F-880 – Infection Control
(For use in determining compliance with F880 - §483.80(a)(1)(2)(40(e)(f)
Skills Validation
Confidential Data: Risk Management/QA Committee Work Document
Purpose: To determine if nursing staff are following various infection control procedural guidelines.
Instructions: Observe facility staff performing linen changes or resident care procedures. Record findings below. Record additional information in the “Comments” section. Provide
completed report to the Risk Management/QA Committee. Use additional copies of this form as necessary.
Observations
Date
Time
Observed
Name of Staff Being Observed
Glucometer
Disinfection
Y
Example
05/2/19
Date:
9:30 am
Karen Weeks, LPN
√
N*
Handling
Soiled
Linen
Y
Removal of
PPE
N*
Y
√
√
Observed By:
* If NO, provide explanation in “Comments” Column. ** If NO, complete Verification Checklist.
Comments
N*
Placed soiled linen on the floor.
Job Position/Title:
F-880 - Infection Control
Validation Checklist
Glucometer Disinfection
Purpose: To determine if the nurse is performing the procedure in accordance with the facility’s standard of practice. Record
observations below. Review findings with the nurse. Provide corrective action as needed.
#
Procedure Observed
Correct
Y
1
Checked Physicians order.
2
Reviewed care plan.
3
Obtained appropriate equipment.
4
Followed RR protocol (e.g., knocked on door)
5
Washed hands.
6
Explained procedure.
7
Provided privacy.
8
Put on gloves.
9
Obtain capillary blood sample.
10
Remove gloves and wash hands prior to exiting room.
11
Reapply gloves if there was contamination of the device.
12
Retrieve disinfectant wipe from container.
13
Cleanse the glucometer with the disinfectant wipe.
14
Discard disinfectant wipe in waste receptacle.
15
Allow device to dry for five (5) minutes or per manufacturer
recommendations.
16
Wash hands or use alcohol gel as appropriate.
17
Recorded/Reported appropriate data.
Comments
N
18
19
20
Observer: List procedures (if any) that requires corrective action/measures.
#
Nurse Being
Observed:
Observed By:
Procedure
Corrective Action/Measures Taken/Recommended
Printed Name:
Signature:
Printed Name:
Signature:
Title:
Date:
F-880-Infection Control
Validation Checklist
Handling Soiled Linen
Purpose: To determine if the nurse is performing the procedure in accordance with the facility’s standard of practice. Record
observations below. Review findings with the nurse. Provide corrective action as needed.
#
Procedure Observed
Correct
Y
1
Checked presence of infectious / contagious condition.
2
Obtained appropriate equipment / supplies.
3
Washed hands.
4
Followed RR protocol (e.g., knocked on door)
5
Explained procedure to resident (if appropriate).
6
Provided privacy (if appropriate).
7
Put on gloves.
8
10
Remove soiled linen.
Soiled linen placed in proper bag / container without unnecessary
handling.
Did Soiled linen touch uniform / floor?
11
Remove gloves and wash hands prior to handling clean linen.
12
Reapply gloves.
13
Clean linen applied without contact with uniform or floor.
14
Wash hands or use alcohol gel as appropriate.
15
Recorded/Reported appropriate data.
9
Comments
N
16
17
Observer: List procedures (if any) that requires corrective action/measures.
#
Nurse Being
Observed:
Observed By:
Procedure
Corrective Action/Measures Taken/Recommended
Printed Name:
Signature:
Printed Name:
Signature:
Title:
Date:
F-880-Infection Control
Validation Checklist
Removing PPE
Purpose: To determine if the employee is removing protective equipment in a manner to prevent recontamination. Record
observations below. Review findings with the employee. Provide corrective action as needed.
#
Procedure Observed
Correct
Y
Comments
N
Removing gloves:
1
Using a gloved hand, grasped the palm area of the other gloved
hand to peel off the first glove.
2
Held removed glove in the gloved hand.
3
Slid fingers of ungloved hand under remaining glove at wrist
and peeled off second glove over first glove.
Removing goggles or face shield:
1
Removed goggles or face shield from the back by lifting head
band or ear pieces.
2
Discarded appropriately.
Removing gown:
Unfastened gown ties, taking care that sleeves don’t come in
contact with body.
Pulled gown away from neck and shoulders, touching inside of
gown only.
1
2
3
Turned down inside out.
4
Folded or rolled gown into a bundle and discarded
appropriately.
Removing mask:
1
Grasped bottom ties or elastics of the mask, then the ones at the
top, and removed without touching the front.
2
Discarded appropriately.
Washed hands or used alcohol-based hand sanitizer
immediately after removing all PPE.
Observer: List procedures (if any) that requires corrective action/measures.
#
Person Being
Observed:
Observed By:
Procedure
Corrective Action/Measures Taken/Recommended
Printed Name:
Signature:
Printed Name:
Signature:
Title:
Date: