Mercyone Dubuque Medical Center


About the Facility

CMS Certification Number (CCN)
16T069
Ownership Type
Non-profit
CMS Region
Kansas City
Certification Date
Address
250 Mercy Drive
Dubuque, Iowa 52001
Phone Number
(563) 589-8488

Facility Medical Condition Statistics

All other conditions
15
Brain disease or condition (non-traumatic)
Data not available for this reporting period.
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
12
Hip or knee replacement, amputation or other bone or joint condition
Data not available for this reporting period.
Nervous system disorder (excluding stroke)
Data not available for this reporting period.
Spinal cord disease or condition (non-traumatic)
33
Spinal cord injury (traumatic)
-
Stroke
42

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
112
Predicted number of infections (B)
0.304
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
117
Denominator
117
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
13.1
Denominator
106
Average observed change score
14.7
Change in patients ability to move around
Average risk-adjusted change score
28.5
Denominator
106
Average observed change score
31.4
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
72
Denominator
106
Facility rate
67.9
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
50
Denominator
106
Facility rate
47.2
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
117
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
Not Available
Comparative performance category
Not Available
Patient days
1,876
Predicted number of infections (B)
0.723
Number of infections reported (A)
0
SIR (A/B)
Not Available
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
258
Number of health care workers
573
Rate of flu vaccination
45.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
4
Number of eligible stays
61
Unadjusted potentially preventable readmission rate
6.56
Risk-standardized potentially preventable readmission rate (RSRR)
8.65
Lower limit of the 95% confidence interval on the RSRR
6.45
Upper limit of the 95% confidence interval on the RSRR
11.44
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
1
Number of eligible stays
65
Unadjusted potentially preventable readmission rate
1.54
Risk-standardized potentially preventable readmission rate (RSRR)
4.57
Lower limit of the 95% confidence interval on the RSRR
2.61
Upper limit of the 95% confidence interval on the RSRR
6.64
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)
39
Number of eligible stays
54
Observed discharge to community rate
72.22
Risk-standardized discharge to community rate
66.60
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
58.95
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.33
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
56
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
117
Denominator
117
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
1
Denominator
115
Facility observed rate
0.9
Facility risk-adjusted rate
0.9
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
1,864
Number of health care workers
2,107
Rate of COVID-19 vaccination
88.5