Bethesda Rehabilitation Hospital


About the Facility

CMS Certification Number (CCN)
193092
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
7414 Sumrall Drive, Suite A
Phone Number
(225) 767-2034

Facility Medical Condition Statistics

All other conditions
Data not available for this reporting period.
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
-
Hip or knee replacement, amputation or other bone or joint condition
23
Nervous system disorder (excluding stroke)
30
Spinal cord disease or condition (non-traumatic)
-
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
34

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
0
Predicted number of infections (B)
Not Available
Number of infections reported (A)
Not Available
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
96
Denominator
96
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
16.4
Denominator
89
Average observed change score
15.0
Change in patients ability to move around
Average risk-adjusted change score
42.5
Denominator
89
Average observed change score
35.8
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
79
Denominator
89
Facility rate
88.8
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
79
Denominator
89
Facility rate
88.8
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
96
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
Not Available
Predicted number of infections (B)
Not Available
Number of infections reported (A)
Not Available
SIR (A/B)
Not Available
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
9
Number of health care workers
48
Rate of flu vaccination
18.8
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
Not Available
Number of eligible stays
19
Unadjusted potentially preventable readmission rate
Not Available
Risk-standardized potentially preventable readmission rate (RSRR)
Not Available
Lower limit of the 95% confidence interval on the RSRR
Not Available
Upper limit of the 95% confidence interval on the RSRR
Not Available
Comparative performance category
Not Available
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
Not Available
Number of eligible stays
19
Unadjusted potentially preventable readmission rate
Not Available
Risk-standardized potentially preventable readmission rate (RSRR)
Not Available
Lower limit of the 95% confidence interval on the RSRR
Not Available
Upper limit of the 95% confidence interval on the RSRR
Not Available
Comparative performance category
Not Available
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
Not Available
Number of eligible stays
12
Observed discharge to community rate
Not Available
Risk-standardized discharge to community rate
Not Available
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
Not Available
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
Not Available
Comparative performance category
Not Available
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.82
Number of eligible episodes
133
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
89
Denominator
96
Facility rate
92.7
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
95
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
39
Number of health care workers
48
Rate of COVID-19 vaccination
81.3