Environmental Rounds Worksheet
Area Surveyed
Surveyor & Unit Administrator/Designee present
Date
Surveyors are to check yes, no, or N/A for each criteria. A comment should follow any indication of non compliance. At the completion of the
rounds, the results are to be given to the Unit Administer (UA) for appropriate follow-up. Within one week of receiving the completed survey, the
UA is to forward the Worksheet to the Infection Control Department with indications of Corrective Actions Completed (CAC) or Follow-up
required (FU). Any FU must have the plan of correction attached.
Criteria
I. General Unit/Patient Care Areas
a. Special instructions for entry into unit/patient
care area are visible and clear
b. Nurses’ station area is clean
c. Nurses’ station area is uncluttered
d. Staff food/beverages observed only inside the
pantry and staff lounge/breakrooms/conference
rooms
e. Medication Cart is clean
f. Crash Cart is clean
g. Corridors are clear
h. Corridors are clean
i. Adequate hand hygiene supplies are available,
appropriately placed and easily accessible
j. Staff were observed appropriately performing
hand hygiene
k. Patient rooms are clean and free of clutter
l. Covers on mattresses, gerichairs, stretchers, &
other equipment is intact
m. Wheelchairs and stretchers are clean
n. Pt. Entertainment items are stored separately
from other supplies and covered if in the corridor
o. Staff know how to clean entertainment items or
dispose of them when not cleanable (e.g.
magazines).
Yes
No
N/A
Comments
CAC
FU
Criteria
p. Medication, specimens, and foods are kept in
separate refrigerators
q. Ice machine is clean and free of scales
r. Vents are clean
II. Storage and Utility
a. Clean patient care items, supplies, linens, &
equipment are stored physically separate from
dirty supplies, linen, equipment, and waste
b. Clean patient care supplies are stored in the
clean supply room (not corridors)
c. Clean supply room is clean and orderly
d. All clean supplies are stored 8 to 10 inches
above the floor & 18 inches from the ceiling
e. All clean supplies are removed from outer
shipping cartons for storage
f. No supplies are stored under sinks
g. Patient food is stored in the patients’ pantry
h. Trash cans are not overfilled
i. Bagged waste is placed in the appropriate
container in the soiled utility room, not in
corridors
j. Staff are aware of the proper method of
disposing of biohazardous waste
k. All clean linen is stored in the designated room
and covered when out in the corridor
l. Dirty linen is placed in a covered hamper at the
point of use.
m. All chemicals are stored in appropriate places
n. All chemicals are labeled
III. Refrigerators
a. Refrigerators are clean without frost build up
b. Daily checklist completed for temperatures
Yes
No
N/A
Comments
CAC
FU
Criteria
c. Medication temp is within range (2 to 8 degrees
C.)
d. Pt. Food refrigerator temp is within range (0
to 4 degrees C)
e. Refrigerator log indicates follow up if the
temperature was out of range
IV. Safety
a. Needles and syringes are disposed of properly
b. Workplace Hazardous Material Information
system (WHMIS) manual is current
c. Staff are aware of the manual’s location
V. Isolation/Precautions
a. Staff know which rooms have negative
pressure capability
b. Negative pressure rooms are monitored 3Xs
per day when in use and results are posted on the
unit
c. Staff know who to notify in the event a
negative pressure room check fails
d. Respiratory/Contact Precaution Rooms:
 Door is closed
 Instructions are posted for entering the room
 Instructions are posted for leaving the
room(inside room door)
 Instructions for specimen collection
 Contact sheet is posted
e. Adequate PPE (including various sizes of
gloves) is available outside patient rooms.
f. Staff observed using appropriate PPE
Surveyors – Additional Comments:
Yes
No
N/A
Comments
CAC
FU
Surveyors – Additional Comments continued:
Surveyors
and
Original copy to be given to the Unit Administrator after the survey for follow-up.
A copy is to be kept in the Infection Prevention and Control Office.
Unit Administrator’s response (to include corrective actions completed and plans of correction for items requiring follow-up). This
response is to be forwarded to the Infection Prevention and Control Office no later than one week after the survey.
Unit Administrator
Completed survey received in Infection Prevention and Control Office
Review by Infection Prevention and Control Team
Date