Gundersen Lutheran Medical Center Inc


About the Facility

CMS Certification Number (CCN)
52T087
Ownership Type
Non-profit
CMS Region
Chicago
Certification Date
Address
1900 South Avenue
Phone Number
(608) 775-3064

Facility Medical Condition Statistics

All other conditions
85
Brain disease or condition (non-traumatic)
15
Brain injury (traumatic)
24
Hip or femur fracture
21
Hip or knee replacement, amputation or other bone or joint condition
50
Nervous system disorder (excluding stroke)
15
Spinal cord disease or condition (non-traumatic)
32
Spinal cord injury (traumatic)
Data not available for this reporting period.
Stroke
89

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
0.037
SIR 95% confidence interval - upper limit
3.664
Comparative performance category
No Different than the National Benchmark
Catheter days
494
Predicted number of infections (B)
1.346
Number of infections reported (A)
1
SIR (A/B)
0.743
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
336
Denominator
336
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
12.1
Denominator
306
Average observed change score
12.7
Change in patients ability to move around
Average risk-adjusted change score
26.2
Denominator
306
Average observed change score
25.6
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
185
Denominator
306
Facility rate
60.5
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
138
Denominator
306
Facility rate
45.1
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
336
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
0.949
Comparative performance category
Better than the National Benchmark
Patient days
6,117
Predicted number of infections (B)
3.156
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
118
Number of health care workers
145
Rate of flu vaccination
81.4
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
13
Number of eligible stays
257
Unadjusted potentially preventable readmission rate
5.06
Risk-standardized potentially preventable readmission rate (RSRR)
7.80
Lower limit of the 95% confidence interval on the RSRR
6.09
Upper limit of the 95% confidence interval on the RSRR
9.94
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
276
Unadjusted potentially preventable readmission rate
2.90
Risk-standardized potentially preventable readmission rate (RSRR)
4.51
Lower limit of the 95% confidence interval on the RSRR
3.12
Upper limit of the 95% confidence interval on the RSRR
6.74
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)
160
Number of eligible stays
224
Observed discharge to community rate
71.43
Risk-standardized discharge to community rate
66.81
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
61.93
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
71.07
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.92
Number of eligible episodes
285
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
336
Denominator
336
Facility rate
100.0
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
8
Denominator
335
Facility observed rate
2.4
Facility risk-adjusted rate
3.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
129
Number of health care workers
136
Rate of COVID-19 vaccination
94.9