COMMUNITY MEMORIAL HEALTHCENTER, INC (SOUTH HILL, VA) Detailed Hospital Profile

Process of Care

Heart Attack

Percent of Patients Given Aspirin at Arrival

This Hospital:	100.0%
Virginia:	99.5%

Percent of Patients Given Aspirin at Discharge

This Hospital:	100.0%
Virginia:	99.3%

Percent of Patients Given Beta Blocker at Discharge

Here:	100.0%
State:	99.1%

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

This Hospital:	8
State:	9

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

Here:	100.0%
State:	98.1%

Heart Failure

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

Here:	100.0%
Virginia:	99.5%

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

Here:	100.0%
Virginia:	97.3%

Percent of Patients Given Discharge Instructions

This Hospital:	100.0%
Virginia:	94.7%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	100.0%
Virginia:	99.7%

Pneumonia

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

Here:	100.0%
Virginia:	97.0%

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

Here:	98.0%
State:	97.5%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	100.0%
State:	99.4%

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

Here:	99.0%
Virginia:	95.5%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	95.0%
State:	94.9%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	99.0%
Virginia:	96.9%

Surgery

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

Here:	100.0%
Virginia:	98.4%

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

Here:	98.0%
Virginia:	97.7%

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

Here:	98.0%
State:	98.9%

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

Here:	100.0%
State:	97.1%

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

This Hospital:	100.0%
State:	97.9%

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

Here:	100.0%
Virginia:	100.0%

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

Here:	100.0%
State:	95.0%

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

Here:	100.0%
Virginia:	97.7%

Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)

This Hospital:	97.0%
State:	96.7%

Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)

Here:	97.0%
State:	96.9%

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

Here:	100.0%
Virginia:	99.9%

Outcome of Care

30-Day Mortality Rates from Heart Attack

This Hospital:	15.3%
State:	15.2%

30-Day Mortality Rates from Heart Failure

Here:	13.9%
State:	11.6%

30-Day Mortality Rates from Pneumonia

This Hospital:	12.4%
Virginia:	12.2%

30-Day Readmission Rates from Heart Attack

This Hospital:	20.8%
State:	20.0%

30-Day Readmission Rates from Heart Failure

Here:	23.8%
State:	24.6%

30-Day Readmission Rates from Pneumonia

Here:	19.6%
State:	19.2%

Hospital Acquired Conditions

Falls and injuries

Here:	0.225%
Virginia:	0.637%

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

Acute Myocardial Infarction, Discharged Alive with Complications

Average Covered Charges

Here:	$15,416
Virginia:	$24,489

Average Total Payments

Here:	$5,949
Virginia:	$7,575

Number of discharges: 13

Here:	0.90%
State:	0.64%

Atherosclerosis without Major Complications

Average Covered Charges

Here:	$13,260
Virginia:	$13,265

Average Total Payments

Here:	$3,419
Virginia:	$3,621

Number of discharges: 31

This Hospital:	2.15%
Virginia:	0.39%

Cardiac Arrhythmia and Conduction Disorders with Complications

Average Covered Charges

Here:	$14,627
Virginia:	$16,713

Average Total Payments

Here:	$4,194
Virginia:	$5,355

Number of discharges: 25

Here:	1.73%
State:	1.46%

Cardiac Arrhythmia and Conduction Disorders with Major Complications

Average Covered Charges

Here:	$18,774
Virginia:	$24,425

Average Total Payments

Here:	$6,108
Virginia:	$7,960

Number of discharges: 14

This Hospital:	0.97%
State:	0.92%

Cardiac Arrhythmia and Conduction Disorders without Complications

Average Covered Charges

This Hospital:	$10,594
State:	$11,985

Average Total Payments

This Hospital:	$3,061
Virginia:	$3,674

Number of discharges: 40

Here:	2.77%
Virginia:	1.66%

Cellulitis without Major Complications

Average Covered Charges

Here:	$14,069
State:	$16,080

Average Total Payments

This Hospital:	$4,553
Virginia:	$5,268

Number of discharges: 32

Here:	2.22%
State:	1.88%

Chest Pain

Average Covered Charges

Here:	$14,514
Virginia:	$13,309

Average Total Payments

Here:	$2,989
State:	$3,508

Number of discharges: 60

This Hospital:	4.16%
State:	2.02%

Chronic Obstructive Pulmonary Disease with Complications

Average Covered Charges

This Hospital:	$15,747
State:	$18,712

Average Total Payments

Here:	$5,292
State:	$6,003

Number of discharges: 40

Here:	2.77%
Virginia:	2.09%

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

Here:	$21,388
State:	$22,971

Average Total Payments

This Hospital:	$6,397
State:	$7,375

Number of discharges: 43

Here:	2.98%
State:	2.01%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

Here:	$12,211
State:	$14,677

Average Total Payments

This Hospital:	$3,921
State:	$4,562

Number of discharges: 32

Here:	2.22%
Virginia:	1.55%

Diabetes with Complications

Average Covered Charges

This Hospital:	$15,311
Virginia:	$16,675

Average Total Payments

This Hospital:	$4,425
State:	$5,442

Number of discharges: 25

This Hospital:	1.73%
State:	0.73%

Disorders of Pancreas Except Malignancy with Complications

Average Covered Charges

Here:	$15,438
Virginia:	$21,185

Average Total Payments

This Hospital:	$5,484
State:	$7,102

Number of discharges: 12

This Hospital:	0.83%
State:	0.28%

Dysequilibrium

Average Covered Charges

This Hospital:	$14,817
Virginia:	$14,526

Average Total Payments

Here:	$3,450
Virginia:	$4,129

Number of discharges: 14

Here:	0.97%
Virginia:	0.30%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders with Major Complications

Average Covered Charges

This Hospital:	$17,624
Virginia:	$26,117

Average Total Payments

This Hospital:	$6,000
Virginia:	$7,657

Number of discharges: 11

Here:	0.76%
State:	0.55%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

Here:	$14,034
Virginia:	$16,267

Average Total Payments

Here:	$4,036
State:	$4,677

Number of discharges: 94

Here:	6.52%
State:	3.33%

G.I. Hemorrhage with Complications

Average Covered Charges

This Hospital:	$17,529
State:	$19,562

Average Total Payments

This Hospital:	$5,585
Virginia:	$6,368

Number of discharges: 33

This Hospital:	2.29%
Virginia:	2.17%

G.I. Hemorrhage with Major Complications

Average Covered Charges

This Hospital:	$28,027
Virginia:	$33,327

Average Total Payments

Here:	$9,198
Virginia:	$11,053

Number of discharges: 17

This Hospital:	1.18%
State:	0.78%

G.I. Hemorrhage without Complications

Average Covered Charges

This Hospital:	$17,151
Virginia:	$14,928

Average Total Payments

This Hospital:	$4,523
State:	$4,663

Number of discharges: 11

This Hospital:	0.76%
Virginia:	0.42%

G.I. Obstruction with Complications

Average Covered Charges

This Hospital:	$16,210
Virginia:	$19,150

Average Total Payments

Here:	$5,079
Virginia:	$6,043

Number of discharges: 15

This Hospital:	1.04%
State:	0.66%

Heart Failure and Shock with Complications

Average Covered Charges

This Hospital:	$14,232
Virginia:	$18,524

Average Total Payments

This Hospital:	$5,383
Virginia:	$6,409

Number of discharges: 84

Here:	5.83%
State:	3.24%

Heart Failure and Shock with Major Complications

Average Covered Charges

Here:	$21,498
Virginia:	$27,627

Average Total Payments

This Hospital:	$8,084
State:	$9,254

Number of discharges: 61

This Hospital:	4.23%
Virginia:	3.02%

Heart Failure and Shock without Complications

Average Covered Charges

Here:	$9,984
State:	$13,642

Average Total Payments

This Hospital:	$3,725
Virginia:	$4,360

Number of discharges: 30

Here:	2.08%
Virginia:	1.17%

Hip and Femur Procedures Except Major Joint with Complications

Average Covered Charges

This Hospital:	$35,438
State:	$42,571

Average Total Payments

Here:	$11,396
Virginia:	$11,742

Number of discharges: 13

This Hospital:	0.90%
State:	1.12%

Intracranial Hemorrhage or Cerebral Infarction with Complications

Average Covered Charges

This Hospital:	$21,568
State:	$23,909

Average Total Payments

This Hospital:	$6,246
State:	$7,314

Number of discharges: 33

This Hospital:	2.29%
Virginia:	1.75%

Intracranial Hemorrhage or Cerebral Infarction with Major Complications

Average Covered Charges

Here:	$27,782
Virginia:	$35,480

Average Total Payments

Here:	$9,848
State:	$12,363

Number of discharges: 21

This Hospital:	1.46%
Virginia:	1.08%

Intracranial Hemorrhage or Cerebral Infarction without Complications

Average Covered Charges

Here:	$14,983
Virginia:	$19,084

Average Total Payments

This Hospital:	$4,464
Virginia:	$5,409

Number of discharges: 16

Here:	1.11%
Virginia:	0.95%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

This Hospital:	$13,238
State:	$15,209

Average Total Payments

Here:	$4,258
Virginia:	$4,914

Number of discharges: 30

Here:	2.08%
Virginia:	2.90%

Laparoscopic Cholecystectomy without C.D.E. without Complications

Average Covered Charges

Here:	$29,261
Virginia:	$31,423

Average Total Payments

Here:	$6,359
State:	$7,258

Number of discharges: 15

Here:	1.04%
Virginia:	0.23%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

Here:	$50,840
Virginia:	$47,709

Average Total Payments

Here:	$11,781
State:	$13,248

Number of discharges: 26

This Hospital:	1.80%
State:	6.42%

Misc Disorders of Nutrition, Metabolism, Fluids or Electrolytes with Major Complications

Average Covered Charges

Here:	$18,994
State:	$22,123

Average Total Payments

This Hospital:	$6,068
State:	$7,532

Number of discharges: 16

This Hospital:	1.11%
Virginia:	0.77%

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

Average Covered Charges

This Hospital:	$13,184
Virginia:	$14,229

Average Total Payments

Here:	$3,712
Virginia:	$4,420

Number of discharges: 50

Here:	3.47%
Virginia:	2.07%

Other Digestive System Diagnoses with Complications

Average Covered Charges

Here:	$23,983
Virginia:	$21,528

Average Total Payments

This Hospital:	$5,403
Virginia:	$6,787

Number of discharges: 11

This Hospital:	0.76%
State:	0.51%

Pulmonary Edema and Respiratory Failure

Average Covered Charges

Here:	$14,398
State:	$25,878

Average Total Payments

This Hospital:	$6,963
Virginia:	$8,160

Number of discharges: 16

This Hospital:	1.11%
State:	1.90%

Red Blood Cell Disorders with Major Complications

Average Covered Charges

This Hospital:	$21,166
Virginia:	$27,406

Average Total Payments

This Hospital:	$6,819
Virginia:	$8,783

Number of discharges: 17

Here:	1.18%
State:	0.35%

Red Blood Cell Disorders without Major Complications

Average Covered Charges

Here:	$15,848
Virginia:	$16,210

Average Total Payments

This Hospital:	$4,325
Virginia:	$5,305

Number of discharges: 23

This Hospital:	1.60%
Virginia:	1.21%

Renal Failure with Complications

Average Covered Charges

This Hospital:	$15,799
Virginia:	$19,940

Average Total Payments

This Hospital:	$5,568
State:	$6,384

Number of discharges: 31

Here:	2.15%
Virginia:	2.46%

Renal Failure with Major Complications

Average Covered Charges

Here:	$32,678
State:	$30,290

Average Total Payments

This Hospital:	$10,385
State:	$10,421

Number of discharges: 18

Here:	1.25%
Virginia:	1.68%

Respiratory Infections and Inflammations with Complications

Average Covered Charges

This Hospital:	$27,935
State:	$26,604

Average Total Payments

Here:	$8,092
State:	$9,105

Number of discharges: 16

This Hospital:	1.11%
State:	0.77%

Respiratory Infections and Inflammations with Major Complications

Average Covered Charges

This Hospital:	$31,674
Virginia:	$37,946

Average Total Payments

This Hospital:	$11,234
Virginia:	$12,347

Number of discharges: 14

This Hospital:	0.97%
State:	1.03%

Respiratory System Diagnosis with Ventilator Support <96 Hours

Average Covered Charges

This Hospital:	$40,628
Virginia:	$51,609

Average Total Payments

This Hospital:	$10,839
Virginia:	$15,311

Number of discharges: 15

Here:	1.04%
State:	0.85%

Seizures without Major Complications

Average Covered Charges

Here:	$16,512
Virginia:	$17,714

Average Total Payments

Here:	$4,253
State:	$5,190

Number of discharges: 21

Here:	1.46%
Virginia:	0.66%

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

Average Covered Charges

Here:	$29,543
Virginia:	$36,847

Average Total Payments

Here:	$10,087
State:	$12,110

Number of discharges: 97

This Hospital:	6.73%
State:	5.11%

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

Average Covered Charges

Here:	$20,400
Virginia:	$22,569

Average Total Payments

Here:	$6,080
Virginia:	$7,309

Number of discharges: 50

Here:	3.47%
Virginia:	1.85%

Signs and Symptoms without Major Complications

Average Covered Charges

This Hospital:	$13,341
Virginia:	$15,097

Average Total Payments

Here:	$3,651
State:	$4,461

Number of discharges: 12

Here:	0.83%
Virginia:	0.65%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

This Hospital:	$17,533
Virginia:	$19,305

Average Total Payments

This Hospital:	$5,383
Virginia:	$6,423

Number of discharges: 39

This Hospital:	2.70%
State:	2.58%

Simple Pneumonia and Pleurisy with Major Complications

Average Covered Charges

Here:	$23,319
Virginia:	$27,841

Average Total Payments

Here:	$8,043
State:	$9,090

Number of discharges: 22

This Hospital:	1.53%
State:	1.96%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

Here:	$13,392
State:	$14,202

Average Total Payments

This Hospital:	$3,857
Virginia:	$4,467

Number of discharges: 13

Here:	0.90%
State:	1.02%

Syncope and Collapse

Average Covered Charges

Here:	$15,960
Virginia:	$15,506

Average Total Payments

Here:	$4,157
Virginia:	$4,539

Number of discharges: 52

Here:	3.61%
Virginia:	2.14%

Transient Ischemia

Average Covered Charges

This Hospital:	$16,930
State:	$16,483

Average Total Payments

Here:	$3,974
Virginia:	$4,621

Number of discharges: 18

This Hospital:	1.25%
State:	1.34%

Complaint Deficiency

Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Protect each resident from all abuse, physical punishment, and being separated from others
- 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: Few
Provide activities to meet the interests and needs of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide medically-related social services to help each resident achieve the highest possible quality of life
- 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
Make sure services provided by the nursing facility meet professional standards of quality
- 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: Some
Make sure that residents are safe from serious medication errors
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that special or therapeutic diets are ordered by the attending doctor
- 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: Few
Give or get specialized rehabilitative services per the patient's assessment or plan of care
- Harm: Actual harm
- Scope: Few
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Be administered in an acceptable way that maintains the well-being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give or get quality lab services/tests in a timely manner to meet the needs of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
- 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
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Determine if it is safe for the resident to self-administer drugs
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from physical restraints, unless needed for medical treatment
- 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
Provide a safe, clean, comfortable and homelike environment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure each resident receives an accurate assessment by a qualified health professional
- 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
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 residents' abilities in activities of daily living do not decline, unless unavoidable
- 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
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that a working call system is available in each resident's room or bathroom and bathing area
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure medically necessary lab services/tests are ordered by the attending physician
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Smoke barrier doors that can resist smoke for at least 20 minutes
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
Proper backup exit lighting
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly located and lighted Exit signs
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly sized and located linen or trash receptacles
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Few
The appropriate emergency electrical equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- 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
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: 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
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible
- 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
Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give each resident enough fluids to keep them healthy and prevent dehydration
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
- 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: Some
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that doctors visit residents regularly, as required
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give or get quality lab services/tests in a timely manner to meet the needs of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Quickly tell the resident's doctor the results of lab tests
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Smoke barrier doors that can resist smoke for at least 20 minutes
- 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
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
No-smoking signs where oxygen is used
- Harm: Potential for minimal harm
- Scope: Some

Use of Medical Imaging

Outpatients with low back pain who had an MRI without trying recommended treatments first, such as physical therapy.

This Hospital:	44.600%
State:	34.209%

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

This Hospital:	3.800%
State:	7.783%

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

This Hospital:	0.367%
Virginia:	0.107%

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

This Hospital:	0.043%
Virginia:	0.028%

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

Here:	2.600%
State:	5.232%

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

This Hospital:	1.700%
State:	2.134%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 34%

How often did nurses communicate well with patients?

Sometimes or never

Here:	6%
State:	6%

Usually

Here:	17%
Virginia:	17%

Always

This Hospital:	77%
State:	77%

How often did doctors communicate well with patients?

Sometimes or never

This Hospital:	4%
Virginia:	5%

Usually

This Hospital:	15%
State:	15%

Always

This Hospital:	81%
State:	80%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	11%
State:	11%

Usually

Here:	23%
State:	26%

Always

This Hospital:	66%
State:	63%

How often was patients' pain well controlled?

Sometimes or never

Here:	11%
Virginia:	8%

Usually

This Hospital:	22%
State:	23%

Always

Here:	67%
State:	69%

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

Sometimes or never

This Hospital:	21%
State:	21%

Usually

Here:	17%
State:	18%

Always

Here:	62%
State:	61%

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

Sometimes or never

Here:	12%
Virginia:	10%

Usually

Here:	24%
Virginia:	20%

Always

Here:	64%
State:	70%

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

Sometimes or never

This Hospital:	13%
State:	11%

Usually

Here:	28%
State:	30%

Always

Here:	59%
State:	59%

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

Yes

This Hospital:	86%
Virginia:	84%

This Hospital:	14%
Virginia:	16%

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

6 or lower

Here:	12%
State:	9%

7 or 8

This Hospital:	26%
State:	25%

9 or 10

This Hospital:	62%
State:	66%

Would patients recommend the hospital to friends and family?

Here:	4%
State:	6%

Yes, probably

This Hospital:	38%
State:	26%

Yes, definitely

This Hospital:	58%
Virginia:	68%

Quality Measures

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

This Hospital:	21.6%
State:	18.8%

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

Here:	17.6%
Virginia:	10.6%

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

Here:	5.1%
Virginia:	7.0%

Percent of long-stay residents who lose too much weight

This Hospital:	12.1%
State:	7.6%

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

Here:	6.0%
State:	3.2%

Percent of long-stay residents with a urinary tract infection

This Hospital:	16.2%
State:	7.9%

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

This Hospital:	1.0%
Virginia:	3.2%

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

This Hospital:	100.0%
Virginia:	93.7%

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

Here:	99.0%
Virginia:	94.6%

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

This Hospital:	21.1%
Virginia:	19.3%

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

Here:	0.6%
State:	1.3%

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

This Hospital:	89.7%
State:	85.3%

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

Here:	89.8%
State:	83.6%

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

This Hospital:	4.8%
State:	3.0%

Percent of long-stay residents who received an antipsychotic medication

This Hospital:	14.7%
Virginia:	22.2%

COMMUNITY MEMORIAL HEALTHCENTER, INC - SOUTH HILL, VA

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Hospital Acquired Conditions

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

Complaint Deficiency

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

Quality Measures

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