Monitoring for COVID 19 Areas

General Information
Date of Inspection

Name of Department

Number of patients present

Number of Nurses/ medical staff present

Nurse in Charge

1.0 Hand Hygiene Compliance

1.1. Hand washing stations are available in all areas as needed?

1.2. Hand sanitizers are available as needed?

1.3. Hand washing / hand hygiene is performed between patients?

1.4. Hand Hygiene reminder posters present?

1.5. Hand soap is available in all hand washing stations?

1.6. Paper towel is available in all hand washing stations?

1.7. Hand washing stations are equipped with running water?

1.8. Hand washing stations are outfitted with a waste receptacle?

1.9.

Indicate other findings

2.0. General Sanitary Condition
2.1. Date of last cleaning

2.2. Trolleys and shelves are clean and tidy?

2.3. Waste receptacles are not overflowing?

2.4. Ceiling tiles are not stained or wet?

2.5. Floors are clean?

2.6. Walls are clean?

2.7. Supplies are stored at least 6 inches off of the floor?

2.8. Air intake vents and diffusers are clean?

2.9. Are there any additional findings?

Indicate additional findings

3.0 Patient Rooms

3.1. Waste receptacles are not overflowing?

3.2 Bathrooms are clean?

3.3. Hand hygiene stations are available?

3.4. Soap and paper towels are available as needed?

3.5. PPE's are available as needed?

3.6. Patient equipment is clean?

3.7. Ceiling tiles are not discolored, wet, missing, or damaged?

3.8. Air intake vents and diffusers are clean?

3.9. Furniture (chairs, sleepers) are without tears or wear?

3.10. Mattress pad is without tears or puncture holes?

3.11. Floors are clean?

3.12. Sharp containers are no more than 3/4 full?

3.13. Dust not found in high places?

3.14. General area is dust free?

3.15. Foley catheters hanging and secured appropriately?

3.16. IV pumps and poles, feeding pumps etc. are clean?

3.17. There is no evidence of pest present?

3.18. Clean / dirty linen handled appropropriatly?

3.19. No needles, syringes, medications within reach of the patient?

3.20. No signs of mildew or mold present?

3.21. Are there any additional findings?

Indicate additional findings

4.0 Patient / Staff Bathroom

4.1. Floors and walls clean?

4.2. There is no evidence of pest present?

4.3. Adequate supply of water present?

4.4. Bathroom free from leaks or plumbing defects?

4.5. Water closets functioning properly?

4.6. Hand washing sinks are adequate in number?

4.7. Soap and paper towels are available?

Waste receptacles not overflowing?

4.9. Are there any additional findings?

Indicate additional findings

5.0 Waste Management

5.1. Biohazard waste separated appropriately?

5.2. Infectious waste placed in Marked red bag or container?

5.3. Infectious linen placed in marked white bag or container?

5.4. Needles, syringes and other sharps disposed of appropriately?

5.5. Sharps containers no more than 3/4 full?

5.6. Food-related waste are disposed of appropriately?

5.7. Waste receptacles covered and not overflowing?

5.8. Are there any additional findings?

Indicate additional findings

6.0 PPE/ Storage

6.1 Adequate supply of masks?

6.2. Adequate supply of gowns?

6.3. Adequate supplyof gloves?

6.4. Adequate supply of face shield/ goggles?

6.5. Other PPE available?

6.6. PPE stored in a clean, dry place?

6.7. PPE donning procedure done properly?

6.8. PPE doffing procedure done properly?

6.9. PPE clean and free of tips or signs of damage?

6.10. Are there any additional findings?

Indicate additional findings

Additional Comments

Additional Comments

Surveyor's Signature
Charge Nurse's Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.