University of Colorado Health - Memorial Health


About the Facility

CMS Certification Number (CCN)
06T022
Ownership Type
Government
CMS Region
Denver
Certification Date
Address
Memorial Hospital Central
1400 E. Boulder
Phone Number
(719) 365-2702

Facility Medical Condition Statistics

All other conditions
55
Brain disease or condition (non-traumatic)
24
Brain injury (traumatic)
14
Hip or femur fracture
37
Hip or knee replacement, amputation or other bone or joint condition
65
Nervous system disorder (excluding stroke)
11
Spinal cord disease or condition (non-traumatic)
16
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
90

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
97
Predicted number of infections (B)
0.221
Number of infections reported (A)
0
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
317
Denominator
318
Facility rate
99.7
Change in patients ability to care for themselves
Average risk-adjusted change score
13.3
Denominator
300
Average observed change score
16.0
Change in patients ability to move around
Average risk-adjusted change score
34.4
Denominator
300
Average observed change score
38.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
202
Denominator
300
Facility rate
67.3
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
205
Denominator
300
Facility rate
68.3
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
318
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.020
SIR 95% confidence interval - upper limit
1.967
Comparative performance category
No Different than the National Benchmark
Patient days
6,524
Predicted number of infections (B)
2.508
Number of infections reported (A)
1
SIR (A/B)
0.399
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
37
Number of health care workers
37
Rate of flu vaccination
100.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
13
Number of eligible stays
396
Unadjusted potentially preventable readmission rate
3.28
Risk-standardized potentially preventable readmission rate (RSRR)
7.01
Lower limit of the 95% confidence interval on the RSRR
5.45
Upper limit of the 95% confidence interval on the RSRR
8.93
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
10
Number of eligible stays
419
Unadjusted potentially preventable readmission rate
2.39
Risk-standardized potentially preventable readmission rate (RSRR)
3.85
Lower limit of the 95% confidence interval on the RSRR
2.86
Upper limit of the 95% confidence interval on the RSRR
5.72
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)
256
Number of eligible stays
350
Observed discharge to community rate
73.14
Risk-standardized discharge to community rate
70.44
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
66.25
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
74.13
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.93
Number of eligible episodes
404
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
315
Denominator
318
Facility rate
99.1
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
318
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
1,062
Number of health care workers
1,076
Rate of COVID-19 vaccination
98.7