:Al-Mezan Hospital Staff Name
General Infection Control Checklist
Hand Hygiene Ye No Comment
s
1 Sinks for hand hygiene are well stocked?
2 Alcohol hand rubs are well stocked?
3 Sinks are available in all areas as needed?
4 Alcohol hand rubs are available in patient's rooms?
5 Placement of alcohol hand rubs is compliant with safety?
6 Hand washing/hand hygiene is performed between patients?
7 Hand Hygiene reminder posters present?
8 Hand soap is available in all hand washing
stations/bathrooms?
Score:
Clean Utility / Central Supply / Storage Ye No Comment
s
1 Clean linen cart is covered?
2 Clean linen cart has solid surface on bottom shelf?
3 Sink storage area empty and clean?
4 Trash cans or waste baskets are not overfilled or
overflowing?
5 Ceiling tiles are not stained or wet?
6 Floors are clean?
7 Supplies are stored at least 6 inches off of the floor?
8 Air intake vents and diffusers are clean?
Score:
Patient Rooms Yes No Comment
1 Horizontal surfaces are clean?
2 Trash cans or waste baskets are not overfilled or
overflowing?
3 Bathrooms are clean?
4 Hand hygiene products are available?
5 Soap and paper towels are available in each bathroom?
6 PPE's are available as needed?
7 Patient equipment is clean?
8 No visible soil on vertical surfaces?
9 Ceiling tiles are not discolored, wet, missing, or damaged?
02/12/2019
:Al-Mezan Hospital Staff Name
1 Air intake vents and diffusers are clean?
0
1 Furniture's (chairs, sleepers) are without tears or wear?
1
1 Mattress pad is without tears or puncture holes?
2
1 Floors are clean?
3
1 Sharp containers are no more than 3/4 full?
4
1 Dust not found in high places?
5
1 General area is dust free?
6
1 IV pumps and poles, feeding pumps etc. are clean?
7
1 Clean / dirty linen handled appropriately?
8
1 No needles, syringes, medications within reach of the
patient?
9
Score:
Employee Room / Kitchen Ye No Comment
s
1 Floors and walls clean?
2 Horizontal and vertical surfaces are clean?
3 Microwave oven clean?
4 Refrigerator clean and thawed of ice?
5 Under sink clean and without storage?
6 Room odder/smell are good?
Score:
Nurses Station / Medication Room Yes No Comment
1 Unit/area generally clean (without dust, clutter or debris)?
2 Unused patient equipment/supplies are stored and handled
appropriately?
3 Medication, specimens, and food are handled
appropriately?
02/12/2019
:Al-Mezan Hospital Staff Name
4 Biohazard trash is separated from regular trash?
5 Needles and syringes are disposed of properly?
6 Out of date supplies are not present?
7 Infectious waste in red bag or container?
8 Lab supplies are not expired?
9 Ceiling tiles are not discolored, wet, missing, or damaged?
1 Air intake vents and diffusers are clean?
0
1 Furniture's (chairs, sleepers) are without tears or wear?
1
1 Nothing is stored under the sink and there is no sign of
leaks?
2
1 Floors are clean?
3
1 Sharp containers are no more than 3/4 full?
4
1 Dust not found in high places?
5
1 General area is dust free?
6 .............................................................................
Trash baskets are not overflowing?
1
7 .............................................................................
1 Biohazard symbol on door of biomedical waste storage?
.............................................................................
8
1 .............................................................................
Medication cart locked?
9
2
.............................................................................
No artificial/acrylic nails use. Nails are no more than 1/4
0 .............................................................................
inch above finger?
2 Medication Room refrigerator is clean and without ice?
1 .............................................................................
.............................................................................
Score:
.............................................................................
In this section, write a general report about your
.............................................................................
department condition:
.............................................................................
.............................................................................
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02/12/2019
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:Al-Mezan Hospital Staff Name
02/12/2019
