Marian Regional Medical Center


About the Facility

CMS Certification Number (CCN)
05T107
Ownership Type
Non-profit
CMS Region
San Francisco
Certification Date
Address
1400 E Church Street
Phone Number
(502) 596-6346

Facility Medical Condition Statistics

All other conditions
96
Brain disease or condition (non-traumatic)
33
Brain injury (traumatic)
42
Hip or femur fracture
68
Hip or knee replacement, amputation or other bone or joint condition
32
Nervous system disorder (excluding stroke)
16
Spinal cord disease or condition (non-traumatic)
14
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
149

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
Not Available
Comparative performance category
Not Available
Catheter days
273
Predicted number of infections (B)
0.519
Number of infections reported (A)
1
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
445
Denominator
446
Facility rate
99.8
Change in patients ability to care for themselves
Average risk-adjusted change score
12.3
Denominator
418
Average observed change score
13.3
Change in patients ability to move around
Average risk-adjusted change score
27.5
Denominator
418
Average observed change score
28.8
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
254
Denominator
418
Facility rate
60.8
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
183
Denominator
418
Facility rate
43.8
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
446
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
0.997
Comparative performance category
Better than the National Benchmark
Patient days
6,876
Predicted number of infections (B)
3.006
Number of infections reported (A)
0
SIR (A/B)
0.000
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
46
Number of health care workers
57
Rate of flu vaccination
80.7
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
58
Number of eligible stays
727
Unadjusted potentially preventable readmission rate
7.98
Risk-standardized potentially preventable readmission rate (RSRR)
9.44
Lower limit of the 95% confidence interval on the RSRR
7.83
Upper limit of the 95% confidence interval on the RSRR
11.46
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
22
Number of eligible stays
764
Unadjusted potentially preventable readmission rate
2.88
Risk-standardized potentially preventable readmission rate (RSRR)
4.22
Lower limit of the 95% confidence interval on the RSRR
3.35
Upper limit of the 95% confidence interval on the RSRR
6.03
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)
490
Number of eligible stays
641
Observed discharge to community rate
76.44
Risk-standardized discharge to community rate
71.04
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
68.35
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.65
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.86
Number of eligible episodes
671
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
446
Denominator
446
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
446
Facility observed rate
0.0
Facility risk-adjusted rate
0.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
540
Number of health care workers
576
Rate of COVID-19 vaccination
93.8