St. Marys Hospital and Medical Center Inc


About the Facility

CMS Certification Number (CCN)
06T023
Ownership Type
Non-profit
CMS Region
Denver
Certification Date
Address
2635 7th St
Box 1628
Phone Number
(970) 298-7646

Facility Medical Condition Statistics

All other conditions
95
Brain disease or condition (non-traumatic)
47
Brain injury (traumatic)
41
Hip or femur fracture
44
Hip or knee replacement, amputation or other bone or joint condition
46
Nervous system disorder (excluding stroke)
36
Spinal cord disease or condition (non-traumatic)
25
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
104

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.037
SIR 95% confidence interval - upper limit
3.637
Comparative performance category
No Different than the National Benchmark
Catheter days
655
Predicted number of infections (B)
1.356
Number of infections reported (A)
1
SIR (A/B)
0.737
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
430
Denominator
430
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
12.2
Denominator
376
Average observed change score
13.7
Change in patients ability to move around
Average risk-adjusted change score
32.7
Denominator
376
Average observed change score
36.1
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
223
Denominator
376
Facility rate
59.3
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
237
Denominator
376
Facility rate
63.0
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
430
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.016
SIR 95% confidence interval - upper limit
1.545
Comparative performance category
No Different than the National Benchmark
Patient days
6,808
Predicted number of infections (B)
3.193
Number of infections reported (A)
1
SIR (A/B)
0.313
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
93
Number of health care workers
137
Rate of flu vaccination
67.9
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
29
Number of eligible stays
391
Unadjusted potentially preventable readmission rate
7.42
Risk-standardized potentially preventable readmission rate (RSRR)
8.80
Lower limit of the 95% confidence interval on the RSRR
6.97
Upper limit of the 95% confidence interval on the RSRR
11.01
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
24
Number of eligible stays
430
Unadjusted potentially preventable readmission rate
5.58
Risk-standardized potentially preventable readmission rate (RSRR)
5.48
Lower limit of the 95% confidence interval on the RSRR
3.93
Upper limit of the 95% confidence interval on the RSRR
7.04
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)
235
Number of eligible stays
342
Observed discharge to community rate
68.71
Risk-standardized discharge to community rate
67.14
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
62.82
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
71.19
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.96
Number of eligible episodes
393
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
417
Denominator
430
Facility rate
97.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
430
Facility observed rate
0.5
Facility risk-adjusted rate
0.6
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
51
Number of health care workers
68
Rate of COVID-19 vaccination
75.0