San Juan Regional Medical Center Inc


About the Facility

CMS Certification Number (CCN)
32T005
Ownership Type
Non-profit
CMS Region
Dallas
Certification Date
Address
801 West Maple Street
Phone Number
(505) 609-2000

Facility Medical Condition Statistics

All other conditions
41
Brain disease or condition (non-traumatic)
13
Brain injury (traumatic)
12
Hip or femur fracture
56
Hip or knee replacement, amputation or other bone or joint condition
34
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)
Data not available for this reporting period.
Stroke
52

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
191
Predicted number of infections (B)
0.276
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
217
Denominator
217
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
11.9
Denominator
208
Average observed change score
13.2
Change in patients ability to move around
Average risk-adjusted change score
33.8
Denominator
208
Average observed change score
37.0
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
127
Denominator
208
Facility rate
61.1
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
147
Denominator
208
Facility rate
70.7
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
217
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
2.076
Comparative performance category
No Different than the National Benchmark
Patient days
3,515
Predicted number of infections (B)
1.443
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
13
Number of health care workers
17
Rate of flu vaccination
76.5
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
15
Number of eligible stays
216
Unadjusted potentially preventable readmission rate
6.94
Risk-standardized potentially preventable readmission rate (RSRR)
9.17
Lower limit of the 95% confidence interval on the RSRR
7.06
Upper limit of the 95% confidence interval on the RSRR
11.60
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
8
Number of eligible stays
228
Unadjusted potentially preventable readmission rate
3.51
Risk-standardized potentially preventable readmission rate (RSRR)
4.97
Lower limit of the 95% confidence interval on the RSRR
3.16
Upper limit of the 95% confidence interval on the RSRR
7.36
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)
145
Number of eligible stays
193
Observed discharge to community rate
75.13
Risk-standardized discharge to community rate
68.46
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
63.43
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
72.78
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.89
Number of eligible episodes
205
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
217
Denominator
217
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
217
Facility observed rate
0.9
Facility risk-adjusted rate
1.1
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
21
Number of health care workers
21
Rate of COVID-19 vaccination
100.0