Mercy Regional Medical Center


About the Facility

CMS Certification Number (CCN)
36T172
Ownership Type
Non-profit
CMS Region
Chicago
Certification Date
Address
3700 Kolbe Road
Lorain, Ohio 44053
Phone Number
(440) 960-3952

Facility Medical Condition Statistics

All other conditions
52
Brain disease or condition (non-traumatic)
27
Brain injury (traumatic)
21
Hip or femur fracture
23
Hip or knee replacement, amputation or other bone or joint condition
87
Nervous system disorder (excluding stroke)
73
Spinal cord disease or condition (non-traumatic)
38
Spinal cord injury (traumatic)
-
Stroke
80

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.280
SIR 95% confidence interval - upper limit
5.525
Comparative performance category
No Different than the National Benchmark
Catheter days
578
Predicted number of infections (B)
1.196
Number of infections reported (A)
2
SIR (A/B)
1.672
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
360
Denominator
364
Facility rate
98.9
Change in patients ability to care for themselves
Average risk-adjusted change score
11.4
Denominator
312
Average observed change score
12.7
Change in patients ability to move around
Average risk-adjusted change score
34.2
Denominator
312
Average observed change score
37.0
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
175
Denominator
312
Facility rate
56.1
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
217
Denominator
312
Facility rate
69.6
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
364
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
1.332
Comparative performance category
No Different than the National Benchmark
Patient days
4,796
Predicted number of infections (B)
2.249
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
101
Number of health care workers
190
Rate of flu vaccination
53.2
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
28
Number of eligible stays
406
Unadjusted potentially preventable readmission rate
6.90
Risk-standardized potentially preventable readmission rate (RSRR)
7.58
Lower limit of the 95% confidence interval on the RSRR
6.11
Upper limit of the 95% confidence interval on the RSRR
9.23
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
10
Number of eligible stays
440
Unadjusted potentially preventable readmission rate
2.27
Risk-standardized potentially preventable readmission rate (RSRR)
3.70
Lower limit of the 95% confidence interval on the RSRR
2.55
Upper limit of the 95% confidence interval on the RSRR
4.99
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)
225
Number of eligible stays
345
Observed discharge to community rate
65.22
Risk-standardized discharge to community rate
64.10
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
59.66
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
68.39
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.99
Number of eligible episodes
449
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
286
Denominator
364
Facility rate
78.6
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
10
Denominator
351
Facility observed rate
2.8
Facility risk-adjusted rate
3.3
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
173
Number of health care workers
188
Rate of COVID-19 vaccination
92.0