Mercy West Hospital


About the Facility

CMS Certification Number (CCN)
36T234
Ownership Type
Non-profit
CMS Region
Chicago
Certification Date
Address
3300 Mercy Health Blvd
Phone Number
(502) 596-6346

Facility Medical Condition Statistics

All other conditions
64
Brain disease or condition (non-traumatic)
35
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
35
Hip or knee replacement, amputation or other bone or joint condition
42
Nervous system disorder (excluding stroke)
17
Spinal cord disease or condition (non-traumatic)
11
Spinal cord injury (traumatic)
-
Stroke
79

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
253
Predicted number of infections (B)
0.425
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
286
Denominator
287
Facility rate
99.7
Change in patients ability to care for themselves
Average risk-adjusted change score
12.7
Denominator
272
Average observed change score
13.4
Change in patients ability to move around
Average risk-adjusted change score
32.0
Denominator
272
Average observed change score
33.9
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
175
Denominator
272
Facility rate
64.3
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
184
Denominator
272
Facility rate
67.6
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
287
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.034
SIR 95% confidence interval - upper limit
3.309
Comparative performance category
No Different than the National Benchmark
Patient days
4,580
Predicted number of infections (B)
1.490
Number of infections reported (A)
1
SIR (A/B)
0.671
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
169
Number of health care workers
260
Rate of flu vaccination
65.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
24
Number of eligible stays
332
Unadjusted potentially preventable readmission rate
7.23
Risk-standardized potentially preventable readmission rate (RSRR)
8.27
Lower limit of the 95% confidence interval on the RSRR
6.56
Upper limit of the 95% confidence interval on the RSRR
10.13
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
15
Number of eligible stays
352
Unadjusted potentially preventable readmission rate
4.26
Risk-standardized potentially preventable readmission rate (RSRR)
5.07
Lower limit of the 95% confidence interval on the RSRR
3.53
Upper limit of the 95% confidence interval on the RSRR
7.05
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
303
Observed discharge to community rate
74.26
Risk-standardized discharge to community rate
70.17
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
65.52
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
74.07
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
301
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
279
Denominator
287
Facility rate
97.2
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
286
Facility observed rate
0.7
Facility risk-adjusted rate
0.9
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
199
Number of health care workers
221
Rate of COVID-19 vaccination
90.0