Baptist Memorial Hospital North Mississippi


About the Facility

CMS Certification Number (CCN)
25T034
Ownership Type
Non-profit
CMS Region
Atlanta
Certification Date
Address
1100 Belk Blvd.
Phone Number
(662) 636-4152

Facility Medical Condition Statistics

All other conditions
35
Brain disease or condition (non-traumatic)
17
Brain injury (traumatic)
-
Hip or femur fracture
45
Hip or knee replacement, amputation or other bone or joint condition
22
Nervous system disorder (excluding stroke)
Data not available for this reporting period.
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
-
Stroke
27

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
40
Predicted number of infections (B)
0.108
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
155
Denominator
155
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
10.8
Denominator
147
Average observed change score
10.6
Change in patients ability to move around
Average risk-adjusted change score
25.9
Denominator
147
Average observed change score
25.4
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
72
Denominator
147
Facility rate
49.0
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
60
Denominator
147
Facility rate
40.8
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
155
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
2,064
Predicted number of infections (B)
0.650
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
22
Number of health care workers
26
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
16
Number of eligible stays
261
Unadjusted potentially preventable readmission rate
6.13
Risk-standardized potentially preventable readmission rate (RSRR)
8.40
Lower limit of the 95% confidence interval on the RSRR
6.64
Upper limit of the 95% confidence interval on the RSRR
10.76
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
11
Number of eligible stays
278
Unadjusted potentially preventable readmission rate
3.96
Risk-standardized potentially preventable readmission rate (RSRR)
5.42
Lower limit of the 95% confidence interval on the RSRR
3.86
Upper limit of the 95% confidence interval on the RSRR
7.47
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)
178
Number of eligible stays
224
Observed discharge to community rate
79.46
Risk-standardized discharge to community rate
69.17
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
65.30
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.87
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.78
Number of eligible episodes
252
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
153
Denominator
155
Facility rate
98.7
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
155
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
16
Number of health care workers
17
Rate of COVID-19 vaccination
94.1