ENVIRONMENTAL CHECKLIST -

Hospital: _____________________________________
Date:________________________________________ Time:_______________________
Unit:_________________________________________ Room:______________________
Instruction Component Yes No N/A
At start, perform hand hygiene.
Review outside door for isolation signage.
Put on PPE: Gloves for all rooms. PPE as required for isolations.
Empty waste receptacles:
Clean receptacle inside, outside and on the bottom if wet or dirty inside.
Replace liner.
Gather all dirty linen:
Place on dirty bed linen, roll together and put in linen bag for transport to
soiled linen room.
DAILY
High Dust above eye level:
1) Do not dust over a patient or in an occupied ICU/CCU patient room.
2) work from right to left, or in clockwise direction around the room.
Ledges: above shoulders
Vents
Lights: room and bathroom
Overhead light (if the bed is empty)
TV & Stand/Cables
Door Hinges
DAILY Ledges: shoulders and below
Disinfect high touch surfaces: Door knobs/handles
Door surface
Bed: top to bottom, head to foot
Bed rails
Call button
Phone
Overbed table & Drawer
Countertop
Light switches
Furniture
Arms of patient chairs/sofa
Seat of patient chairs/sofa
All other misc. horizontal surfaces
Window sills
Medical equipment (e.g., IV controls)
Spot clean walls with disinfectant cloth
Bedside commode
DAILY Pour disinfectant in toilet bowl, allow to stay
Disinfect Bathroom: Faucets (at sink)
Sink
Mirror
Bathroom door knob Inside Toilet with brush (Do not touch outside of toilet with toilet bowl
brush)
Toilet horizontal surface/seat
Toilet lever/flush
Tub/shower
Bathroom handrails
DAILY Dust mop floor
Clean Floor: Wet mop floor
Replace as needed: Hand sanitizer
Paper towels
Soiled curtains
For terminal cleaning, damp dust: Bed frame
Mattress: top, sides, bottom
Remake bed with clean linen
Thoroughly dust after patient has been discharged
Replace as needed: Pillows, mattresses, pillow covers, matress covers
Discard dust cloths.
Change mop heads after each isolation room.
Remove PPE before exit.
Perform hand hygiene.
Any significant areas not mentioned above (please describe):____________________________________________________________________________________
Sign-off by Observer:_____________________________________________________________
FOR DAILY CLEANING - ROOM OBSERVATIONS: Please review a sample of 10 patients per month