Fort Duncan Regional Medical Center


About the Facility

CMS Certification Number (CCN)
45T092
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
3333 N Foster Maldonado Blvd
Phone Number
(830) 872-2990

Facility Medical Condition Statistics

All other conditions
31
Brain disease or condition (non-traumatic)
-
Brain injury (traumatic)
-
Hip or femur fracture
18
Hip or knee replacement, amputation or other bone or joint condition
17
Nervous system disorder (excluding stroke)
64
Spinal cord disease or condition (non-traumatic)
-
Spinal cord injury (traumatic)
-
Stroke
18

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
146
Predicted number of infections (B)
0.212
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
147
Denominator
147
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
17.1
Denominator
132
Average observed change score
19.5
Change in patients ability to move around
Average risk-adjusted change score
29.0
Denominator
132
Average observed change score
27.5
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
122
Denominator
132
Facility rate
92.4
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
84
Denominator
132
Facility rate
63.6
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
147
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
Not Available
Comparative performance category
Not Available
Patient days
2,159
Predicted number of infections (B)
0.915
Number of infections reported (A)
0
SIR (A/B)
Not Available
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
Not Available
Number of health care workers
Not Available
Rate of flu vaccination
Not Available
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
20
Number of eligible stays
151
Unadjusted potentially preventable readmission rate
13.25
Risk-standardized potentially preventable readmission rate (RSRR)
9.24
Lower limit of the 95% confidence interval on the RSRR
7.35
Upper limit of the 95% confidence interval on the RSRR
11.71
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
164
Unadjusted potentially preventable readmission rate
4.88
Risk-standardized potentially preventable readmission rate (RSRR)
4.84
Lower limit of the 95% confidence interval on the RSRR
3.54
Upper limit of the 95% confidence interval on the RSRR
7.35
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)
76
Number of eligible stays
129
Observed discharge to community rate
58.91
Risk-standardized discharge to community rate
64.23
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
56.78
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
70.70
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.00
Number of eligible episodes
180
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
146
Denominator
147
Facility rate
99.3
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
4
Denominator
147
Facility observed rate
2.7
Facility risk-adjusted rate
1.7
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
30
Number of health care workers
30
Rate of COVID-19 vaccination
100.0