Northwest Texas Healthcare Sys


About the Facility

CMS Certification Number (CCN)
45T209
Ownership Type
Non-profit
CMS Region
Dallas
Certification Date
Address
1501 S Coulter
Phone Number
(806) 351-5115

Facility Medical Condition Statistics

All other conditions
89
Brain disease or condition (non-traumatic)
44
Brain injury (traumatic)
12
Hip or femur fracture
50
Hip or knee replacement, amputation or other bone or joint condition
51
Nervous system disorder (excluding stroke)
18
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
49

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
633
Predicted number of infections (B)
0.913
Number of infections reported (A)
1
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
309
Denominator
310
Facility rate
99.7
Change in patients ability to care for themselves
Average risk-adjusted change score
13.3
Denominator
277
Average observed change score
14.9
Change in patients ability to move around
Average risk-adjusted change score
35.7
Denominator
277
Average observed change score
39.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
194
Denominator
277
Facility rate
70.0
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
212
Denominator
277
Facility rate
76.5
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
310
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
1.571
Comparative performance category
No Different than the National Benchmark
Patient days
5,356
Predicted number of infections (B)
1.907
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
1,132
Number of health care workers
1,166
Rate of flu vaccination
97.1
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
22
Number of eligible stays
365
Unadjusted potentially preventable readmission rate
6.03
Risk-standardized potentially preventable readmission rate (RSRR)
8.07
Lower limit of the 95% confidence interval on the RSRR
6.37
Upper limit of the 95% confidence interval on the RSRR
10.20
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
6
Number of eligible stays
383
Unadjusted potentially preventable readmission rate
1.57
Risk-standardized potentially preventable readmission rate (RSRR)
3.43
Lower limit of the 95% confidence interval on the RSRR
2.55
Upper limit of the 95% confidence interval on the RSRR
4.95
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)
221
Number of eligible stays
299
Observed discharge to community rate
73.91
Risk-standardized discharge to community rate
69.49
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
65.26
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.60
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.98
Number of eligible episodes
330
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
301
Denominator
310
Facility rate
97.1
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
310
Facility observed rate
0.6
Facility risk-adjusted rate
0.7
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
1,361
Number of health care workers
1,704
Rate of COVID-19 vaccination
79.9