St Mary Mercy Hospital


About the Facility

CMS Certification Number (CCN)
23T002
Ownership Type
Non-profit
CMS Region
Chicago
Certification Date
Address
36475 Five Mile Road
Phone Number
(734) 655-2815

Facility Medical Condition Statistics

All other conditions
40
Brain disease or condition (non-traumatic)
15
Brain injury (traumatic)
22
Hip or femur fracture
-
Hip or knee replacement, amputation or other bone or joint condition
26
Nervous system disorder (excluding stroke)
48
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
94

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
462
Predicted number of infections (B)
0.879
Number of infections reported (A)
2
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
257
Denominator
257
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
11.4
Denominator
214
Average observed change score
11.7
Change in patients ability to move around
Average risk-adjusted change score
29.5
Denominator
214
Average observed change score
31.1
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
109
Denominator
214
Facility rate
50.9
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
111
Denominator
214
Facility rate
51.9
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
2
Denominator
257
Facility rate
0.8
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.024
SIR 95% confidence interval - upper limit
2.413
Comparative performance category
No Different than the National Benchmark
Patient days
4,675
Predicted number of infections (B)
2.044
Number of infections reported (A)
1
SIR (A/B)
0.489
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
Not Available
Number of health care workers
Not Available
Rate of flu vaccination
Not Available
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
19
Number of eligible stays
218
Unadjusted potentially preventable readmission rate
8.72
Risk-standardized potentially preventable readmission rate (RSRR)
8.30
Lower limit of the 95% confidence interval on the RSRR
6.57
Upper limit of the 95% confidence interval on the RSRR
10.28
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
5
Number of eligible stays
229
Unadjusted potentially preventable readmission rate
2.18
Risk-standardized potentially preventable readmission rate (RSRR)
3.90
Lower limit of the 95% confidence interval on the RSRR
2.58
Upper limit of the 95% confidence interval on the RSRR
6.18
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)
128
Number of eligible stays
176
Observed discharge to community rate
72.73
Risk-standardized discharge to community rate
72.86
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
67.46
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
78.72
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.96
Number of eligible episodes
207
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
256
Denominator
257
Facility rate
99.6
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
4
Denominator
257
Facility observed rate
1.6
Facility risk-adjusted rate
2.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
31
Number of health care workers
41
Rate of COVID-19 vaccination
75.6