Christus St. Frances Cabrini Hospital


About the Facility

CMS Certification Number (CCN)
19T019
Ownership Type
Non-profit
CMS Region
Dallas
Certification Date
Address
3330 Masonic Dr.
Phone Number
(318) 561-4163

Facility Medical Condition Statistics

All other conditions
103
Brain disease or condition (non-traumatic)
19
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
79
Hip or knee replacement, amputation or other bone or joint condition
69
Nervous system disorder (excluding stroke)
44
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
47

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
363
Predicted number of infections (B)
0.524
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
373
Denominator
373
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
12.9
Denominator
319
Average observed change score
14.6
Change in patients ability to move around
Average risk-adjusted change score
37.1
Denominator
319
Average observed change score
39.8
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
205
Denominator
319
Facility rate
64.3
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
230
Denominator
319
Facility rate
72.1
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
373
Facility rate
0.3
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
1.093
Comparative performance category
No Different than the National Benchmark
Patient days
6,302
Predicted number of infections (B)
2.742
Number of infections reported (A)
0
SIR (A/B)
0.000
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
58
Number of health care workers
63
Rate of flu vaccination
92.1
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
34
Number of eligible stays
476
Unadjusted potentially preventable readmission rate
7.14
Risk-standardized potentially preventable readmission rate (RSRR)
8.56
Lower limit of the 95% confidence interval on the RSRR
6.86
Upper limit of the 95% confidence interval on the RSRR
10.65
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
518
Unadjusted potentially preventable readmission rate
4.05
Risk-standardized potentially preventable readmission rate (RSRR)
4.87
Lower limit of the 95% confidence interval on the RSRR
3.35
Upper limit of the 95% confidence interval on the RSRR
6.93
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)
304
Number of eligible stays
426
Observed discharge to community rate
71.36
Risk-standardized discharge to community rate
69.25
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
65.48
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.94
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.02
Number of eligible episodes
494
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
364
Denominator
373
Facility rate
97.6
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
371
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
44
Number of health care workers
75
Rate of COVID-19 vaccination
58.7