Mercy Regional Medical Center


About the Facility

CMS Certification Number (CCN)
19T167
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
800 E Main St
Phone Number
(337) 360-9714

Facility Medical Condition Statistics

All other conditions
41
Brain disease or condition (non-traumatic)
11
Brain injury (traumatic)
-
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)
20
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
-
Stroke
41

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
110
Predicted number of infections (B)
0.209
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
127
Denominator
127
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
13.1
Denominator
112
Average observed change score
14.8
Change in patients ability to move around
Average risk-adjusted change score
29.7
Denominator
112
Average observed change score
31.6
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
69
Denominator
112
Facility rate
61.6
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
55
Denominator
112
Facility rate
49.1
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
127
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
1,584
Predicted number of infections (B)
0.693
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
246
Number of health care workers
424
Rate of flu vaccination
58.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
17
Number of eligible stays
185
Unadjusted potentially preventable readmission rate
9.19
Risk-standardized potentially preventable readmission rate (RSRR)
8.78
Lower limit of the 95% confidence interval on the RSRR
6.90
Upper limit of the 95% confidence interval on the RSRR
11.13
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
6
Number of eligible stays
196
Unadjusted potentially preventable readmission rate
3.06
Risk-standardized potentially preventable readmission rate (RSRR)
4.30
Lower limit of the 95% confidence interval on the RSRR
3.10
Upper limit of the 95% confidence interval on the RSRR
6.30
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)
108
Number of eligible stays
159
Observed discharge to community rate
67.92
Risk-standardized discharge to community rate
67.19
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
61.12
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.66
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.05
Number of eligible episodes
163
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
126
Denominator
127
Facility rate
99.2
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
1
Denominator
126
Facility observed rate
0.8
Facility risk-adjusted rate
0.7
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
353
Number of health care workers
434
Rate of COVID-19 vaccination
81.3