Doctors Hospital at Renaissance


About the Facility

CMS Certification Number (CCN)
45T869
Ownership Type
Physician
CMS Region
Dallas
Certification Date
Address
5501 S. Mccoll
Phone Number
(956) 362-6607

Facility Medical Condition Statistics

All other conditions
184
Brain disease or condition (non-traumatic)
24
Brain injury (traumatic)
11
Hip or femur fracture
67
Hip or knee replacement, amputation or other bone or joint condition
56
Nervous system disorder (excluding stroke)
37
Spinal cord disease or condition (non-traumatic)
25
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
103

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.152
SIR 95% confidence interval - upper limit
2.997
Comparative performance category
No Different than the National Benchmark
Catheter days
1,065
Predicted number of infections (B)
2.205
Number of infections reported (A)
2
SIR (A/B)
0.907
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
496
Denominator
496
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
14.3
Denominator
440
Average observed change score
15.8
Change in patients ability to move around
Average risk-adjusted change score
34.0
Denominator
440
Average observed change score
34.9
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
330
Denominator
440
Facility rate
75.0
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
287
Denominator
440
Facility rate
65.2
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
496
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
0.844
Comparative performance category
Better than the National Benchmark
Patient days
9,420
Predicted number of infections (B)
3.549
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
174
Number of health care workers
177
Rate of flu vaccination
98.3
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
41
Number of eligible stays
397
Unadjusted potentially preventable readmission rate
10.33
Risk-standardized potentially preventable readmission rate (RSRR)
9.29
Lower limit of the 95% confidence interval on the RSRR
7.67
Upper limit of the 95% confidence interval on the RSRR
11.26
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
29
Number of eligible stays
445
Unadjusted potentially preventable readmission rate
6.52
Risk-standardized potentially preventable readmission rate (RSRR)
5.60
Lower limit of the 95% confidence interval on the RSRR
4.31
Upper limit of the 95% confidence interval on the RSRR
7.12
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)
227
Number of eligible stays
350
Observed discharge to community rate
64.86
Risk-standardized discharge to community rate
68.84
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
64.24
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
73.54
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
412
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
494
Denominator
496
Facility rate
99.6
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
4
Denominator
496
Facility observed rate
0.8
Facility risk-adjusted rate
0.5
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
212
Number of health care workers
216
Rate of COVID-19 vaccination
98.1