INFECTION CONTROL CHECKLIST Nursing Department INFECTION CONTROL REVIEW I.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Quarter 1 Not Met Met Quarter 2 Not Met Met Quarter 3 Not Met Met Page 1 Quarter 4 Not Met Met

PERSONNEL
Personnel wear neat, untorn and appropriate clothing Good personal hygiene, including hair and body cleanliness, is practiced Fingernails are clean and trimmed Hair is neat and off the collar Personnel follow strict clothing and linen handling procedures to avoid contaminating their clothes Disposable gloves are worn when handling contaminated equipment Suspected infections are reported so appropriate action can be taken Personnel are oriented to Infection Control policies when hired and this orientation is documented Personnel attend department and facility-wide Infection Control inservice programs Personnel review isolation procedures at least annually Personnel are screened for infectious diseases when hired and at other times deemed necessary Personnel are informed of potential dangers/toxicities of cleaning compounds and other supplies All jewelry on Hands are removed and washed: 13.1 when going from a dirty to a clean area 13.2 when hands are soiled 13.3 before and after coming in contact with a resident, their equipment or belongings 13.4 before, between and after resident food or feeding equipment 13.5 before and after eating 13.6 after combing hair 13.7 after using a handkerchief or tissue

INFECTION CONTROL CHECKLIST Nursing Department INFECTION CONTROL REVIEW

13.8 after handling soiled linen 13.9 before handling clean linen 14. Proper technique is used for: 14.1 wound care 14.2 catheter procedures 14.3 dressing changes 14.4 tracheostomy distribution 14.5 tube feedings 14.6 obtaining cultures 14.7 other resident treatments 14.8 14.9
14.10

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Disposal of resident wastes Parenteral and fluid administration Handling oxygen equipment

II.
1. 2. 3. 4. 5. 6. 7. 8. 9.

BEDSIDE STAND
Dentures are kept in a clean denture cup labeled with residents name Comb and brush are separate from toothbrush Oral hygiene brush is in a separate sanitary container Bedpan and wash basin are clean and separated Bedpan/urinal covers are available All equipment is clean Soiled clothes are removed Bar soap is kept in a clean container and labeled with residents name Perishable food is removed from within the bedside stand

INFECTION CONTROL CHECKLIST Nursing Department INFECTION CONTROL REVIEW

10. 11. Medications are not removed unless specified by a physicians order Non-perishable food is kept in a closed container Quarter 1 Not Met Met Quarter 2 Not Met Met Quarter 3 Not Met Met Page 3 Quarter 4 Not Met Met

III.
1. 2. 3. 4. 5. 6. 7.

BED
Rails are clean Mattress is intact with protective covering and odor-free Eggcrate mattress is in a sheath No dirt or dust Food particles are removed Linen is clean and untorn, not stained Supportive devices (restraints, pillows, foot guards, etc.) are clean

IV.
1. 2. 3. 4. 5.

CLOSET
Clothes are clean and odor-free Clothes are labeled Perishables are absent Non-perishables are in a closed container Soiled laundry to be done outside facility is stored in closed, plastic-lined container

V.
1. 2.

OVERBED TABLE
Table is clean and unchipped There is a clean water pitcher, glass and tray

VI.
1.

OTHER EQUIPMENT
Wheelchairs, gerichairs and walkers are clean

INFECTION CONTROL CHECKLIST Nursing Department INFECTION CONTROL REVIEW

2. 3. 4. 5. Commodes are clean and unchipped Suction equipment, tube feeding equipment and oxygen equipment are clean IV stands are clean A cleaning schedule is followed for all the above Quarter 1 Not Met Met Quarter 2 Not Met Met Quarter 3 Not Met Met Page 4 Quarter 4 Not Met Met

VII.
1. 2. 3. 4. 5. 6. 7.

SHOWER ROOM
Tubs, showers and showerchairs are clean and in good repair Tubs, shower and showerchairs are disinfected between residents Individual resident items are labeled with residents name Storage wareas are clean, paint unchipped, orderly and locked (if necessary) Linen, personal belongings and equipment are off floor and not stored in room Privacy curtains are clean and dry Room is well-ventilated and fan is dust-free

VIII. BATHROOMS
1. 2 3. 4. 5. Toilet seats and other equipment are clean and in good repair Cleaning schedule is followed Paper towel dispensers are filled and functioning Soap dispensers are filled and functioning Residents personal equipment is clean, labeled and stored properly

IX.
1. 2. 3.

CLEAN UTILITY ROOM

Handwashing sinks are present and functioning Equipment is clean, dry and stored in an orderly fashion Autoclaved equipment is not outdated

INFECTION CONTROL CHECKLIST Nursing Department INFECTION CONTROL REVIEW

4. 5. Soap and towel dispensers are filled and working Clean are is marked accordingly and clearly separated from dirty area Quarter 1 Not Met Met Quarter 2 Not Met Met Quarter 3 Not Met Met Page 5 Quarter 4 Not Met Met

VIII. DIRTY UTILITY ROOM

1. 2. 3. 4. 5. 6. 7. 8. 9. Equipment is rinsed before washing The flush/sink hopper is operating Handwashing sink is functioning well Procedures for disinfecting equipment are developed, available and used Cleaning, disinfecting and sterilizing solutions are available for all procedures Countertops are dry and clutter-free by end of each shift Room is ventilated and dust-free Cleaned equipment is removed in a timely fashion Dirty area is marked accordingly and clearly separated from clean area

XI.
1. 2. 3. 4. 5. 6.

MEDICATION ROOM AND MED CHARTS

Syringes/sharps are disposed of in-impervious container Internal and external medications are stored separately and properly Medication room and charts are clean Refrigerator is clean Supplies and equipment are stored above floor level Sterile solutions are dated when opened and disposed of within 24 hours