Pam Specialty Hospital of Victoria North


About the Facility

CMS Certification Number (CCN)
45TA94
Ownership Type
For Profit
CMS Region
Dallas
Certification Date
Address
102 Medical Drive
Phone Number
(361) 576-6200

Facility Medical Condition Statistics

All other conditions
145
Brain disease or condition (non-traumatic)
13
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
17
Hip or knee replacement, amputation or other bone or joint condition
38
Nervous system disorder (excluding stroke)
69
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
30

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
401
Predicted number of infections (B)
0.578
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
310
Denominator
310
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
11.8
Denominator
269
Average observed change score
11.8
Change in patients ability to move around
Average risk-adjusted change score
32.0
Denominator
269
Average observed change score
30.7
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
148
Denominator
269
Facility rate
55.0
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
155
Denominator
269
Facility rate
57.6
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
1
Denominator
310
Facility rate
0.3
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.524
SIR 95% confidence interval - upper limit
5.602
Comparative performance category
No Different than the National Benchmark
Patient days
3,365
Predicted number of infections (B)
1.458
Number of infections reported (A)
3
SIR (A/B)
2.058
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
10
Number of health care workers
10
Rate of flu vaccination
100.0
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
31
Number of eligible stays
193
Unadjusted potentially preventable readmission rate
16.06
Risk-standardized potentially preventable readmission rate (RSRR)
10.21
Lower limit of the 95% confidence interval on the RSRR
8.11
Upper limit of the 95% confidence interval on the RSRR
12.85
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
11
Number of eligible stays
215
Unadjusted potentially preventable readmission rate
5.12
Risk-standardized potentially preventable readmission rate (RSRR)
4.88
Lower limit of the 95% confidence interval on the RSRR
3.59
Upper limit of the 95% confidence interval on the RSRR
6.81
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)
101
Number of eligible stays
177
Observed discharge to community rate
57.06
Risk-standardized discharge to community rate
59.78
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
53.48
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
65.57
Comparative performance category
Worse than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
1.12
Number of eligible episodes
289
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
305
Denominator
310
Facility rate
98.4
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
5
Denominator
308
Facility observed rate
1.6
Facility risk-adjusted rate
1.5
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
12
Number of health care workers
12
Rate of COVID-19 vaccination
100.0