hand Hygiene before and after patient care
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Hospital approved hand lotion is available
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Hospital approved disinfectant is available
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No artificial nails/products worn by direct patient care staff
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No staff food, drinks, cosmetics, applying of contact lenses, use of personal lotions, or storing of personal items in patient care areas
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Staff correctly observe isolation precautions posted for patients
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Single use items (scissors, tweezers) not re-used
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Enzymatic cleaner available in each PR
Cleaning
No high dust present
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Scope cabinets are clean and dust free
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Supply Cabinets are clean and dust/rust free
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Air Vents/ Air supply grills are clean and dust free
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Equipment is cleaned according to manufacturer's recommendations
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Equipment is with current inspection stickers
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All appliances for prep/storage of medications are visibly clean
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No tape residue on equipment or on table
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No tape residue anywhere in the procedure room
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Anesthesia cart is clean. All drawers free of dust and clutter.
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All other carts in the PR: clean and no tape residues on the inside. All drawers are free of dust and clutter.
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PR suite properly stocked without clutter
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Patient table clean, no dirt, bodily fluids, rust... found when broken down
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Wheels, furniture, lights clean (no rusty wheels)
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Door handles are clean
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All other surfaces free of dust and debris
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Ceiling tiles are in place, dry and free from stains, cracks, and holes
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Hallways are clean and free of clutter
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Walls free of breaks and penetrations, tape residue, dried bodily fluids
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PR is cleaned between patients and at the end of the day per policy
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Mattresses /cushions are clean with no holes / cracks / tears
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EVS closet (if applicable) is clean, organized and secure
Storage
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Clean utility room is clean and organized
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Items are stored in a manner that will not compromise sterility (compressed, crushed, susceptible to tears, away from sources of moisture)
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Supplies > or = to 18" from ceiling and 10" above floor on lined shelving
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Storage units /bins/shelving are clean and organized
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Storage of supplies is clean and organized
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No expired supplies
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No torn or compromised supplies
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No items stored on the floor
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Supplies are not stored where food/ drinks are consumed. (or no food /drinks in supply room)
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Linen carts/ room are clean and organized
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Clean equipment is stored separately from soiled equipment
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Dirty Utility Room (if applicable) is labeled, clean and organized.
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Inappropriate or unnecessary equipment and supplies are not present in the area
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Items are stored in appropriate or safe locations (nothing on top of trash containers, shred bins, blocking hallways, doors or exits)
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All medications are secured with access only to authorized hospital personnel. narcotics are secured and stored separate from other medications
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All open vials of medications have an expiration date from the manufacturers with no obvious signs of contamination, and are dated when opened. Multi-dose vials expire within 28 days of opening (USP 797)
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Refrigerator thermometers reads 36-45 degrees Fahrenheit
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Refrigerator and freezer logs are read at least twice a day (twice if used to store vaccines) (CDC)
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Refrigerator and freezer temperature logs are dated and signed by the person performing the check and are readily available if requested (CDC)
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Staff able to articulate the action taken if temperature is out of range
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Corrective action is documented if temperature is out of range
Supply & Scope Cabinets
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No high dust
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Bottom of all shelves lined
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No expired equipment during spot check
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No expired supplies during spot check
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Cabinets kept closed at all times
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Scopes not touching each other
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Scopes labeled appropriately
Anesthesia Cart
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When unlocked by appropriate staff, no expired medications found
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No evidence of reuse of single dose vials
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Intubation equipment sealed in unopened peel packs, clean and sterilized
PR Workstation on Wheels /Work Desk (if any)
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Free of clutter
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No food or drink
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No laboratory samples on the computer or at desk
Waste Management
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Biohazardous waste containers do not hold regular trash
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No biohazardous waste in the regular trash containers
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Waste holding areas and carts are clean
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Sharps containers are secured
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ONLY sharps in sharps box
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Sharps boxes <2/3 full
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Nothing on top of sharps boxes
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Dirty linen hamper is no more than 3/4 full
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Dirty linen is covered and transported in leak resistant container
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Cleaning products stored properly
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Mop water and buckets clean
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Cleaning tools clean
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Adequate supply of cleaning materials
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Soiled materials segregated
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Floors clean
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PPE available
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Red bags tied properly
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Trash bins clean
Staff and Space / Work Flow
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Hand hygiene procedure monitored and reported to department leadership
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PPE worn as appropriate
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Doors are not propped open
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Egress corridors are free from obstruction
Staff Knowledge
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Staff able to articulate the 5 moments of hand hygiene
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Staff able to articulate the care of instruments at point of care.
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Staff able to articulate how isolation patients are identified.
Other Findings
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