Infection Control Checklist
Make sure to implement initial control measures to prevent healthcare-associated infections.
Hospital Name
Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hand Hygiene
Rows
Yes
No
Comments
Are the sinks adequately supplied for hand hygiene?
1
2
Are sinks readily available in all areas?
3
4
Are there sufficient stocks of alcohol hand rubs?
5
6
Are alcohol hand rubs easily accessible in patient rooms?
7
8
Is the placement of alcohol hand rubs compliant with safety regulations?
9
10
Are healthcare workers performing hand washing/hand hygiene between patients?
11
12
Are there reminders for hand hygiene present in the form of posters?
13
14
Is hand soap available in all hand washing stations/bathrooms?
15
16
Clean Utility / Central Supply / Storage
Rows
Yes
No
Comments
Is the clean linen cart covered?
17
18
Does the clean linen cart have a solid surface on the bottom shelf?
19
20
Is the sink storage area empty and clean?
21
22
Are the trash cans or waste baskets not overfilled or overflowing?
23
24
Are the ceiling tiles free of stains or wetness?
25
26
Are the floors clean?
27
28
Are supplies stored at least 6 inches off of the floor?
29
30
Are the air intake vents and diffusers clean?
31
32
Are there no additional findings in this section?
33
34
Patient Rooms
Rows
Yes
No
Comments
Horizontal surfaces are clean?
35
36
Thrash cans or waste basket are not overfilled or overflowing?
37
38
Bathrooms are clean?
39
40
Hand hygiene products are available?
41
42
Soap and paper towels are available in each bathroom?
43
44
PPE's are available as needed?
45
46
Patient equipment is clean?
47
48
No visible soil on vertical surfaces?
49
50
Ceiling tiles are not discolored, wet, missing, or damaged?
51
52
Air intake vents and diffusers are clean?
53
54
Furniture (chairs, sleepers) are without tears or wear?
55
56
The mattress pad is without tears or puncture holes?
57
58
Floors are clean?
59
60
Sharp containers are no more than 3/4 full.
61
62
Dust not found in high places?
63
64
The general area is dust free?
65
66
Are Foley catheters appropriately hanging and secured?
67
68
Are IV pumps, poles, feeding pumps, etc. clean?
69
70
Is there no evidence of pests present?
71
72
Is clean/dirty linen handled appropriately?
73
74
Are there no needles, syringes, or medications within reach of the patient?
75
76
Are there no signs of mildew or mold present?
77
78
Are there no additional findings in this section?
79
80
Patient Kitchen / Breakroom
Rows
Yes
No
Comments
Are the floors and walls clean?
81
82
Are horizontal and vertical surfaces clean?
83
84
Is the microwave oven clean?
85
86
Is the refrigerator clean and free of ice buildup?
87
88
Is the area under the sink clean and without storage?
89
90
Is the patient refrigerator labeled for patient use only?
91
92
Are temperature checks documented with corrective action taken when the temperature is out of range?
93
94
Is patient food labeled appropriately with no expired items found?
95
96
Is the ice machine clean?
97
98
Is there no evidence of pests present?
99
100
Are there no additional findings in this section?
101
102
Employee Kitchen / Breakroom
Rows
Yes
No
Comments
Are the floors and walls clean?
103
104
Are horizontal and vertical surfaces clean?
105
106
Is the microwave oven clean?
107
108
Is the refrigerator clean and free of ice buildup?
109
110
Is the area under the sink clean and without storage?
111
112
Are employee foods labeled and dated?
113
114
Are temperature checks documented with corrective action taken when the temperature is out of range?
115
116
Are there no additional findings in this section?
117
118
General Unit / Nurses Station / Medication Room
Rows
Yes
No
Comments
Is the unit/area generally clean and free of dust, clutter, or debris?
119
120
Are unused patient equipment/supplies stored and handled appropriately?
121
122
Are medication, specimens, and food handled appropriately?
123
124
Is biohazard trash segregated from regular trash?
125
126
Is clean linen handled appropriately?
127
128
Is dirty linen handled appropriately?
129
130
Are all clean linen carts covered?
131
132
Do linen carts have a solid bottom shelf?
133
134
Are needles and syringes disposed of properly?
135
136
Are there no out-of-date supplies present?
137
138
Is infectious waste stored in a red bag or container?
139
140
Are clean items not stored in the soiled utility room?
141
142
Are ceiling tiles not discolored, wet, missing, or damaged?
143
144
Are lab supplies not expired?
145
146
Is there nothing stored under the sink and no sign of leaks?
147
148
Are halls uncluttered?
149
150
Is respiratory hygiene available?
151
152
Are restrooms clean?
153
154
Are trash baskets not overflowing?
155
156
Is there a biohazard symbol on the door of the biomedical waste storage area?
157
158
Is the medication cart locked?
159
160
Are artificial/acrylic nails not allowed, and nails no more than 1/4 inch above the finger?
161
162
Is personal lotion not allowed?
163
164
Is the Medication Room refrigerator clean and without ice?
165
166
Are there no expired products found, such as IV solutions, medications, reagents, nutritional supplements, sterile items, etc.?
167
168
Are there no additional findings in this section?
169
170
Logs
Rows
Yes
No
Comments
Is the crash cart checked daily?
171
172
Is the defibrillator checked daily?
173
174
Are narcotic counts documented every shift?
175
176
Is the temperature checked twice a day for vaccine/medication storage?
177
178
Are daily refrigerator checks performed with corrective actions taken as needed?
179
180
Is the ice machine cleaning date/time stamped?
181
182
Are glucose meter strips dated?
183
184
Is the Cidex monitoring log complete?
185
186
Are there no additional findings in this section?
187
188
Isolation Rooms
Rows
Yes
No
Comments
Are there signs that are suitable and in place?
189
190
Are there sufficient supplies and personal protective equipment (PPEs)?
191
192
Are trash and linen being handled according to established policies?
193
194
Is the staff using appropriate PPEs?
195
196
Is the door being closed as necessary?
197
198
Is negative pressure being provided as needed?
199
200
Have patients and their families been informed of isolation requirements?
201
202
Are patients properly attired during transportation?
203
204
Is there no other issue found in this section?
205
206
Employee General Knowledge
Rows
Yes
No
Comments
Employees know the procedure for blood exposure?
207
208
Personnel can locate their Infection Control Manual?
209
210
Personnel can locate their Exposure Control Plan?
211
212
Personnel can locate the blood spill kit?
213
214
Personnel can locate their spill kit for Cidex?
215
216
Employees can state the WHO's 5 moments of Hand Hygiene.
217
218
Dust not found in high places?
219
220
Is this section free of additional findings?
221
222
Soiled Linen / Dirty Utility Room
Rows
Yes
No
Comments
Is there a biohazard symbol displayed on the door of the biomedical waste storage area?
223
224
Are boxes stored at a minimum of 6 inches above the floor?
225
226
Are the walls and floors clean?
227
228
Are the ceiling tiles not discolored, wet, missing, or damaged?
229
230
Is there no dust found in high places?
231
232
Are there no additional issues found in this section?
233
234
Patient Shower Room
Rows
Yes
No
Comments
Is the shower clean?
235
236
Is the shower room clean and well-organized?
237
238
Are the walls and floor clean?
239
240
Are the ceiling tiles not discolored, wet, missing, or damaged?
241
242
Is there no dust found in high places?
243
244
Are there no additional issues found in this section?
245
246
Any comments
Surveyor's Name
First Name
Last Name
Profession
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: