Section 439.915 - Mandatory reports of sentinel events: Submission; form and contents1. A report submitted pursuant to NRS 439.835 must be submitted in the format prescribed pursuant to subsection 4 and must include, without limitation: (a) The unique identification code assigned to the medical facility by the Division pursuant to subsection 5;(b) The name of the person who is making the report;(c) The date on which the sentinel event occurred;(d) The date that the medical facility was notified of the occurrence of the sentinel event;(e) If the patient resides in this State, the county in which the patient resides;(f) If the patient does not reside in this State, the state or country in which the patient resides;(g) The date of birth of the patient;(h) The sex of the patient;(i) A description of the sentinel event; and(j) The department of the medical facility at which the sentinel event occurred.2. Within 45 days after receiving notification or becoming aware of the occurrence of a sentinel event pursuant to subsection 1 or 2 of NRS 439.835, the patient safety officer of the medical facility in which the sentinel event occurred must submit a second report to the Division. A report required by this subsection must be submitted in the format prescribed pursuant to subsection 4 and must include, without limitation: (a) The factors that contributed to the sentinel event, including, without limitation: (1) Any medical or other condition of the patient;(2) Any policy, procedure or process of the medical facility;(3) Any environmental condition of the medical facility;(4) Any behavior of a member of the staff of the medical facility;(5) Any situation present at the medical facility; and(6) Any problem involving communication or documentation at the medical facility.(b) The corrective actions, if any, identified pursuant to NAC 439.917 that will be taken by the medical facility to address the factors that contributed to the sentinel event, including, without limitation:(1) A review of the policies, procedures or processes of the medical facility;(2) Any change or development of the policies, procedures or processes of the medical facility;(3) Any disciplinary actions taken against a member of the staff of the medical facility by the medical facility;(4) Any environmental or equipment changes made in the medical facility;(5) Any education or retraining provided to the staff of the medical facility;(6) The date by which each corrective action will be completed; and(7) The title of the person who is responsible for overseeing each corrective action.(c) A copy of the plan to remedy the causes or contributing factors, or both, of the sentinel event developed pursuant to subsection 3 of NAC 439.917 or the statement prepared pursuant to subsection 4 of that section.3. A report submitted pursuant to subsection 1 must indicate the date that the report was submitted to the Division. Proof satisfactory to the Division of the date that a report was submitted includes: (a) The postmark on the package in which the report was submitted to the Division;(b) The date stamp created by a facsimile machine used to transmit the report to the Division;(c) The electronic date stamp created by a program of electronic mail used to transmit the report to the Division; and(d) Any other evidence acceptable to the Division, as indicated on the form created by the Division pursuant to subsection 4.4. The Division shall develop the format for each report required by subsection 1 or 2, which must require, without limitation, the reporting of information relating to sentinel events. The Division shall distribute copies of the forms created pursuant to this subsection to each medical facility in this State. The Division shall notify medical facilities that an update to a form is available within 30 days after making a change to a form.5. The Division shall assign a unique identification code to each medical facility in this State, to be used on the reports required by subsections 1 and 2.Nev. Admin. Code § 439.915
Added to NAC by Health Div. by R118-04, eff. 11-4-2004; A by Bd. of Health by R044-10, 10-15-2010; Added to NAC by Health Div. by R118-04, eff. 11-4-2004; A by Bd. of Health by R044-10, 10-15-2010; R104-12, 10/24/2014