2009 Annual Hospitals Report - Nevada State Health Division ...

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ACRONYMS AOA American Osteopathic Association BHCQC Bureau of Health Care Quality and Compliance CDC Centers for Disease Control and Prevention CMS Centers for Medicare and Medicaid Services DNV Det Norske Veritas HAC hospital-acquired condition HAI healthcare-associated infection TJC The Joint Commission NAC Nevada Administrative Code NHSN National Healthcare Safety Network NRS Nevada Revised Statutes NSHD Nevada State Health Division 2009 Annual Hospitals Report Page | v
INTRODUCTION 2009 Annual Hospitals Report This first annual report provides information concerning the regulation of hospitals in Nevada. The intent is two-fold: first, to provide insight on any systemic issues that may be affecting facilities of this type, and second, to identify areas for each facility where improvements with the most immediate impact can be made, either by the facilities themselves or in collaboration with NSHD. The report is a work-in-progress, meaning that future editions of the report will reflect improvements and innovations in measuring quality of care. These supplemental response documents will contain tangible and measurable actions representing improvements that will have been made at various hospitals in Nevada to elevate the quality of care provided. The data provided in this report is based on calendar year 2009. The report begins with an overview of hospitals followed by individual profiles for each. The individual profiles are presented to inform both the public and each hospital of the findings for each and are followed by responses to the findings from the hospitals themselves or the organizations that govern them. The reader should use caution if attempting to compare facilities as the comparability is limited on account of differences in patient populations, geographic location, and facility resources. A considerable effort has been made to ensure the accuracy of the data contained in the profiles. It is the sincere hope of the Health Division that through regular public reporting and collaboration with facilities we can identify and jointly address the issues that impact the quality of care provided at healthcare facilities in Nevada. The Health Division encourages healthcare facilities to strive to provide the highest level of care possible, and to seek the assistance of the division to meet our common goals. Page | 1
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Page 11 and 12: HOW TO USE THIS REPORT 2009 Annual
Page 13 and 14: Inspections Inspections conducted b
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Page 33 and 34: For all hospitals, the most common
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Page 49 and 50: Findings from the Infection Risk As
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Page 53 and 54: Tracking Healthcare-Associated Infe
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Hospital Inpatient Dataset Overview
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Hospital-Acquired Conditions 2009 A
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2009 Annual Hospitals Report Advers
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2009 Annual Hospitals Report NSHD a
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HOSPITALS NRS 449.012 defines a hos
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2009 Annual Hospitals Report how to
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2009 Annual Hospitals Report Banner
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Battle Mountain General Hospital ad
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BHC West Hills Hospital address: 12
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Boulder City Hospital address: 901
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Boulder City Hospital‘s Response
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Carson Tahoe Regional Medical Cente
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2009 Annual Hospitals Report Carson
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3B: How will the organization measu
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2009 Annual Hospitals Report Centen
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ContinueCARE Hospital of Carson Tah
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2009 Annual Hospitals Report Contin
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Desert Springs Hospital Medical Cen
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3A: What is the long-term improveme
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Desert Willow Treatment Center addr
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Dini-Townsend Hospital at Northern
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2009 Annual Hospitals Report Dini-T
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Grover C Dils Medical Center addres
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2009 Annual Hospitals Report These
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2009 Annual Hospitals Report Harmon
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HealthSouth Hospital at Tenaya addr
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2009 Annual Hospitals Report Health
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HealthSouth Rehabilitation Hospital
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HealthSouth Rehabilitation Hospital
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Incline Village Community Hospital
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2009 Annual Hospitals Report Inclin
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Kindred Hospital - Las Vegas (Flami
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2009 Annual Hospitals Report Kindre
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GOAL 6: Reduce the risk of patient
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Mesa View Regional Hospital address
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Montevista Hospital address: 5900 W
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Montevista Hospital‘s Response to
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2009 Annual Hospitals Report Mounta
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North Vista Hospital‘s Response t
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Northeastern Nevada Regional Hospit
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Northern Nevada Medical Center addr
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Pershing General Hospital address:
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2009 Annual Hospitals Report Pershi
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Renown Regional Medical Center addr
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Renown South Meadows Medical Center
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2009 Annual Hospitals Report Vascul
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2009 Annual Hospitals Report Saint
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Seven Hills Behavioral Institute ad
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2009 Annual Hospitals Report Sierra
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Southern Hills Hospital and Medical
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4: Please give a statement of commi
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2009 Annual Hospitals Report b) Imp
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Spring Mountain Sahara address: 546
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2009 Annual Hospitals Report Spring
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Spring Valley Hospital Medical Cent
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2009 Annual Hospitals Report St. Ro
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St. Rose Dominican Hospitals - San
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2009 Annual Hospitals Report St. Ro
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Summerlin Hospital Medical Center a
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2009 Annual Hospitals Report Sunris
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Tahoe Pacific Hospitals - Meadows a
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2009 Annual Hospitals Report Tahoe
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University Medical Center of Southe
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2009 Annual Hospitals Report Univer
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University Medical Center Rancho Re
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Valley Hospital Medical Center addr
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Willow Springs Center address: 690
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Willow Springs Center‘s Response
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APPENDICES Appendix A 2009 Annual H
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Level 1 Level 2 Level 3 Level 4 Lev
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2009 Annual Hospitals Report defici
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Appendix B DEFICIENCIES CITED IN 20
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DEFICIENCIES CITED IN 2009 deficien
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Appendix C URBAN HOSPITALS LICENSED
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Appendix D RURAL HOSPITALS LICENSED
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