QUESTION STANDARD LOCATION YES 1 Date of Observation
2 Name of Observer
3 Are floors clean, intact, and free from damage? observed in clinic Floors are clean, intact, and free from damage 4 Are ceiling tiles free of stains, cracks, or missing tiles? observed in clinic
Ceiling tiles are free of stains, cracks, or missing tiles
5 Grids are secure and free from rust? observed in clinic Grids are secure and free from rust
6
Is the interior lighting clean, illuminated, intact, and free
from damage? observed in clinic
The interior lighting is clean, illuminated, intact, and free from damage
7 Is door clearance adequate? observed in clinic The door clearance is adequate
8 Do Fire Doors remain closed? observed in clinic Fire doors are closed
9 Are walls and baseboards intact and free from damage? observed in clinic
Walls and baseboards are intact and free from damage.
10 Are windows and window blinds clean? observed in clinic Windows and window blinds are clean. 11
Are the lobby/waiting room chairs clean and in good
repair? Observed in Lobby
The lobby/waiting room chairs are clean and in good repair.
12 Are Emergency Call Systems fully operational?
Observed in Lobby
restroom Emergency Call System is fully operational
13
Are countertops intact and free from damage allowing
cleaning and disinfection? observed in clinic
Countertops are intact and free from damage to allow cleaning and disinfection.
Updated: 3/01/2015
DIALYSIS SPECIFIC EOC OBSERVATION
This audit is to be completed by the manager or designee on a monthly basis. "Dialysis Specific EOC Observation" audits are due by the last day of the month.
Instructions: Indicate Yes, No, NA (Not Applicable) for each question below.
Submit 1 "Dialysis Specific EOC Observation" audit per month using the "Dialysis Specific EOC Observation" audit tool.
Data Definition Tool
14 Date of Observation 15 Staff Observed
16
Were gloves, gown, protective eyewear and mask or faceshield worn during the cleaning and disinfection procedure?
observed at chairside
Gloves, gown, protective eyewear and mask or faceshield were worn during the cleaning and disinfection procedure
17
Were all blood lines and disposables discarded in the biohazardous waste?
observed at chairside
All blood lines and disposables were discarded in the biohazardous waste
18 Was the prime waste receptacle emptied and disinfected?
observed at chairside
The prime waste receptacle was emptied and disinfected
19
Were gloves removed following the disposal and disinfection part of the procedure?
observed at chairside
Gloves were removed following the disposal and disinfection part of the procedure 20
Was hand hygiene performed before putting on new gloves?
observed at chairside
Hand hygiene was performed before putting on new gloves
21
Were clean gloves put on before beginning the next cleaning step?
observed at chairside
Clean gloves were put on before beginning the next cleaning step
22
Were the internal and external surfaces of the prime waste receptacle wiped and allowed to dry?
observed at chairside
The internal and external surfaces of the prime waste receptacle were wiped and allowed to dry
23
Was a disinfectant-soaked cloth used to wipe the top, front, and side surfaces of the machine?
observed at chairside
A disinfectant-soaked cloth was used to wipe the top, front, and side surfaces of the machine
24
Was a disinfectant-soaked cloth used to wipe the dialysate hoses of the machine?
observed at chairside
A disinfectant-soaked cloth was used to wipe the dialysate hoses of the machine
25
Was a disinfectant-soaked cloth used to wipe the Hansen
connectors of the machine? observed at
chairside
A disinfectant-soaked cloth was used to wipe the Hansen connectors of the machine 26
Was a disinfectant-soaked cloth used to wipe the BP cuff and tubing?
observed at chairside
A disinfectant-soaked cloth was used to wipe the BP cuff and tubing
27
Was a disinfectant-soaked cloth used to wipe the outside surfaces of the dialysate concentrate containers?
observed at chairside
A disinfectant-soaked cloth was used to wipe the outside surfaces of the dialysate
concentrate containers DIALYSIS - CLEANING AND DISINFECTION OF THE DIALYSIS STATION
28
Was a disinfectant-soaked cloth used to wipe the data entry station?
observed at chairside
A disinfectant-soaked cloth was used to wipe the data entry station
29
Were any unused disposable supplies removed from the dialysis chair and disposed ?
observed at chairside
Any unused disposable supplies were removed from the dialysis chair and disposed
30
Was a disinfectant-soaked cloth used to wipe all external front-facing and side surfaces of the fully reclined chair?
observed at chairside
A disinfectant-soaked cloth was used to wipe all external front-facing and side surfaces of the fully reclined chair
31
Was a disinfectant-soaked cloth used to wipe the sides of the seat cushion of the fully reclined chair?
observed at chairside
A disinfectant-soaked cloth was used to wipe the sides of the seat cushion of the fully reclined chair?
32
Was a disinfectant-soaked cloth used to wipe the tops of the side tables beside the fully-reclined chair?
observed at chairside
A disinfectant-soaked cloth was used to wipe the tops of the side tables beside the fully-reclined chair
33
Was a disinfectant-soaked cloth used to wipe the TV controls?
observed at chairside
A disinfectant-soaked cloth was used to wipe the TV controls
34
Was a disinfectant-soaked cloth used to wipe the call button?
observed at chairside
A disinfectant-soaked cloth was used to wipe the call button?
35 Was a disinfectant-soaked cloth used to wipe the IV poles?
observed at chairside
A disinfectant-soaked cloth was used to wipe the IV poles
36
Was a disinfectant-soaked cloth used to wipe the O2 concentrators?
observed at chairside
A disinfectant-soaked cloth was used to wipe the O2 concentrators
37
Was a disinfectant-soaked cloth used to wipe the counters around the dialysis station?
observed at chairside
A disinfectant-soaked cloth was used to wipe the counters around the dialysis station 38 Were all clamps cleaned?
observed at
chairside All clamps were cleaned 39 Were all cloths and wipes discarded properly?
observed at
chairside Aall cloths and wipes were discarded properly
40
Was hand hygiene performed immediately after cleaning and disinfecting the Dialysis Station?
observed at chairside
Hand hygiene was performed immediately after cleaning and disinfecting the Dialysis Station
41
Is there a documented method in place to summon immediate assistance for a patient or solitary staff?
observed at chairside
There is a documented method in place to summon immediate assistance for a patient or solitary staff
42
Is emergency resuscitation equipment immediately available?
observed at chairside
The emergency resuscitation equipment is immediately available
43
Did staff respond to a TEST emergency call for assistance in < 4 minutes?
observed at chairside
The staff responded to a TEST emergency call for assistance in < 4 minutes
44
Is the treatment space adequate to prevent cross-contamination when multiple patients are training?
observed at chairside
The treatment space is adequate to prevent cross-contamination when multiple patients are training
45
Does the treatment space provide adequate patient privacy?
observed at chairside
The treatment space provide adequate patient privacy
46
There is no visible evidence of dry or wet blood on the equipment or surfaces?
observed at chairside
There is visible evidence of dry or wet blood on the equipment or surfaces
47
There is no visible evidence of dry or wet PD effluent on the equipment or surfaces?
observed at chairside
There is visible evidence of dry or wet PD effluent on the equipment or surfaces
48
Is the patient treatment area (including floors, countertops, and ceiling tiles) in good repair?
observed at chairside
The patient treatment area (including floors, countertops, and ceiling tiles) is in good repair 49 Are treatment chairs in good repair and functional?
observed at chairside
Treatment chairs are in good repair and functional
50
Is the Isolation room or area equipped with dedicated equipment and supplies for use by only HBsAG+ positive patients?
observed at chairside
The Isolation room or area equipped with dedicated equipment and supplies for use by only HBsAG+ positive patients
51
Is the door to the Isolation room closed during initiation and discontinuation of dialysis treatment?
observed at chairside
The door to the Isolation room is closed during initiation and discontinuation of dialysis treatment
52
Do staff caring for HBVsAG positive ANTIGEN+ patients only provide care for HBsAG positive V ANTIBODY+ patients in close proximity during the same shift maintaining a proper buffer zone?
observed at chairside
Staff caring for HBVsAG positive ANTIGEN+ patients only provide care for HBsAG positive V ANTIBODY+ patients in close proximity during the same shift maintaining a proper buffer zone.
53
Do all patients seated in the "Buffer Zone" have a documented HBsABy titer of > 10 in the past 12 months?
observed at chairside
All patients seated in the "Buffer Zone" have a documented HBsABy titer of > 10 in the past 12 months
54
Are staff providing medications to isolation patients prohibited from caring for susceptible patients during the same shift?
observed at chairside
Staff providing medications to isolation patients are prohibited from caring for susceptible patients during the same shift
55
Is Isolation equipment labeled and dedicated for use for HBsAG positive V+ patients only?
observed at chairside
The Isolation equipment is labeled and dedicated for use for HBsAG positive V+ patients only
56
Is the Isolation room used for HBsAg positive V+ patients when the census includes any HBsAg positive V+ patients?
observed at chairside
The Isolation room is used for HBsAg positive V+ patients when the census includes any HBsAg positive V+ patient
57
Does staff wear gloves, gown, protective eyewear and mask or faceshield when entering the isolation room during treatment?
observed at chairside
The staff wears gloves, gown, protective eyewear and mask or faceshield when entering the isolation room during treatment
58
Does staff remove gloves, gown, protective eyewear and mask or faceshield when entering the isolation room during treatment?
observed at chairside
The staff removes gloves, gown, protective eyewear and mask or faceshield when leaving the isolation room during treatment
59
Does staff perform hand hygiene immediately after leaving the isolation room?
observed at chairside
The staff performs hand hygiene immediately after leaving the isolation room
60
Does the isolation room or area have equipment, instruments, and supplies desginated to be used only for patients with MRSA?
observed at chairside
The isolation room or area has equipment, instruments, and supplies desginated to be used only for patients with MRSA
61
Does the isolation room or area have equipment, instruments, and supplies desginated to be used only for patients with VRE?
observed at chairside
The isolation room or area has equipment, instruments, and supplies desginated to be used only for patients with VRE
62 Are there dummy drip chambers in the patient care area?
observed at chairside
No Dummy drip chambers are present in the patient care area
63 Is the patient care area in good repair?
observed at
chairside The patient care area is in good repair 64 Are the patient chairs in good repair?
observed at
chairside The patient chairs are in good repair 65 Emergency supplies include: AED?
Observed on
emergency cart Emergency supplies include: AED 66 Emergency supplies include: O2?
Observed on
emergency cart Emergency supplies include: O2 67 Emergency supplies include: Suction?
Observed on
emergency cart Emergency supplies include: Suction 68 Emergency supplies include: Ambu bag with face mask?
Observed in emergency cart
Emergency supplies include: Ambu bag with face mask
69 Emergency supplies include: IV solutions?
Observed in
emergency cart Emergency supplies include: IV solutions 70 Emergency supplies include: Back board?
Observed in
emergency cart Emergency supplies include: Back board 71 Emergency supplies include: Oral airway?
Observed in
emergency cart Emergency supplies include: Oral airway 72 Emergency supplies include: Emergency medications?
Observed in medication room
Emergency supplies include: Emergency medications
73 Are AED checks performed daily?
documented in AED
log AED checks were performed daily.
74
Are emergency supplies checked monthly or after use for expiration dates, cleanliness, and proper function?
Observed in medication room
The emergency supplies are checked monthly or after use for expiration dates, cleanliness, and proper function
75 Date of Observation 76 Staff Observed
77
Were all supplies stored in designated clean areas at a safe distance from the dialysis stations?
observed at chairside
All supplies were stored in designated clean areas at a safe distance from the dialysis stations.
78
Was the staff member compliant with never keeping patient care supplies in pockets or on their person?
observed at chairside
The staff member was compliant with never keeping patient care supplies in pockets or on their person.
79
Was all non-disposable equipment (thermometers, IV poles, pH/conductivity meters, O2 concentrators, glucometers, stethoscopes) disinfected when removed from the used dialysis station BEFORE is was returned to a common area or another dialysis station?
observed at chairside
All non-disposable equipment (thermometers, IV poles, pH/conductivity meters, O2
concentrators, glucometers, stethoscopes) were disinfected when removed from the used dialysis station BEFORE is was returned to a common area or another dialysis station.
80
Was all non-disposable equipment disinfected by wiping all surfaces with EPA-registered hospital disinfectant and allowed to dry?
observed at chairside
All non-disposable equipment was disinfected by wiping all surfaces with EPA-registered hospital disinfectant and allowed to dry.
81
Were all unused disposable supplies discarded or dedicated to the patient and not returned to the common supplies?
observed at chairside
All unused disposable supplies were discarded or dedicated to the patient and not returned to the common supplies.
