ARKANSAS VALLEY REGIONAL MEDICAL CENTER (LA JUNTA, CO) Detailed Hospital Profile

Use of Medical Imaging

Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram.

Here:	4.300%
Colorado:	8.917%

Outpatient CT scans of the abdomen that were combination (double) scans.

This Hospital:	0.075%
Colorado:	0.136%

Outpatient CT scans of the chest that were combination (double) scans.

This Hospital:	0.022%
Colorado:	0.028%

Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery

This Hospital:	5.200%
Colorado:	4.979%

Outpatients with brain CT scans who got a sinus CT scan at the same time

This Hospital:	1.000%
State:	1.941%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 29%

How often did nurses communicate well with patients?

Sometimes or never

This Hospital:	4%
Colorado:	4%

Usually

Here:	21%
State:	18%

Always

This Hospital:	75%
Colorado:	78%

How often did doctors communicate well with patients?

Sometimes or never

Here:	2%
State:	4%

Usually

Here:	14%
Colorado:	15%

Always

This Hospital:	84%
Colorado:	81%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Hospital:	10%
Colorado:	7%

Usually

Here:	25%
State:	24%

Always

This Hospital:	65%
Colorado:	69%

How often was patients' pain well controlled?

Sometimes or never

This Hospital:	6%
State:	6%

Usually

This Hospital:	27%
Colorado:	23%

Always

Here:	67%
State:	71%

How often did staff explain about medicines before giving them to patients?

Sometimes or never

This Hospital:	21%
Colorado:	17%

Usually

This Hospital:	20%
Colorado:	19%

Always

This Hospital:	59%
State:	64%

How often were the patients' rooms and bathrooms kept clean?

Sometimes or never

This Hospital:	4%
State:	7%

Usually

This Hospital:	19%
State:	19%

Always

Here:	77%
Colorado:	74%

How often was the area around patients' rooms kept quiet at night?

Sometimes or never

Here:	7%
Colorado:	7%

Usually

Here:	36%
State:	30%

Always

This Hospital:	57%
State:	63%

Were patients given information about what to do during their recovery at home?

Yes

Here:	82%
State:	86%

Here:	18%
Colorado:	14%

How do patients rate the hospital overall on a scale from 0 (lowest) to 10 (highest)?

6 or lower

Here:	10%
State:	7%

7 or 8

This Hospital:	32%
Colorado:	20%

9 or 10

Here:	58%
Colorado:	73%

Would patients recommend the hospital to friends and family?

This Hospital:	5%
State:	4%

Yes, probably

Here:	36%
Colorado:	20%

Yes, definitely

This Hospital:	59%
State:	76%

Hospital Acquired Conditions

Falls and injuries

This Hospital:	0.556%
State:	0.765%

Complaint Deficiency

Make sure each resident receives an accurate assessment by a qualified health professional
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Many
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Use a registered nurse at least 8 hours a day, 7 days a week
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Be administered in an acceptable way that maintains the well-being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Train all employees on what to do in an emergency, and carry out announced staff drills
- Harm: Minimal harm or potential for actual harm
- Scope: Many
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Emergency lighting that can last at least 1 1/2 hours
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Try to resolve each resident's complaints quickly
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Allow the resident the right to participate in the planning or revision of the resident's care plan
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies and procedures for influenza and pneumococcal immunizations
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep clinical record information safe, so that it will not be lost, destroyed or used by the wrong person
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few

Process of Care

Heart Attack

Average number of minutes before outpatients with chest pain or possible heart attack got an ECG

This Hospital:	20
Colorado:	8

Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival

This Hospital:	99.0%
Colorado:	97.8%

Heart Failure

Percent of patients who were given an evaluation of Left Ventricular Systolic Dysfunction (LVSD)

Here:	100.0%
State:	98.5%

Percent of Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)

This Hospital:	91.0%
State:	97.4%

Percent of Patients Given Discharge Instructions

Here:	90.0%
Colorado:	93.6%

Pneumonia

Percent of Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

Here:	90.0%
Colorado:	97.0%

Percent of Patients Whose Initial ER Blood Culture Was Performed Prior To Administration Of First Dose Of Antibiotics

Here:	93.0%
State:	97.0%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	96.0%
Colorado:	97.8%

Percent of Patients Given the Most Appropriate Initial Antibiotic(s)

This Hospital:	80.0%
State:	94.2%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	94.0%
Colorado:	92.7%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	95.0%
State:	94.4%

Surgery

Percent of Surgery Patients given an antibiotic at the right time (within one hour before surgery) to help prevent infection

Here:	81.0%
State:	97.9%

Percent of Surgery Patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)

Here:	100.0%
State:	97.0%

Percent of Surgery Patients who were given the right kind of antibiotic to help prevent infection

Here:	93.0%
Colorado:	98.6%

Percent of Surgery Patients who got treatment at right time (within 24 hours before or after surgery) to help prevent blood clot

This Hospital:	82.0%
Colorado:	96.9%

Percent of Surgery Patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries

This Hospital:	85.0%
State:	98.0%

Percent of Surgery Patients needing hair removed from the surgical area before surgery who had hair removed using a safer method

Here:	99.0%
Colorado:	99.9%

Percent of Surgery Patients whose urinary catheters were removed on the first or second day after surgery

Here:	88.0%
Colorado:	93.2%

Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on them

This Hospital:	88.0%
State:	95.6%

Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal

This Hospital:	100.0%
State:	99.8%

Outcome of Care

30-Day Mortality Rates from Heart Attack

Here:	15.1%
Colorado:	14.2%

30-Day Mortality Rates from Heart Failure

This Hospital:	10.6%
State:	11.5%

30-Day Mortality Rates from Pneumonia

Here:	11.7%
Colorado:	10.9%

30-Day Readmission Rates from Heart Attack

This Hospital:	19.3%
Colorado:	18.7%

30-Day Readmission Rates from Heart Failure

Here:	22.9%
Colorado:	23.0%

30-Day Readmission Rates from Pneumonia

This Hospital:	19.6%
Colorado:	17.7%

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Cardiac Arrhythmia and Conduction Disorders with Complications

Average Covered Charges

Here:	$11,300
State:	$23,218

Average Total Payments

This Hospital:	$5,701
Colorado:	$5,563

Number of discharges: 15

Here:	2.86%
State:	1.55%

Cellulitis without Major Complications

Average Covered Charges

This Hospital:	$7,462
State:	$22,045

Average Total Payments

This Hospital:	$5,450
Colorado:	$5,516

Number of discharges: 11

This Hospital:	2.10%
State:	1.76%

Chronic Obstructive Pulmonary Disease with Complications

Average Covered Charges

Here:	$9,488
Colorado:	$26,328

Average Total Payments

This Hospital:	$6,482
State:	$6,453

Number of discharges: 23

Here:	4.39%
State:	1.68%

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

Here:	$14,715
State:	$31,599

Average Total Payments

Here:	$7,793
Colorado:	$7,942

Number of discharges: 11

Here:	2.10%
Colorado:	1.67%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

This Hospital:	$9,094
Colorado:	$18,609

Average Total Payments

Here:	$4,757
Colorado:	$4,788

Number of discharges: 23

Here:	4.39%
State:	1.13%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

Here:	$9,354
Colorado:	$21,923

Average Total Payments

Here:	$4,840
State:	$4,804

Number of discharges: 39

This Hospital:	7.44%
State:	3.81%

G.I. Hemorrhage with Complications

Average Covered Charges

Here:	$11,036
Colorado:	$27,678

Average Total Payments

Here:	$6,942
Colorado:	$6,667

Number of discharges: 24

Here:	4.58%
Colorado:	2.09%

G.I. Hemorrhage with Major Complications

Average Covered Charges

This Hospital:	$18,797
State:	$45,134

Average Total Payments

This Hospital:	$11,741
State:	$11,658

Number of discharges: 13

Here:	2.48%
Colorado:	0.62%

G.I. Obstruction with Complications

Average Covered Charges

This Hospital:	$12,117
State:	$26,472

Average Total Payments

Here:	$6,352
Colorado:	$6,394

Number of discharges: 13

This Hospital:	2.48%
State:	0.86%

Heart Failure and Shock with Complications

Average Covered Charges

This Hospital:	$10,649
Colorado:	$27,517

Average Total Payments

This Hospital:	$6,734
State:	$6,762

Number of discharges: 26

This Hospital:	4.96%
State:	2.59%

Heart Failure and Shock with Major Complications

Average Covered Charges

Here:	$15,843
Colorado:	$42,116

Average Total Payments

Here:	$9,795
Colorado:	$9,818

Number of discharges: 14

This Hospital:	2.67%
State:	1.50%

Kidney and Urinary Tract Infections with Major Complications

Average Covered Charges

Here:	$11,853
State:	$31,298

Average Total Payments

This Hospital:	$7,923
Colorado:	$7,439

Number of discharges: 20

This Hospital:	3.82%
Colorado:	0.77%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

Here:	$7,744
Colorado:	$20,158

Average Total Payments

This Hospital:	$5,130
State:	$5,034

Number of discharges: 16

Here:	3.05%
Colorado:	2.99%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

Here:	$30,894
State:	$60,268

Average Total Payments

This Hospital:	$14,302
Colorado:	$14,362

Number of discharges: 32

This Hospital:	6.11%
State:	11.40%

Misc Disorders of Nutrition, Metabolism, Fluids or Electrolytes without Major Complications

Average Covered Charges

This Hospital:	$7,093
Colorado:	$19,878

Average Total Payments

This Hospital:	$4,701
Colorado:	$4,590

Number of discharges: 20

This Hospital:	3.82%
State:	2.62%

Poisoning and Toxic Effects of Drugs without Major Complications

Average Covered Charges

This Hospital:	$12,560
State:	$19,033

Average Total Payments

Here:	$4,245
State:	$4,278

Number of discharges: 12

This Hospital:	2.29%
State:	0.49%

Respiratory Infections and Inflammations with Complications

Average Covered Charges

Here:	$13,116
State:	$40,841

Average Total Payments

This Hospital:	$8,600
Colorado:	$9,549

Number of discharges: 34

Here:	6.49%
Colorado:	0.92%

Respiratory Infections and Inflammations with Major Complications

Average Covered Charges

Here:	$14,788
Colorado:	$56,028

Average Total Payments

This Hospital:	$12,287
Colorado:	$12,961

Number of discharges: 19

This Hospital:	3.63%
State:	0.97%

Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours without Major Complications

Average Covered Charges

Here:	$10,406
State:	$30,341

Average Total Payments

This Hospital:	$7,073
Colorado:	$7,760

Number of discharges: 18

This Hospital:	3.44%
Colorado:	1.58%

Signs and Symptoms without Major Complications

Average Covered Charges

Here:	$8,711
Colorado:	$21,122

Average Total Payments

Here:	$4,566
State:	$4,592

Number of discharges: 12

This Hospital:	2.29%
State:	1.05%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

This Hospital:	$11,032
State:	$25,346

Average Total Payments

Here:	$6,637
Colorado:	$6,612

Number of discharges: 71

Here:	13.55%
Colorado:	3.36%

Simple Pneumonia and Pleurisy with Major Complications

Average Covered Charges

Here:	$16,799
Colorado:	$36,512

Average Total Payments

This Hospital:	$9,396
Colorado:	$9,377

Number of discharges: 47

Here:	8.97%
Colorado:	1.93%

Syncope and Collapse

Average Covered Charges

This Hospital:	$8,855
Colorado:	$22,065

Average Total Payments

This Hospital:	$4,875
Colorado:	$4,800

Number of discharges: 11

This Hospital:	2.10%
State:	1.68%

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

Here:	18.6%
Colorado:	15.7%

Percent of long-stay residents who self-report moderate to severe pain

Here:	7.0%
State:	12.4%

Percent of long-stay high-risk residents with pressure ulcers

This Hospital:	4.4%
State:	5.2%

Percent of long-stay residents who lose too much weight

Here:	6.3%
Colorado:	7.7%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

This Hospital:	35.9%
Colorado:	46.6%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	8.4%
Colorado:	5.4%

Percent of long-stay residents with a urinary tract infection

Here:	10.9%
State:	7.0%

Percent of long-stay residents who have depressive symptoms

Here:	13.3%
State:	7.1%

Percent of long-stay residents experiencing one or more falls with major injury

This Hospital:	6.2%
Colorado:	4.0%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Hospital:	73.8%
Colorado:	91.9%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Hospital:	100.0%
State:	91.4%

Percent of short-stay residents who self-report moderate to severe pain

This Hospital:	28.1%
Colorado:	24.1%

Percent of short-stay residents with Pressure ulcers that are new or worsened

This Hospital:	3.1%
Colorado:	1.5%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	95.8%
Colorado:	83.9%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	96.6%
Colorado:	78.2%

Percent of short-stay residents who newly received an antipsychotic medication

This Hospital:	2.0%
State:	2.1%

Percent of long-stay residents who received an antipsychotic medication

Here:	20.0%
State:	20.4%

ARKANSAS VALLEY REGIONAL MEDICAL CENTER - LA JUNTA, CO

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

Hospital Acquired Conditions

Complaint Deficiency

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Quality Measures

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