Baptist Health System


About the Facility

CMS Certification Number (CCN)
45T058
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
7930 Floyd Curl
Phone Number
(210) 297-5192

Facility Medical Condition Statistics

All other conditions
356
Brain disease or condition (non-traumatic)
67
Brain injury (traumatic)
35
Hip or femur fracture
130
Hip or knee replacement, amputation or other bone or joint condition
181
Nervous system disorder (excluding stroke)
53
Spinal cord disease or condition (non-traumatic)
32
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
228

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.203
SIR 95% confidence interval - upper limit
2.171
Comparative performance category
No Different than the National Benchmark
Catheter days
2,137
Predicted number of infections (B)
3.760
Number of infections reported (A)
3
SIR (A/B)
0.798
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
1,062
Denominator
1,065
Facility rate
99.7
Change in patients ability to care for themselves
Average risk-adjusted change score
10.8
Denominator
895
Average observed change score
10.5
Change in patients ability to move around
Average risk-adjusted change score
25.0
Denominator
896
Average observed change score
24.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
458
Denominator
897
Facility rate
51.1
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
363
Denominator
897
Facility rate
40.5
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
2
Denominator
1,065
Facility rate
0.2
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
0.217
Comparative performance category
Better than the National Benchmark
Patient days
27,307
Predicted number of infections (B)
13.792
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
261
Number of health care workers
291
Rate of flu vaccination
89.7
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
75
Number of eligible stays
1,048
Unadjusted potentially preventable readmission rate
7.16
Risk-standardized potentially preventable readmission rate (RSRR)
8.20
Lower limit of the 95% confidence interval on the RSRR
6.87
Upper limit of the 95% confidence interval on the RSRR
9.62
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
61
Number of eligible stays
1,183
Unadjusted potentially preventable readmission rate
5.16
Risk-standardized potentially preventable readmission rate (RSRR)
5.85
Lower limit of the 95% confidence interval on the RSRR
4.87
Upper limit of the 95% confidence interval on the RSRR
7.38
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)
632
Number of eligible stays
954
Observed discharge to community rate
66.25
Risk-standardized discharge to community rate
64.32
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
61.65
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
67.01
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.01
Number of eligible episodes
1,031
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
1,043
Denominator
1,065
Facility rate
97.9
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
22
Denominator
1,063
Facility observed rate
2.1
Facility risk-adjusted rate
2.2
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
160
Number of health care workers
162
Rate of COVID-19 vaccination
98.8