Legacy Good Samaritan Hosp & Med Ctr


About the Facility

CMS Certification Number (CCN)
38T017
Ownership Type
Non-profit
CMS Region
Seattle
Certification Date
Address
1015 Nw 22nd Avenue
Legacy Good Samaritan Med Ctr
Phone Number
(503) 413-6477

Facility Medical Condition Statistics

All other conditions
Data not available for this reporting period.
Brain disease or condition (non-traumatic)
20
Brain injury (traumatic)
13
Hip or femur fracture
Data not available for this reporting period.
Hip or knee replacement, amputation or other bone or joint condition
19
Nervous system disorder (excluding stroke)
14
Spinal cord disease or condition (non-traumatic)
21
Spinal cord injury (traumatic)
11
Stroke
195

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
209
Predicted number of infections (B)
0.569
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
307
Denominator
307
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
10.0
Denominator
276
Average observed change score
8.9
Change in patients ability to move around
Average risk-adjusted change score
22.6
Denominator
276
Average observed change score
22.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
111
Denominator
276
Facility rate
40.2
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
89
Denominator
276
Facility rate
32.2
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
307
Facility rate
0.3
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.011
SIR 95% confidence interval - upper limit
1.068
Comparative performance category
No Different than the National Benchmark
Patient days
8,952
Predicted number of infections (B)
4.619
Number of infections reported (A)
1
SIR (A/B)
0.216
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
51
Number of health care workers
57
Rate of flu vaccination
89.5
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
4
Number of eligible stays
199
Unadjusted potentially preventable readmission rate
2.01
Risk-standardized potentially preventable readmission rate (RSRR)
7.54
Lower limit of the 95% confidence interval on the RSRR
5.79
Upper limit of the 95% confidence interval on the RSRR
9.87
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
2
Number of eligible stays
209
Unadjusted potentially preventable readmission rate
0.96
Risk-standardized potentially preventable readmission rate (RSRR)
3.89
Lower limit of the 95% confidence interval on the RSRR
2.60
Upper limit of the 95% confidence interval on the RSRR
5.78
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)
140
Number of eligible stays
170
Observed discharge to community rate
82.35
Risk-standardized discharge to community rate
75.66
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
70.82
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
80.21
Comparative performance category
Better than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.81
Number of eligible episodes
184
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
302
Denominator
307
Facility rate
98.4
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
6
Denominator
307
Facility observed rate
2.0
Facility risk-adjusted rate
2.3
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
90
Number of health care workers
90
Rate of COVID-19 vaccination
100.0