Wright Memorial Hospital

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Managers - Infection Control performed an inspection of your unit. Please review your survey and document your Plan of Correction next to each deficiency.

• Return this form to me by:

  Date

Summary of Survey

• Number of deficiencies found during this Inspection:

• Score - Total Survey Score %

Employee Hand Hygiene Compliance

• Employees Monitored

1.0 Hand Hygiene

• 1.1. Sinks for hand hygiene are well stocked?

  Yes

  No

  N/A

• 1.2. Alcohol hand rubs are well stocked?

  Yes

  No

  N/A

• 1.3. Sinks are available in all areas as needed?

  Yes

  No

  N/A

• 1.4. Alcohol hand rubs are available in patient's rooms?

  Yes

  No

  N/A

• 1.5. Placement of alcohol hand rubs is compliant with safety?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 1.7. Hand Hygiene reminder posters present?

  Yes

  No

  N/A

• 1.8. Hand soap is available in all hand washing stations / bathrooms?

  Yes

  No

  N/A

2.0. Clean Utility / Central Supply / Storage

• 2.1. Clean linen cart is covered?

  Yes

  No

  N/A

• 2.2. Clean linen cart has solid surface on bottom shelf?

  Yes

  No

  N/A

• 2.3. Sink storage area empty and clean?

  Yes

  No

  N/A

• 2.4. Thrash cans or waste basket are not overfilled or overflowing?

  Yes

  No

  N/A

• 2.5. Ceiling tiles are not stained or wet?

  Yes

  No

  N/A

• 2.6. Floors are clean?

  Yes

  No

  N/A

• 2.7. Supplies are stored at least 6 inches off of the floor and with a solid bottom?

  Yes

  No

  N/A

• 2.8. Air intake vents and diffusers are clean?

  Yes

  No

  N/A

• 2.9 Is this section free of additional findings?

  Yes

  No

  N/A

3.0 Patient Rooms

• 3.1. Horizontal surfaces are clean?

  Yes

  No

  N/A

• 3.2 Thrash cans or waste basket are not overfilled or overflowing?

  Yes

  No

  N/A

• 3.3. Bathrooms are clean?

  Yes

  No

  N/A

• 3.4. Hand hygiene products are available?

  Yes

  No

  N/A

• 3.5. Soap and paper towels are available in each bathroom?

  Yes

  No

  N/A

• 3.6. PPE's are available as needed?

  Yes

  No

  N/A

• 3.7. Patient equipment is clean?

  Yes

  No

  N/A

• 3.8. No visible soil on vertical surfaces?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.10. Air intake vents and diffusers are clean?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.13. Floors are clean?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.15. Dust not found in high places?

  Yes

  No

  N/A

• 3.16. General area is dust free?

  Yes

  No

  N/A

• 3.17. Foley catheters hanging and secured appropriately?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.19. There is no evidence of pest present?

  Yes

  No

  N/A

• 3.20. Clean / dirty linen handled appropropriatly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 3.22. No signs of mildew or mold present?

  Yes

  No

  N/A

• 3.23 Is this section free of additional findings?

  Yes

  No

  N/A

4.0 Patient Kitchen / Breakroom

• 4.1. Floors and walls clean?

  Yes

  No

  N/A

• 4.2. Horizontal and vertical surfaces are clean?

  Yes

  No

  N/A

• 4.3. Microwave oven clean?

  Yes

  No

  N/A

• 4.4. Refrigerator clean and thawed of ice?

  Yes

  No

  N/A

• 4.5. Under sink clean and without storage?

  Yes

  No

  N/A

• 4.6. Patient refrigerator labeled for patient use only?

  Yes

  No

  N/A

• 4.7. Temperature checks are documented with corrective action when temp is out of range?

  Yes

  No

  N/A

• 4.8. Patient food is labeled appropriately with no expired food found?

  Yes

  No

  N/A

• 4.9. Ice machine is clean?

  Yes

  No

  N/A

• 4.10 There is no evidence of pest present?

  Yes

  No

  N/A

• 4.11 Is this section free of additional findings?

  Yes

  No

  N/A

5.0. Employee Kitchen / Breakroom

• 5.1. Floors and walls clean?

  Yes

  No

  N/A

• 5.2. Horizontal and vertical surfaces are clean?

  Yes

  No

  N/A

• 5.3. Microwave oven clean?

  Yes

  No

  N/A

• 5.4. Refrigerator clean and thawed of ice?

  Yes

  No

  N/A

• 5.5. Under sink clean and without storage?

  Yes

  No

  N/A

• 5.6. Employee food labeled and dated?

  Yes

  No

  N/A

• 5.7. Temperature checks are documented with corrective action when temp is out of range?

  Yes

  No

  N/A

• 5.8 is this section free of additional findings?

  Yes

  No

  N/A

6.0 General Unit / Nurses Station / Medication Room

• 6.1 Unit / area generally clean (without dust, clutter or debris)?

  Yes

  No

  N/A

• 6.2. Unused patient equipment/supplies are stored and handled appropriately?

  Yes

  No

  N/A

• 6.3. Medication, specimens, and food are handled appropriately?

  Yes

  No

  N/A

• 6.4. Biohazard trash is segregated from regular trash?

  Yes

  No

  N/A

• 6.5. Clean linen is handled appropriately?

  Yes

  No

  N/A

• 6.7. Dirty linen is handled appropriately?

  Yes

  No

  N/A

• 6.8. All clean linen carts are covered?

  Yes

  No

  N/A

• 6.7. Linen carts have a solid bottom shelf?

  Yes

  No

  N/A

• 6.8. Needles and syringes are disposed of properly?

  Yes

  No

  N/A

• 6.9. Out of date supplies are not present?

  Yes

  No

  N/A

• 6.10. Infectious waste in red bag or container?

  Yes

  No

  N/A

• 6.11. Clean items are not stored in soiled utility room?

  Yes

  No

  N/A

• 6.12 Ceiling tiles are not discolored/ wet/ missing / damaged?

  Yes

  No

  N/A

• 6.13. Lab supplies are not expired?

  Yes

  No

  N/A

• 6.14. Nothing is stored under the sink and there is no sign of leaks?

  Yes

  No

  N/A

• 6.15. Halls/Area are uncluttered?

  Yes

  No

  N/A

• 6.16. Respiratory hygiene available?

  Yes

  No

  N/A

• 6.17 Restrooms clean?

  Yes

  No

  N/A

• 6.18. Trash basket are not overflowing?

  Yes

  No

  N/A

• 6.19. Biohazard symbol on door of biomedical waste storage?

  Yes

  No

  N/A

• 6.20. Medication cart locked?

  Yes

  No

  N/A

• 6.21. No artificial / acrylic nails use. Nails are no more than 1/4 inch above finger?

  Yes

  No

  N/A

• 6.22. No personal lotion use.

  Yes

  No

  N/A

• 6.23. Medication Room refrigerator is clean and without ice?

  Yes

  No

  N/A

• 6.24. There are no expired products found(IV solutions, medications, reagents, nutritional supplement, sterile items, etc.)

  Yes

  No

  N/A

• 6.25. Is this section free of additional findings?

  Yes

  No

  N/A

• 6.26. Are fire doors free of obstacles?

  Yes

  No

  N/A

7.0 Logs

• 7.1. Crash cart checked daily?

  Yes

  No

  N/A

• 7.2. Defibrillator checked daily

  Yes

  No

  N/A

• 7.3. Narcotic counts documented every shift?

  Yes

  No

  N/A

• 7.4. Temperature checked BID for vaccine / medication storage?

  Yes

  No

  N/A

• 7.5. Daily refrigerators checks with corrective actions as needed?

  Yes

  No

  N/A

• 7.6. Ice machine cleaning date / time stamped?

  Yes

  No

  N/A

• 7.7. Glucose meter strips dated

  Yes

  No

  N/A

• 7.8. Cidex monitoring Log complete?

  Yes

  No

  N/A

• 7.9. Is this section free of additional findings.

  Yes

  No

  N/A

8.0. Isolation Rooms

• 8.1. Appropriate signage in place?

  Yes

  No

  N/A

• 8.2. Supplies and PPE's available?

  Yes

  No

  N/A

• 8.3. Trash and linen handled per policy?

  Yes

  No

  N/A

• 8.4. Appropriate PPE's used by staff?

  Yes

  No

  N/A

• 8.5. Door closed as appropriate?

  Yes

  No

  N/A

• 8.6. Negative pressure is being supplied as required?

  Yes

  No

  N/A

• 8.7 Patient and family instructed on isolation requirements?

  Yes

  No

  N/A

• 8.8. Patient with proper attire when being transported?

  Yes

  No

  N/A

• 8.9. Is this section free of additional findings?

  Yes

  No

  N/A

9.0. Employee General Knowledge

• 9.1. Employees know the procedure for blood exposure?

  Yes

  No

  N/A

• 9.2. Personnel can locate their Infection Control Manual?

  Yes

  No

  N/A

• 9.3. Personnel can locate their Exposure Control Plan?

  Yes

  No

  N/A

• 9.4. Personnel can locate the blood spill kit?

  Yes

  No

  N/A

• 9.5. Personnel can locate their spill kit for Cidex?

  Yes

  No

  N/A

• 9.6 Dust not found in high places?

  Yes

  No

  N/A

• 9.7. Is this section free of additional findings?

  Yes

  No

  N/A

10.0. Soiled Linen / Dirty Utility Room

• 10.1 Biohazard symbol on door of biomedical waste storage?

  Yes

  No

  N/A

• 10.2 Boxes are stored at least 6 inches off of the floor?

  Yes

  No

  N/A

• 10.3. Walls / floors are clean

  Yes

  No

  N/A

• 10.4. Ceiling tiles are not discolored/ wet/ missing / damaged?

  Yes

  No

  N/A

• 10.5 Dust not found in high places?

  Yes

  No

  N/A

• 10.6 Is this section free of additional findings?

  Yes

  No

  N/A

11.0. Patient Shower Room

• 11.1. Shower clean?

  Yes

  No

  N/A

• 11.2. Shower room clean and orderly?

  Yes

  No

  N/A

• 11.3. Walls and floor are clean?

  Yes

  No

  N/A

• 11.4. Ceiling tiles are not discolored/ wet/ missing / damaged?

  Yes

  No

  N/A

• 11.5 Dust not found in high places?

  Yes

  No

  N/A

• 11.6 Is this section free of additional findings?

  Yes

  No

  N/A

Additional Comments

• Additional Comments

• Surveyor's Signature

  Sign