St Marys Hospital


About the Facility

CMS Certification Number (CCN)
24T010
Ownership Type
Non-profit
CMS Region
Chicago
Certification Date
Address
1216 2 St. Sw
200 First Street Sw
Phone Number
(507) 538-4168

Facility Medical Condition Statistics

All other conditions
43
Brain disease or condition (non-traumatic)
45
Brain injury (traumatic)
19
Hip or femur fracture
-
Hip or knee replacement, amputation or other bone or joint condition
35
Nervous system disorder (excluding stroke)
16
Spinal cord disease or condition (non-traumatic)
53
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
117

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
358
Predicted number of infections (B)
0.923
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
332
Denominator
335
Facility rate
99.1
Change in patients ability to care for themselves
Average risk-adjusted change score
9.1
Denominator
274
Average observed change score
9.6
Change in patients ability to move around
Average risk-adjusted change score
23.8
Denominator
274
Average observed change score
25.1
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
84
Denominator
274
Facility rate
30.7
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
87
Denominator
274
Facility rate
31.8
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
335
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.499
SIR 95% confidence interval - upper limit
2.561
Comparative performance category
No Different than the National Benchmark
Patient days
8,937
Predicted number of infections (B)
4.873
Number of infections reported (A)
6
SIR (A/B)
1.231
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
209
Number of health care workers
247
Rate of flu vaccination
84.6
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
362
Unadjusted potentially preventable readmission rate
6.91
Risk-standardized potentially preventable readmission rate (RSRR)
8.81
Lower limit of the 95% confidence interval on the RSRR
7.02
Upper limit of the 95% confidence interval on the RSRR
10.78
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
10
Number of eligible stays
385
Unadjusted potentially preventable readmission rate
2.60
Risk-standardized potentially preventable readmission rate (RSRR)
4.00
Lower limit of the 95% confidence interval on the RSRR
2.84
Upper limit of the 95% confidence interval on the RSRR
5.67
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)
228
Number of eligible stays
306
Observed discharge to community rate
74.51
Risk-standardized discharge to community rate
70.70
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
66.11
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
74.24
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.93
Number of eligible episodes
322
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
331
Denominator
335
Facility rate
98.8
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
1
Denominator
335
Facility observed rate
0.3
Facility risk-adjusted rate
0.4
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
215
Number of health care workers
220
Rate of COVID-19 vaccination
97.7