Mercy Hospital Jefferson


About the Facility

CMS Certification Number (CCN)
26T023
Ownership Type
Non-profit
CMS Region
Kansas City
Certification Date
Address
Hwy 61 South
Po Box 350
Phone Number
(636) 933-1000

Facility Medical Condition Statistics

All other conditions
19
Brain disease or condition (non-traumatic)
11
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
13
Hip or knee replacement, amputation or other bone or joint condition
20
Nervous system disorder (excluding stroke)
63
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
-
Stroke
64

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
325
Predicted number of infections (B)
0.618
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
206
Denominator
206
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
12.8
Denominator
177
Average observed change score
15.1
Change in patients ability to move around
Average risk-adjusted change score
30.9
Denominator
177
Average observed change score
30.8
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
107
Denominator
177
Facility rate
60.5
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
101
Denominator
177
Facility rate
57.1
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
206
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
1.828
Comparative performance category
No Different than the National Benchmark
Patient days
3,748
Predicted number of infections (B)
1.639
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
27
Number of health care workers
27
Rate of flu vaccination
100.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
20
Number of eligible stays
246
Unadjusted potentially preventable readmission rate
8.13
Risk-standardized potentially preventable readmission rate (RSRR)
7.99
Lower limit of the 95% confidence interval on the RSRR
6.42
Upper limit of the 95% confidence interval on the RSRR
10.02
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
9
Number of eligible stays
268
Unadjusted potentially preventable readmission rate
3.36
Risk-standardized potentially preventable readmission rate (RSRR)
4.09
Lower limit of the 95% confidence interval on the RSRR
2.99
Upper limit of the 95% confidence interval on the RSRR
5.39
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)
138
Number of eligible stays
211
Observed discharge to community rate
65.40
Risk-standardized discharge to community rate
67.82
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
61.56
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.20
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.94
Number of eligible episodes
231
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
206
Denominator
206
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
1
Denominator
206
Facility observed rate
0.5
Facility risk-adjusted rate
0.6
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
27
Number of health care workers
27
Rate of COVID-19 vaccination
100.0