Huntsville Memorial Hospital


About the Facility

CMS Certification Number (CCN)
45T347
Ownership Type
Non-profit
CMS Region
Dallas
Certification Date
Address
110 Memorial Hospital Drive
P.o. Box 4001, Huntsville, Tx
Phone Number
(936) 291-3411

Facility Medical Condition Statistics

All other conditions
42
Brain disease or condition (non-traumatic)
13
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
31
Hip or knee replacement, amputation or other bone or joint condition
Data not available for this reporting period.
Nervous system disorder (excluding stroke)
14
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
-
Stroke
19

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
185
Predicted number of infections (B)
0.267
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
125
Denominator
125
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
10.0
Denominator
113
Average observed change score
9.5
Change in patients ability to move around
Average risk-adjusted change score
21.9
Denominator
113
Average observed change score
23.2
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
44
Denominator
113
Facility rate
38.9
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
32
Denominator
113
Facility rate
28.3
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
125
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
1,493
Predicted number of infections (B)
0.720
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
18
Number of health care workers
24
Rate of flu vaccination
75.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
14
Number of eligible stays
112
Unadjusted potentially preventable readmission rate
12.50
Risk-standardized potentially preventable readmission rate (RSRR)
9.51
Lower limit of the 95% confidence interval on the RSRR
7.25
Upper limit of the 95% confidence interval on the RSRR
12.18
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
5
Number of eligible stays
121
Unadjusted potentially preventable readmission rate
4.13
Risk-standardized potentially preventable readmission rate (RSRR)
4.89
Lower limit of the 95% confidence interval on the RSRR
3.36
Upper limit of the 95% confidence interval on the RSRR
7.95
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)
70
Number of eligible stays
102
Observed discharge to community rate
68.63
Risk-standardized discharge to community rate
65.70
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
59.23
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
71.47
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.93
Number of eligible episodes
112
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
118
Denominator
125
Facility rate
94.4
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
2
Denominator
123
Facility observed rate
1.6
Facility risk-adjusted rate
1.7
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
8
Number of health care workers
8
Rate of COVID-19 vaccination
100.0