Madonna Rehabilitation Hospital Lincoln


About the Facility

CMS Certification Number (CCN)
283025
Ownership Type
Non-profit
CMS Region
Kansas City
Certification Date
Address
5401 South St
Phone Number
(402) 413-3000

Facility Medical Condition Statistics

All other conditions
27
Brain disease or condition (non-traumatic)
Data not available for this reporting period.
Brain injury (traumatic)
29
Hip or femur fracture
Data not available for this reporting period.
Hip or knee replacement, amputation or other bone or joint condition
28
Nervous system disorder (excluding stroke)
Data not available for this reporting period.
Spinal cord disease or condition (non-traumatic)
33
Spinal cord injury (traumatic)
25
Stroke
86

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.312
SIR 95% confidence interval - upper limit
2.366
Comparative performance category
No Different than the National Benchmark
Catheter days
1,999
Predicted number of infections (B)
4.078
Number of infections reported (A)
4
SIR (A/B)
0.981
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
245
Denominator
245
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
11.1
Denominator
208
Average observed change score
11.4
Change in patients ability to move around
Average risk-adjusted change score
23.4
Denominator
208
Average observed change score
22.0
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
103
Denominator
208
Facility rate
49.5
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
80
Denominator
208
Facility rate
38.5
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
2
Denominator
245
Facility rate
0.8
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.135
SIR 95% confidence interval - upper limit
1.449
Comparative performance category
No Different than the National Benchmark
Patient days
16,840
Predicted number of infections (B)
5.636
Number of infections reported (A)
3
SIR (A/B)
0.532
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
754
Number of health care workers
1,278
Rate of flu vaccination
59.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
13
Number of eligible stays
199
Unadjusted potentially preventable readmission rate
6.53
Risk-standardized potentially preventable readmission rate (RSRR)
8.45
Lower limit of the 95% confidence interval on the RSRR
6.61
Upper limit of the 95% confidence interval on the RSRR
10.57
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
217
Unadjusted potentially preventable readmission rate
2.30
Risk-standardized potentially preventable readmission rate (RSRR)
4.24
Lower limit of the 95% confidence interval on the RSRR
3.03
Upper limit of the 95% confidence interval on the RSRR
5.98
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)
132
Number of eligible stays
181
Observed discharge to community rate
72.93
Risk-standardized discharge to community rate
68.21
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
62.75
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.21
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
229
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
243
Denominator
245
Facility rate
99.2
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
4
Denominator
245
Facility observed rate
1.6
Facility risk-adjusted rate
1.7
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
1,337
Number of health care workers
1,414
Rate of COVID-19 vaccination
94.6