Assess your organization’s competence in preventing the spread of disease-causing bacteria and pathogens by surveilling your infection control methods. This includes auditing your employee’s hand hygiene practices and the cleanliness of patients' rooms, supply closets, nurses stations, break rooms, and other hospital facilities.
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:
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?
1.2. Alcohol hand rubs are well stocked?
1.3. Sinks are available in all areas as needed?
1.4. Alcohol hand rubs are available in patient's rooms?
1.5. Placement of alcohol hand rubs is compliant with safety?
1.6. Hand washing / hand hygiene is performed between patients?
1.7. Hand Hygiene reminder posters present?
1.8. Hand soap is available in all hand washing stations / bathrooms?
2.0. Clean Utility / Central Supply / Storage
2.1. Clean linen cart is covered?
2.2. Clean linen cart has solid surface on bottom shelf?
2.3. Sink storage area empty and clean?
2.4. Thrash cans or waste basket are not overfilled or overflowing?
2.5. Ceiling tiles are not stained or wet?
2.6. Floors 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 Is this section free of additional findings?
3.0 Patient Rooms
3.1. Horizontal surfaces are clean?
3.2 Thrash cans or waste basket are not overfilled or overflowing?
3.3. Bathrooms are clean?
3.4. Hand hygiene products are available?
3.5. Soap and paper towels are available in each bathroom?
3.6. PPE's are available as needed?
3.7. Patient equipment is clean?
3.8. No visible soil on vertical surfaces?
3.9. Ceiling tiles are not discolored, wet, missing, or damaged?
3.10. Air intake vents and diffusers are clean?
3.11. Furniture (chairs, sleepers) are without tears or wear?
3.12. Mattress pad is without tears or puncture holes?
3.13. Floors are clean?
3.14. Sharp containers are no more than 3/4 full?
3.15. Dust not found in high places?
3.16. General area is dust free?
3.17. Foley catheters hanging and secured appropriately?
3.18. IV pumps and poles, feeding pumps etc. are clean?
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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