_b:., Quality care close to home. ~PRING VALLEY HOSPITAL,. . MEDICAL CENTER

771eValley ~·Health System'"

June 25, 2020

Brenda Erdoes Director of the Legislative Counsel Bureau 401 S. Carson Street Carson City, NV 89701-4747

Re: Annual Patient Safety Report per NRS 439.877 Spring Valley Hospital Medical Center

Dea r Director Erdoes:

Pursuant to NRS 439.877 Spring Valley Hospital Medical Ce nter, is required to annually submit a summary of its Patient Safety Committee Activities to your office, including information relating to the development, revision and usage of patient safety checklists and pa tient safety policies and a summary of the annual review conducted for the prior 12 month period. The following information is being provided in conformity with this requirement.

Establishment of Patient Safety Checkli sts: Pursuant to t he provisions of NRS 439.877 the Patient Safety Committee adopted Patient Safety Checklists. These checklists are reviewed and modified as necessary based upon outcome and performance data on a yearly basis. Currently, Spring Valley Hospital Medical Cent er utilizes and monitors compliance with checklist s covering numerous patient areas. These include Hand Hygiene, Patient Ident ifica tion, Code Blue Cart Inspection, Central Line Insertion, (etc.) Checklist.

Adoption of Pol icies, Procedures and Protocols: In conjunction with the checklists, Spring Valley Hospital Medical Center has developed and implemented policies, procedures and protocols to ensure compliance with the letter and intent of t he checkl ists.

Patient Safety Compliance: During the ca lendar year 2019- 2020 the hospital Patient Safety Officer in conjunction with the hospital Qua lity Management and Risk Management Departments and Nursing leadership conducted reviews of staff and physician compliance with estab lished patient safety po Ii c i es and checklists. These reviews included direct surveillance, clinical process reviews and root cause analysis.

5400 South Rainbow Boulevard • Las Vegas, Nevada 8911 8 Telephone (702) 853-3000• Facsimile (702) 853-3340 Patient Safety Committee: This committee is comprised of the following members: CEO, COO, CNO, Risk Director, Quality Director, Pharmacy Director, Infection Prevention Director, Nursing Leadership, Procedural Area Leadership, and three Physician Charis. The committee discusses primary safety related topics affecting or having the potential to affect the facility, using a 4-step methodology to identify the issue, best practice, recommendations and implementation of safety measures, as well as monitoring for success or need for the application of additional measures.

If you have any questions regarding the hospital's patient safety checklists or its quality programs, please feel free to contact me at your earliest opportunity.

Paula Carlisle, RN, MSJ, CPHRM Patient Safety Officer Spring Valley Hospital Medical Center REPORT TO THE DIRECTOR OF THE LEGISLATIVE COUNSEL BUREAU PURSUANT TO NRS 439.877(4)(D)- SUBMITTED BY: July 1, 2020

Spring Valley Hospital Medical Center Paula Carlisle, Patient Safety Officer 5400 South Rainbow Boulevard, Las Vegas, NV 89118 Contact Number: 702-853-3342 July 1, 2019 - July 1, 2020

Patient Safety Checklists and Patient Safety Policies Developed Include: Usage** New Revisions* Review*** Fire Safety, Equipment Testing Plant Services, Security X Informed Consent Housewide X Womens Services, Case Adoption, Infant X Management Advanced Directives Housewide X Alarm Safety Nursing Ambulation or Gait Training Therapy Services X Amniocentesis/Amniotic Fluid reduction L+D X Amputation Therapy Services Therapy Services X Amputee Training Therapy Services X Anesthesia Workplace Surgical Services, Special Procedures, L+D X Animal Assisted Therapy Housewide X Antepartum Testing L+D X Anticoagulation Safety and Monitoring Housewide X Aseptic Technique Therapy Services X Assessment of Patients Therapy Services X Anesthesia Workplace Surgical Services, Special Procedures, L+D X Animal Assisted Therapy Housewide X Antepartum Testing L+D X Anticoagulation Safety and Monitoring Housewide X Aseptic Technique Therapy Services X Assessment of Patients Therapy Services X Assessment of Pediatric Patients Therapy Services X Assistance- Code Lift Housewide X Back Surgery Therapy Services X Education, All staff with Basic Life Support Education X patient interaction Behavior- Code Grey Housewide X Behaviors Which Undermine A Culture of Safety Medical Staff X Bladder Scanning (checklist) Rehab X Blood Administration (checklist) Lab, Nursing X Cancer Therapy Services X Care and Identification of the neonate at Birth (checklist) L+D X Care of the Perinatal HIV Exposed Newborn L+D, Postpartum, Nursery X Central Line Associated Blood Stream Infection (CLABSI) Prevention Infection Control, Nursing X Cerebral Vascular Accident Therapy Services X Chronic Obstructive Pulmonary Disease Therapy Services X Circulating RN Duties (checklist) Surgical Services X Clinical information for transfer (checklist) Rehab X

Code Blue, Neonatal NICU, Nursery, Maternity, ER, Medical Staff X Code Lockdown (Secure Facility from External Threats) Housewide X Code Silver Housewide X Code Stemi Housewide X Contrast Administration in Radiology (checklist) X Radiology Controlled Substance Discrepancy Resolution X Medical Staff, Nursing Construction Risk Assessment (checklist) Housewide X Controlled Drugs: Automatid Dispensing, Inventory Housewide X Coordination of Services Rehab X CPM Rental Therapy Services X Crash Cart Daily Checklist Nursing X Critical Test Reporting Nursing, Medical Staff X Cryotherapy Therapy Services X Death in the Surgical Area (checklist) Surgical Services X Debridement Therapy Services X Decontamination of Endoscopes and High Level Disinfection Surgical Services X Decorations and Heating Devices Housewide X Diabetic Stop Orders (checklist) Pharmacy X Direct Admit and Inpatient Transfer (checklist) Housewide X Nursing, Case Discharge Planning (checklist) X Management, Medical Staff Discharge Planning (checklist) NICU X Discharge Planning (checklist) Therapy Services X Disclosure of Unanticipated Outcomes (checklist) Nursing, Medical Staff X Documentation Standards Therapy Services X Domestic Violence (checklist) Housewide X Draping the Surgical Field Surgical Services X Pharmacy, Nursing, Medical Drug Recalls (checklist) Staff X Dysphagia/ Swallowing Dysfunction Program Nursing, Speech Therapy X Education Policy Rehab X Electrical Safety Engineering X Electrical Stimulation Therapy Services X Elopement Prevention Code Walk (checklist) Nursing, Security X Emergency Cases Normal Hours (checklist) Surgical Services X Emergency Drugs Nursing, Pharmacy X EMG Biofeedback Therapy Services X EMTALA Emergency, Maternity X Environmental Assessment Rounds (checklist) Housewide X Environmental Services Duty List Environmental Services X EOC Policy, Grounds Plant Services X Epidermolysis Bullosa Care NICU, X Equipment Inventory Management (checklist) Biomed X Ethics Consultation Mechanism Housewide, Medical Staff X Ethyl Chloride and Flourimethane spray and stretch Therapy Services X Evaluation and management of severe pre-eclampsia before 34 L+D weeks gestation X Evaluation of Contracted Services Housewide, Administration X Event Reporting Housewide X Exclusive Breastmilk Feeding of the Newborn Postpartum Expiration and Post Mortem Care Nursing, Medical Staff X Falls Prevention Policy (checklist) Housewide X Federal agency compliance- Information data management Rehab X Fiberoptic Endoscopic Evaluation of Swallowing (FEES) Speech Therapy, Nursing X Fire Safety Management Plan Housewide X Fire Watch Plant Services X First Assistant (non-MD) Surgical Services X Forensic Staff Orientation and Education Security X Formulary Development and Maintenance Pharmacy, Medical Staff X Functional Independent Measure Therapy Services X Generating Communications When the Phones are Out Housewide X Generator Testing (checklist) Housewide X Guideline for Alternative Birthing (checklist) L+D X Guideline for Anesthesia Services (checklist) L+D, Medical Staff X Guideline for Operative Procedures (checklist) L+D X Guideline for Perinatal Loss (checklist) Womens Services, Case Management X Guidelines for Fetal Monitoring (checklist) L+D X Guidelines for the Care and Management of PICC for the Neonate ( checklist) NICU X Handling of Tissue Specimens in Surgery (checklist) Surgical Services X Pharmacy, Medical Staff, Hard Stop Antibiotics After 24 Hours (checklist) Nursing X Hazard Report Housewide X Hazardous Materials Housewide X Hazmat, General Waste Environmental Services X Healthcare Associated Infections Housewide X Hearing Screen (checklist) Nursery, NICU, Therapy X Plant Services, Security, Helipad Safety and Orientation (checklist) X Emergency Department High Alert Medications Pharmacy, Nursing X Home Visit Rehab X Hospital Security Security X Hypoglycemia Protocol (checklist) Pharmacy Identification of Staff-Visitors-Parents Housewide X Identification of the Pediatrician L+D X Infant Driven Feedings (checklist) NICU, Nursery, Maternity X Infection Control (checklist) NICU X Infection Prevention Bundle Checklist Housewide X Infection Prevention and Control Program Housewide X Therapy Services, Infection Prevention Guidelines (checklist) Environmental Services X Initial assessment of L+D/antepartum/Triage patients (checklist) L+D X In-service and Technician Training Biomed X Biomed, Receiving, Plant Inspection of incoming Electrical Equipment (checklist) Services X Integration of Services Rehab X IV Contrast Media- IV Contrast Reaction- IV Contrast Screening Nursing, Radiology Consent X

IV Therapy Pharmacy, Nursing X IVIG Nursing X Joint Mobilization Therapy Services X Late, Prete rm Infants, Caring for NICU, Nursery, Maternity X Lead Device Inspections (checklist) Radiology X Legal 2000 Patient Observation Policy Housewide X Legal 2000 Sexual Perpetrator and Victim Precautions Housewide X Legal 2000 Visitation ER, Med-Surg X Look Alike Sound Alike Medications Pharmacy, Nursing X Lost/Misplaced Belongings Resolution Process (checklist) Housewide X Malignant Hyperthermia Housewide X Management of Patients requiring Cervical Ripening/ induction or L+D X Augmentation of labor.

Management of the patient in labor L+D X Management of Women in Labor with know or unknown HIV Status L+D, Postpartum X Mapping Utility Systems Plant Services X Massage Therapy Services X Maternal Group B Strep L+D X Medical Gas Testing Engineering X Medication Dose Rounding Pharmacy, Nursing X Medication Management- Patient Information Pharmacy, Nursing X Pharmacy, Med Staff, Medication Management- Patient Information Nursing X Pharmacy, Medical Staff, Medication Orders With Use of Qualifiers Nursing X Pharmacy, Medical Staff, Medication Protocols Nursing X Pharmacy, Medical Staff, Medication Range Dose/Frequency Orders Nursing X Pharmacy, Medical Staff, Medication Safety- Black Box Warnings Nursing X Medication Samples Pharmacy, Nursing X Moist Hot Packs Therapy Services X NICU, Therapy, Respiratory Multidisciplinary Rounds X Therapy, Medical Staff Multiple Use Sterile Drugs Pharmacy, Nursing X

Nasal Positive Airway Pressure Ventilation- Nursing Care NICU X Neurological Precaution Therapy Services X Newborn and Infant Safety Postpartum, Nursery X NPO Status for Radiology Exams Radiology, Nursing X Nursing Admission Assessment (checklist ) Rehab X Nursing Care NICU X Occupational Therapy assessment Rehab X On Call Administrator Housewide X Surgical Services, Medical Operating Room Utilization Guidelines Staff X Operative Vaginal Delivery (Vacuum Extractor/Forceps) L+D X Operator Error Equipment Failure Biomed X Oxytocin Checklist Obstetric Nursing X Pain Assessment Outpatient Therapy X Pharmacy, Medical Staff, Pain Management (checklist) Nursing X Parrafin X Therapy Services Patient Access to Protective Services Housewide X Patient admission screening process Rehab X Patient and Family Education (checklist) Outpatient Therapy X Patient and Family Education (checklist) Rehab Patient and Family Education (checklist) Therapy Services X Patient assessment and time frames X Rehab Patient care Documentation X Rehab Patient Grievance/Complaint Management X Housewide Patient Identification and Exam Verification Radiology X Patient Linen Precautions Nursing, EVS X Patient Orientation Rehab X Patient Room Transfer Nursing, EVS X Patient Safety (checklist) Therapy Services X Patient Safety Plan Housewide X Patient Treatment Rehab X Patient with Obstetric Hemorrhage L+D, Maternal Services X Patient/family education Rehab X Patients with Diabetes/Gestational Diabetes L+D, Maternal Services X Performance Monitoring Housewide X Periferal Nerve Block Insertion (checklist) Surgical Services X Perioperative Documentation Surgical Services X Peritoneal Dialysis NICU X Pharmaceutical Waste Management Pharmacy, Nursing X Physical Therapy assessment Rehab X PICC Line Guidance and Care (Adult) Nursing, Medical Staff X Plan of Care Nursing X Plans for Provision of Patient Care Nursing X Pneumatic Tourniquet Use {checklist) Surgical Services X Nursing, Lab, Respiratory POC Blood Glucose Testing {checklist) Therapy X Patient Equipment Cleaning Outpatient Therapy X Patient Safety Outpatient Therapy Patient Treatment Outpatient Therapy Positioning of a Patient Surgical Services X Pre-admission form (checklist) X Rehab Pre-anesthesia Verification Checklist X Surgery Risk Management, Biomed. Product and Medical Device Recalls X Purchasing Risk Management, Biomed. Product Recalls X Purchasing Professional Labor Support Labor and Delivery X Proper Body Mechanics Therapy Services X

Proper Body Mechanics Housewide X

Quality Control Process Housewide X

Quality Plan Housewide X Radiology Student Supervision and Guidelines X Radiology Readmission Rehab X Reassessment of Patients {checklist) Therapy Services X Re-assessment of patients (checklist) Rehab X Receptacle Testing Engineering X Recovery of the Delivered Patient {checklist) L+D, Postpartum X Referral process for ineligible patients Rehab X Referral Sources- Triggers Therapy Services X Pharmacy, Medical Staff, Renal Dosing Nursing X Reporting Adverse Medical Device Incident Bio-med, Risk X Respiratory Therapy, Amnio test Respiratory Therapy X Response to Emergency Outside (checklist) Housewide X Restraint and Seclusion Nursing, Medical Staff X Retinopathy of Prematurity, Laser Surgery NICU X Housewide, Medical Risk Management Plan Staff,Board of Governors X Safeguarding Patient Valuables- Lost and Found (checklist) Housewide X Safety Education Housewide X Safety Management Plan Housewide X Scope of Service Rehab X Security Incidents Security X

Security Office Safe and Vouchering Security X Security Reasons for Personnel Housewide X Security Risk Assessment Program Housewide X Security Sensitive Areas Plant Services, Security X Critical Care, ER, Sedation and Analgesia for Vented Patients Respiratory Therapy, Medical Staff X Shunts, Internal and External NICU X Skin and Pressure Ulcer Prevention Nursing X Skin Care Checklist Nursing X Social and Family Assessment Rehab X Social Service Intervention Outpatient Therapy X Speech Therapy assessment (checklist) Rehab X Spinal Cord Injury Therapy Services X Nursing, Respiratory Sputum Specimen Collection Therapy, Lab X Staffing Plans Nursing X Pharmacy, Medical Staff, Standard Concentration and Preparation of IV Drugs, Adult X Nursing Standards of Documentation Therapy Services X Stress test checklist Nursing X Subgleal and Subdural Hemorrhage NICU, Nursery, Maternity X Supplies and Equipment Therapy Services X Surgical Skin Antisepsis Surgical Services X Surgical Smoke Evacuation Surgical Services X Surrogacy L+D, Case Management X T.N.S. Therapy Services X Telephone Triage of the OB Patient L+D X Telemetry Call Log X Telemetry X Telemetry Standardized Verbiage Procedure Telemetry Telemetry CNA standardized checklist X Med Surg, IMC Temperature and Humidity (checklist) Plant Services, Surgery X Pharmacy, Medical Staff, Temporary Leave Drugs. Nursing X Surgical Services, Terminal Cleaning of Surgical and Invasive Procedure Suites X Environmental Services Therapeutic Exercise Therapy Services X Therapeutic Hypothermia on Neonatal Transport NICU, Nursery X Pharmacy, Medical Staff, Therapeutic Substitution Program Nursing X Tilt Table Therapy Services X Timing of umbilical cord clamping after birth L+D X Time Out Procedure Checklist X Titration Parameters Pharmacy, Medical Staff, Nursing X Total Body Cooling for Neonatal Encephalopathy NICU X Treatment of Shoulder Dystocia L+D X Treatment Planning Therapy Services X Triage {checklist) ER, Womens Services X Tube System Spills Engineering X Ultrasound Therapy Services X Unit Inspection Procedure Housewide X Surgical Services, OB, Universal Protocol (checklist) Radiology, Cathlab, Medical X Staff Use of Magnesium Sulfate Administration L+D X Use of SPO2 monitoring in pregnant patients L+D X Utility Equipment Plant Services X Utility Failure Housewide X Vaginal Birth after cesarean Section L+D X

Vaginal Delivery (checklist) L+D X Variances in L+D/Antepartum/Triage patients L+D X Vascular Access Determination Checklist Nursing X Vehicular Access- Traffic Control Plant Services, Security X Vendor Compliance and Credentialing Housewide X Ventilation Testing Plant Services, Infection Control X Critical Care, ER, Ventilator Weaning Protocol Respiratory Therapy, Medical Staff X VIP Policy Housewide X Sputum Collection Respiratory Therapy X Surgery AM Checklist Surgery X Unit Inspection Procedure Pharmacy X Wound Care competency Checklist Nursing X

Summary of Review Total# Developed Total# Revised Total# Reviewed Patient Safety Checklists 70 0 70 Patient Safety Policies 217 3 214

*Checklists and Patient Safety Policies were reviewed for the stated time period. Need for revision is noted by the date the revision was made.

**Usage outlines the units/departments the checklists are used in.

***As part of the annual review any required revisions will be identified. If revisions are required this is noted in the revision box. Any additional patient safety checklists or policies identified will be noted in this (review} column. If the annual review reveals no changes are required this box will be marked with an "X". An "X" means that the checklists and policies were reviewed but no changes were required.

❖ Reports are due on or before July 1 of each year, address report to: Director LCB Rick Combs {2016) [email protected] Copy to: [email protected] Carson City, NV 89701