St Vincent Hospital


About the Facility

CMS Certification Number (CCN)
32T002
Ownership Type
Non-profit
CMS Region
Dallas
Certification Date
Address
455 St Michaels Drive
Phone Number
(505) 913-5392

Facility Medical Condition Statistics

All other conditions
42
Brain disease or condition (non-traumatic)
Data not available for this reporting period.
Brain injury (traumatic)
12
Hip or femur fracture
86
Hip or knee replacement, amputation or other bone or joint condition
55
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
70

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
335
Predicted number of infections (B)
0.637
Number of infections reported (A)
1
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
275
Denominator
275
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
9.7
Denominator
249
Average observed change score
11.4
Change in patients ability to move around
Average risk-adjusted change score
20.5
Denominator
249
Average observed change score
23.3
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
91
Denominator
249
Facility rate
36.5
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
73
Denominator
249
Facility rate
29.3
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
3
Denominator
275
Facility rate
1.1
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.030
SIR 95% confidence interval - upper limit
2.963
Comparative performance category
No Different than the National Benchmark
Patient days
4,189
Predicted number of infections (B)
1.664
Number of infections reported (A)
1
SIR (A/B)
0.601
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
52
Number of health care workers
70
Rate of flu vaccination
74.3
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
11
Number of eligible stays
320
Unadjusted potentially preventable readmission rate
3.44
Risk-standardized potentially preventable readmission rate (RSRR)
7.79
Lower limit of the 95% confidence interval on the RSRR
5.95
Upper limit of the 95% confidence interval on the RSRR
10.07
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
13
Number of eligible stays
342
Unadjusted potentially preventable readmission rate
3.80
Risk-standardized potentially preventable readmission rate (RSRR)
5.37
Lower limit of the 95% confidence interval on the RSRR
3.51
Upper limit of the 95% confidence interval on the RSRR
6.67
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)
205
Number of eligible stays
286
Observed discharge to community rate
71.68
Risk-standardized discharge to community rate
65.84
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
61.66
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
69.71
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.88
Number of eligible episodes
323
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
97
Denominator
275
Facility rate
35.3
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
274
Facility observed rate
0.7
Facility risk-adjusted rate
1.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
77
Number of health care workers
80
Rate of COVID-19 vaccination
96.3