Mercy Medical Center - Cedar Rapids


About the Facility

CMS Certification Number (CCN)
16T079
Ownership Type
Non-profit
CMS Region
Kansas City
Certification Date
Address
701 Tenth Street Se
Phone Number
(319) 398-6712

Facility Medical Condition Statistics

All other conditions
110
Brain disease or condition (non-traumatic)
28
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
73
Hip or knee replacement, amputation or other bone or joint condition
58
Nervous system disorder (excluding stroke)
46
Spinal cord disease or condition (non-traumatic)
11
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
73

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
654
Predicted number of infections (B)
0.944
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
400
Denominator
400
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
13.8
Denominator
367
Average observed change score
14.1
Change in patients ability to move around
Average risk-adjusted change score
36.5
Denominator
368
Average observed change score
38.7
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
286
Denominator
368
Facility rate
77.7
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
297
Denominator
368
Facility rate
80.7
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
400
Facility rate
0.3
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.022
SIR 95% confidence interval - upper limit
2.203
Comparative performance category
No Different than the National Benchmark
Patient days
5,145
Predicted number of infections (B)
2.238
Number of infections reported (A)
1
SIR (A/B)
0.447
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
30
Number of health care workers
30
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
25
Number of eligible stays
369
Unadjusted potentially preventable readmission rate
6.78
Risk-standardized potentially preventable readmission rate (RSRR)
7.88
Lower limit of the 95% confidence interval on the RSRR
6.23
Upper limit of the 95% confidence interval on the RSRR
9.68
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
21
Number of eligible stays
415
Unadjusted potentially preventable readmission rate
5.06
Risk-standardized potentially preventable readmission rate (RSRR)
5.55
Lower limit of the 95% confidence interval on the RSRR
3.84
Upper limit of the 95% confidence interval on the RSRR
7.48
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)
234
Number of eligible stays
331
Observed discharge to community rate
70.69
Risk-standardized discharge to community rate
66.40
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
62.07
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
70.27
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.89
Number of eligible episodes
373
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
399
Denominator
400
Facility rate
99.8
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
5
Denominator
399
Facility observed rate
1.3
Facility risk-adjusted rate
1.3
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
31
Number of health care workers
32
Rate of COVID-19 vaccination
96.9