Sponsored by AAAHC | This email address is being protected from spambots. You need JavaScript enabled to view it. | (847) 853-6060
The views expressed in articles on this channel do not necessarily reflect the views of AAAHC. 

Sample Infection Control Environmental Review Form

Share on Facebook

Here is a sample infection control environmental review form used by Brainerd Lakes Surgery Center in Baxter, Minn., and provided by Sandy Berreth, administrator of the ASC and a AAAHC surveyor.


Different members of the Brainerd Lakes Surgery Center staff perform the review every quarter to increase their recognition of what needs to be done, according to Ms. Berreth.


To download a copy of this form, click here (doc).


Infection Control Environmental Review


GENERAL: Quarterly review  [Month]

Adequate

Needs improvement

Comments

Handwashing between patients, after patient contact, after glove removal, after personal breaks




Proper handwash technique; wet hands first, 10 second scrub, rinse, turn off faucet with paper towel




Soap dispensers are full and functional




General appearance of area is clean, uncluttered




Inspect patient rooms and bathrooms for inappropriate supplies or outdated supplies




Open bottles of fluids discarded every 24 hours/7 am

(saline for irrigation)




Single use medication vials discarded

(sterile saline, bacteriostatic water)




Multi-use medication vials discarded according to manufacturer outdate (exception: insulin, certain RC products)




IV tubing labeled with date




Urine drainage bags off floor




Linen carts covered

- Linen carts in clean utility with other supplies need

to be covered or behind closed cabinet




No shaking, agitation of linens




Refrigerator temperature logs for patient use refrigerators - monitored and recorded daily ( approp. action taken if necessary)




Only patient items in patient refrigerators




No patient care items under/on sinks

(including cups, paper towels, anything that may get wet)




No wet areas under ice machines




No stuffed animals in toy rooms




Hampers used appropriately

- ie. No bags on floors, no overflowing of linen




Ceiling tiles clean and dry




At least 18" clearance below sprinkler heads




Check biological monitoring logs for completeness,

consistency





OSHA BLOODBORNE

PATHOGEN STANDARD

Adequate

Needs improvement

Comments

Staff following Universal/Standard Precautions




No food, beverages in work area




No applying cosmetics, lip balm in work area




No recapping of needles after use

(single handed technique acceptable)




Maximum fill level of needle boxes as indicated on container




Personal Protective Equipment available (PPE)




Proper use of PPE: -gloves when handling body fluids


-gowns when anticipated exposure to clothing


-masks/face shields when anticipated exposure










Removal of PPE prior to leaving patient room




Glove boxes filled




Proper clean up of blood spills

(spray with bleach [Dispatch], allow contact time of

1-2 minutes, then wipe)




Pick up broken glass with tongs




Proper reporting of exposures

(report immediately, complete event report, report to ETD)




Utilizes safety devices as available





CLEAN UTILITY




Clean items only




No medical supplies on floor




No medical supplies left in original shipping container




Nothing stored under sinks




Check for outdated supplies




Door closed








DIRTY UTILITY




Dirty items only




Door closed on soiled utility room




No mini drinking cups, tissues, paper towels, toilet tissue




No hoses touching in floor drains




PPE available





HANDLING OF SPECIMENS

Adequate

Needs improvement

Comments

PPE utilized when handling specimens




Assure covers are properly secured prior to placement in CTS carrier




HANDLING OF INFECTIOUS/ HAZARDOUS WASTE




Properly identifies examples of hazardous waste




Contaminated waste labeled

(red bag)




Needles/Sharps disposed properly




Utilizes safety devices as available





Source: Sandy Berreth, Brainerd Lakes Surgery Center. Adapted and reprinted with permission.

© Copyright ASC COMMUNICATIONS 2012. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.

 

New from Becker's ASC Review

ASCA builds quality and safety resource

Read Now