Infection prevention rounds checklist
Hospital and ambulatory infection prevention site visit
What does this form include?
This form contains 18 sections:
Return this form to me by: Date
Employee Hand Hygiene Compliance
- Hand hygiene observations submitted monthly?
Name of observer and/or safety coach?
I. Waiting Area
- Signs posted at entrances with instructions to patients with symptoms of respiratory infection to cover their cough.
- Notice of universal precautions posted in waiting area or at check-in desk?
- Tissues and/or masks available to patients for respiratory hygiene
- Network-approved hand sanitizer available for patients to perform hand hygiene
II. Hand Hygiene
- Sinks for hand hygiene and hand sanitizer dispensers are well stocked?
- Sinks are available in all areas as needed?
- Alcohol hand rubs are available in patient's rooms?
- Placement of alcohol hand rubs is compliant with safety (not directly over an electrical outlet)?
- Hand washing / hand hygiene is performed between patients? (Wash In / Wash Out)
III. Clean Utility / Central Supply / Storage
- Clean linen is covered.
- Clean linen/supply cart has solid surface or plastic barrier on bottom shelf.
- Nothing is stored under the sink (except for cleaning supplies) and there are no signs of leaks.
- Ceiling tiles are not stained or wet.
- Floors are clean.
- Supplies are stored at least 6 inches off of the floor.
- There are no expired supplies present.
- Air intake vents and diffusers are clean/free of dust
- Walls / floors are clean and undamaged?
- There are no outside cardboard shipping boxes present among clean supplies.
IV. Soiled Linen / Dirty Utility Room
- Biohazard symbol on door of biomedical waste storage?
- Door to soiled linen / dirty utility room locked?
- Soiled materials are stored appropriately?
- Ceiling tiles are not discolored/ wet/ missing / damaged?
- Dust not found in high places?
- Is this section free of additional findings?
V. Patient Rooms
- Horizontal surfaces are clean?
- Trash cans or waste basket are not overfilled or overflowing?
- Bathrooms are clean?
- PPE is available as needed?
- Patient equipment is clean?
- Ceiling tiles are not discolored, wet, missing, or damaged?
- Air intake vents and diffusers are clean?
- Furniture (chairs, sleepers) are without tears or wear?
- Floors are clean?
- Sharp containers are no more than 3/4 full?
- General area is dust free?
- Foley catheters hanging and secured appropriately?
- There is no evidence of pest infestation present?
- IV pumps and poles, feeding pumps etc. are clean?
- Clean linen handled appropriately?
- Dirty linen handled appropriately?
- No needles, syringes, medications within reach of the patient?
- No signs of mildew or mold present?
- Is this section free of additional findings?
VI. Patient Kitchen / Nutrition Area
- Floors and walls clean?
- Microwave oven clean?
- Refrigerator clean and thawed of ice?
- Nothing is stored under the sink (except for cleaning supplies) and there are no signs of leaks?
- Patient refrigerator labeled for patient use only or patient food clearly separated from employee food if shared?
- Temperature checks are documented daily with corrective action when temperature is out of range?
- Horizontal and vertical surfaces are clean?
- No expired food present (food from home expires in 3 days)?
- Ice and/or water machine is clean?
- There is no evidence of pest present?
- Is this section free of additional findings?
VII. Employee Kitchen / Breakroom
- Floors and walls clean?
- Horizontal and vertical surfaces are clean?
- Microwave oven clean?
- Refrigerator clean and thawed of ice?
- There is nothing stored under the sink (except for cleaning supplies) and there are no signs of leaks?
- No expired or old food found?
- Temperature checks are checked/documented daily with corrective action when temperature is out of range?
- Is this section free of additional findings?
VIII. Nurses Station / Medication Room
- Unit / area generally clean (without dust, clutter or debris)?
- Unused patient equipment/supplies are stored and handled appropriately?
- Medication, specimens, and food are handled appropriately?
- Biohazard trash is segregated from regular trash?
- Clean linen is handled appropriately?
- Dirty linen is handled appropriately?
- All clean linen is covered?
- Linen/supply carts have a solid bottom shelf?
- Needles and syringes are disposed of properly?
- Expired supplies are not present?
- Infectious waste in red bag or container?
- Ceiling tiles are not discolored / wet / missing / damaged?
- Nothing is stored under the sink (except for cleaning supplies) and there are no signs of leaks?
- Respiratory hygiene available?
- Restrooms are clean?
- Trash baskets are not overflowing?
- No artificial / acrylic nails use. Nails are no more than 1/4 inch above finger?
- No personal lotion use.
- Medication room refrigerator is clean and without ice?
- Is this section free of additional findings?
IX. Logs
- Temperature logs complete checked for vaccine / medication storage?
- Equipment cleaning logs complete with corrective actions as needed?
- High-level disinfection documentation
- Items are thoroughly pre-cleaned according to manufacturer instructions and visually inspected for residual soil prior to high-level disinfection.
- Enzymatic cleaner is used and discarded according to manufacturer instructions (typically after each use).
- Manufacturer instructions for chemical disinfectants are followed for preparation, testing for appropriate concentration, and replacement prior to expiration or loss of efficacy.
- Quality control of test strips performed and documented?
- Documentation of proper temperature (ex: OPA disinfectants reaches 68F; Gluteraldehyde/Cidex reaches 77F)
- Devices are disinfected for the appropriate length of time as specified by manufacturer instructions
X. Isolation Rooms
- Appropriate signage in place?
- Supplies and PPE's available?
- Trash and linen handled per policy?
- Door closed as appropriate?
- Negative pressure is being supplied as required?
- Patient with proper attire when being transported?
XI. Patient Shower Room
- Shower clean?
- Shower room clean and orderly?
- Walls and floor are clean and undamaged?
- Ceiling tiles are not discolored/ wet/ missing / damaged?
- Dust not found in high places?
XII. Environmental Services
- Facility has written policies and procedures for routine cleaning and disinfection of environmental surfaces, including identification of responsible personnel.
- Personnel who clean and disinfect patient care areas (e.g., environmental services, technicians, nurses) receive training on cleaning procedures: upon hire, annually, when new equipment or protocols are introduced.
- Facility has a policy/procedure for decontamination of spills of blood or other body fluids.
XIII. Employee General Knowledge and Competency
- Personnel can locate the Infection Control Manual?
- Personnel have an updated list of diseases reportable to public health authority.
- Personnel can demonstrate knowledge of and compliance with mandatory reporting requirements for reportable diseases.
- Personnel can locate PPE.
- Employees know the procedure for blood exposure?
- Personnel know procedure and have PPE available for cleaning up a body fluid spill?
- Personnel can locate their Cidex / chemical spill kit?
Additional Comments
Surveyor's Signature
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