WEEKLY INSPECTION

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Information

• Date of Inspection

  Date

• 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?

  Yes

  No

  N/A

• 1.2. Hand sanitizers are available as needed?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 1.4. Hand Hygiene reminder posters present?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 1.7. Hand washing stations are equipped with running water?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 1.9.

  Yes

  No

  N/A

• Indicate other findings

2.0. General Sanitary Condition

• 2.1. Date of last cleaning

  Date

• 2.2. Trolleys and shelves are clean and tidy?

  Yes

  No

  N/A

• 2.3. Waste receptacles are not overflowing?

  Yes

  No

  N/A

• 2.4. Ceiling tiles are not stained or wet?

  Yes

  No

  N/A

• 2.5. Floors are clean?

  Yes

  No

  N/A

• 2.6. Walls are clean?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 2.8. Air intake vents and diffusers are clean?

  Yes

  No

  N/A

• 2.9. Are there any additional findings?

  Yes

  No

  N/A

• Indicate additional findings

3.0 Patient Rooms

• 3.1. Waste receptacles are not overflowing?

  Yes

  No

  N/A

• 3.2 Bathrooms are clean?

  Yes

  No

  N/A

• 3.3. Hand hygiene stations are available?

  Yes

  No

  N/A

• 3.4. Soap and paper towels are available as needed?

  Yes

  No

  N/A

• 3.5. PPE's are available as needed?

  Yes

  No

  N/A

• 3.6. Patient equipment is clean?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.8. Air intake vents and diffusers are clean?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.10. Mattress pad is without tears or puncture holes?

  Yes

  No

  N/A

• 3.11. Floors are clean?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.13. Dust not found in high places?

  Yes

  No

  N/A

• 3.14. General area is dust free?

  Yes

  No

  N/A

• 3.15. Foley catheters hanging and secured appropriately?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.17. There is no evidence of pest present?

  Yes

  No

  N/A

• 3.18. Clean / dirty linen handled appropropriatly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.20. No signs of mildew or mold present?

  Yes

  No

  N/A

• 3.21. Are there any additional findings?

  Yes

  No

  N/A

• Indicate additional findings

4.0 Patient / Staff Bathroom

• 4.1. Floors and walls clean?

  Yes

  No

  N/A

• 4.2. There is no evidence of pest present?

  Yes

  No

  N/A

• 4.3. Adequate supply of water present?

  Yes

  No

  N/A

• 4.4. Bathroom free from leaks or plumbing defects?

  Yes

  No

  N/A

• 4.5. Water closets functioning properly?

  Yes

  No

  N/A

• 4.6. Hand washing sinks are adequate in number?

  Yes

  No

  N/A

• 4.7. Soap and paper towels are available?

  Yes

  No

  N/A

• Waste receptacles not overflowing?

  Yes

  No

  N/A

• 4.9. Are there any additional findings?

  Yes

  No

  N/A

• Indicate additional findings

5.0 Waste Management

• 5.1. Biohazard waste separated appropriately?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 5.6. Food-related waste are disposed of appropriately?

  Yes

  No

  N/A

• 5.7. Waste receptacles covered and not overflowing?

  Yes

  No

  N/A

• 5.8. Are there any additional findings?

  Yes

  No

  N/A

• Indicate additional findings

6.0 PPE/ Storage

• 6.1 Adequate supply of masks?

  Yes

  No

  N/A

• 6.2. Adequate supply of gowns?

  Yes

  No

  N/A

• 6.3. Adequate supplyof gloves?

  Yes

  No

  N/A

• 6.4. Adequate supply of face shield/ goggles?

  Yes

  No

  N/A

• 6.5. Other PPE available?

• 6.6. PPE stored in a clean, dry place?

  Yes

  No

  N/A

• 6.7. PPE donning procedure done properly?

  Yes

  No

  N/A

• 6.8. PPE doffing procedure done properly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 6.10. Are there any additional findings?

  Yes

  No

  N/A

• Indicate additional findings

Additional Comments

• Additional Comments

• Surveyor's Signature

  Sign

• Charge Nurse's Signature

  Sign