MERCY MEDICAL CENTER

CMS Certification Number

36T070

Ownership Type

Non-profit

Catheter-associated urinary tract infections (CAUTI) - Standardized infection ratio (SIR) 95% confidence interval - lower limit

Not Available

6,7

Other Measure

Not Available

6,7

Catheter-associated urinary tract infections (CAUTI) - Comparative performance category

Not Available

6,7

Catheter-associated urinary tract infections (CAUTI) - Catheter days

376

-

Catheter-associated urinary tract infections (CAUTI) - Predicted number of infections (B)

0.929

-

Catheter-associated urinary tract infections (CAUTI) - Number of infections reported (A)

0

-

Catheter-associated urinary tract infections (CAUTI)

Not Available

6,7

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan - Denominator

212

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan - Numerator

212

-

Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan

100.0

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay - Denominator

212

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay - Numerator

0

-

Percentage of IRF patients who experience one or more falls with major injury during their IRF stay

0.0

-

Change in patients' ability to care for themselves

9.3

-

Change in patients' ability to care for themselves - Denominator

189

-

Change in patients' ability to care for themselves - Average observed change score

10.3

-

Change in patients' ability to move around

24.7

-

Change in patients' ability to move around - Denominator

189

-

Change in patients' ability to move around - Average observed change score

27.3

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Denominator

189

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Numerator

66

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge

34.9

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Denominator

189

-

Percentage of patients who are at or above an expected ability to care for themselves at discharge - Numerator

74

-

Percentage of patients who are at or above an expected ability to move around at discharge

39.2

-

Clostridium difficile Infection (CDI) - Standardized infection ratio (SIR) 95% confidence interval - lower limit

0.032

-

Clostridium difficile Infection (CDI) - SIR 95% confidence interval - upper limit

3.195

-

Clostridium difficile Infection (CDI) - Comparative performance category

No Different than the National Benchmark

-

Clostridium difficile Infection (CDI) - Patient days

3,655

-

Clostridium difficile Infection (CDI) - Predicted number of infections (B)

1.544

-

Clostridium difficile Infection (CDI) - Number of infections reported (A)

1

-

Clostridium difficile Infection (CDI)

0.648

-

Percentage of healthcare personnel who got a flu shot for the current season - Number of health care workers

26

-

Percentage of healthcare personnel who got a flu shot for the current season - Number of health care workers vaccinated

22

-

Percentage of healthcare personnel who got a flu shot for the current season

84.6

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Comparative performance category

No Different than the National Rate

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Unadjusted potentially preventable readmission rate

6.32

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Number of potentially preventable readmissions following discharge

12

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF

8.42

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Lower limit of the 95% confidence interval on the RSRR

6.58

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Upper limit of the 95% confidence interval on the RSRR

10.77

-

Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF - Number of eligible stays

190

-

Rate of potentially preventable hospital readmissions during the IRF stay - Comparative performance category

No Different than the National Rate

-

Rate of potentially preventable hospital readmissions during the IRF stay - Unadjusted potentially preventable readmission rate

1.96

-

Rate of potentially preventable hospital readmissions during the IRF stay - Number of potentially preventable readmissions

4

-

Rate of potentially preventable hospital readmissions during the IRF stay

4.22

-

Rate of potentially preventable hospital readmissions during the IRF stay - Lower limit of the 95% confidence interval on the RSRR

2.86

-

Rate of potentially preventable hospital readmissions during the IRF stay - Upper limit of the 95% confidence interval on the RSRR

6.00

-

Rate of potentially preventable hospital readmissions during the IRF stay - Number of eligible stays

204

-

Rate of successful return to home or community from an IRF - Comparative performance category

No Different than the National Rate

-

Rate of successful return to home or community from an IRF - Observed number of discharges to community (DTC)

124

-

Rate of successful return to home or community from an IRF - Observed discharge to community rate

74.70

-

Rate of successful return to home or community from an IRF

67.89

-

Rate of successful return to home or community from an IRF - Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate

62.50

-

Rate of successful return to home or community from an IRF - Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate

72.58

-

Rate of successful return to home or community from an IRF - Number of eligible stays

166

-

Medicare Spending Per Beneficiary (MSPB) for patients in IRFs - Number of eligible episodes

198

-

Medicare Spending Per Beneficiary (MSPB) for patients in IRFs

0.94

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified - Denominator

212

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified - Numerator

184

-

Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified

86.8

-

Other Measure

2.1

-

Other Measure

212

-

Other Measure

4

-

Percentage of patients with pressure ulcers/pressure injuries that are new or worsened

1.9

-

Other Measure

26

-

Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series - Number of health care workers vaccinated

23

-

Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series

88.5

-