COMMUNITY MEMORIAL HOSPITAL, INC (HAMILTON, NY) Detailed Hospital Profile

Complaint Deficiency

Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have enough outside ventilation via a window or mechanical ventilation, or both
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Tell the resident completely about his or her health status, care and treatments
- 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
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: 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
Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
- 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: Some
Give each resident enough fluids to keep them healthy and prevent dehydration
- 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: Some
Make sure that doctors visit residents regularly, as required
- 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: 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
Keep each resident free from physical restraints, unless needed for medical treatment
- 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 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
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

Process of Care

Heart Attack

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

Here:	6
State:	10

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

This Hospital:	100.0%
State:	97.3%

Heart Failure

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

This Hospital:	97.0%
State:	99.1%

Percent of Patients Given Discharge Instructions

This Hospital:	96.0%
State:	92.8%

Pneumonia

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

This Hospital:	96.0%
State:	93.8%

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

This Hospital:	99.0%
New York:	95.8%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	100.0%
New York:	98.5%

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

Here:	98.0%
New York:	94.8%

Percent of Patients Assessed and Given Influenza Vaccination

This Hospital:	100.0%
New York:	90.8%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	100.0%
New York:	94.0%

Surgery

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

Here:	99.0%
New York:	97.6%

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

Here:	99.0%
New York:	96.4%

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

Here:	100.0%
State:	97.7%

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:	97.2%

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

This Hospital:	100.0%
State:	98.1%

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

Here:	100.0%
New York:	99.8%

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

This Hospital:	100.0%
State:	92.6%

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

This Hospital:	100.0%
New York:	95.0%

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

Here:	100.0%
New York:	94.9%

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

This Hospital:	100.0%
State:	94.4%

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

Here:	100.0%
State:	99.1%

Outcome of Care

30-Day Mortality Rates from Heart Attack

Here:	17.8%
State:	14.3%

30-Day Mortality Rates from Heart Failure

Here:	11.2%
New York:	11.0%

30-Day Mortality Rates from Pneumonia

Here:	15.4%
State:	11.6%

30-Day Readmission Rates from Heart Failure

Here:	24.1%
New York:	26.4%

30-Day Readmission Rates from Pneumonia

Here:	18.0%
State:	19.8%

Use of Medical Imaging

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

This Hospital:	40.900%
New York:	30.865%

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

Here:	3.200%
State:	11.437%

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

This Hospital:	0.168%
State:	0.112%

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

Here:	0.038%
New York:	0.030%

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

Here:	4.200%
State:	5.961%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 62%

How often did nurses communicate well with patients?

Sometimes or never

Here:	3%
State:	7%

Usually

Here:	17%
State:	20%

Always

This Hospital:	80%
New York:	73%

How often did doctors communicate well with patients?

Sometimes or never

This Hospital:	3%
State:	6%

Usually

This Hospital:	15%
State:	17%

Always

This Hospital:	82%
New York:	77%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Hospital:	8%
State:	15%

Usually

This Hospital:	29%
New York:	27%

Always

This Hospital:	63%
New York:	58%

How often was patients' pain well controlled?

Sometimes or never

This Hospital:	5%
New York:	9%

Usually

This Hospital:	23%
State:	25%

Always

Here:	72%
New York:	66%

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

Sometimes or never

Here:	17%
New York:	24%

Usually

Here:	19%
State:	18%

Always

This Hospital:	64%
State:	58%

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

Sometimes or never

This Hospital:	6%
New York:	11%

Usually

Here:	20%
State:	22%

Always

Here:	74%
State:	67%

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

Sometimes or never

Here:	9%
State:	17%

Usually

Here:	30%
New York:	34%

Always

This Hospital:	61%
State:	49%

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

Yes

Here:	86%
State:	81%

This Hospital:	14%
New York:	19%

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

6 or lower

This Hospital:	6%
State:	12%

7 or 8

Here:	20%
New York:	27%

9 or 10

This Hospital:	74%
New York:	61%

Would patients recommend the hospital to friends and family?

Here:	2%
New York:	7%

Yes, probably

This Hospital:	18%
New York:	29%

Yes, definitely

Here:	80%
State:	64%

Hospital Acquired Conditions

Infection from a Urinary Catheter

Here:	0.539%
State:	0.461%

Quality Measures

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

This Hospital:	22.2%
State:	15.6%

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

Here:	2.7%
New York:	7.6%

Percent of long-stay residents who lose too much weight

Here:	19.4%
State:	6.4%

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

Here:	10.8%
New York:	3.1%

Percent of long-stay residents with a urinary tract infection

Here:	2.8%
New York:	6.8%

Percent of long-stay residents who were physically restrained

This Hospital:	2.6%
New York:	2.3%

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

Here:	2.6%
State:	2.9%

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

Here:	100.0%
State:	96.7%

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

This Hospital:	100.0%
New York:	97.3%

Percent of long-stay residents who received an antipsychotic medication

Here:	7.9%
State:	20.8%

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

Cardiac Arrhythmia and Conduction Disorders with Complications

Average Covered Charges

Here:	$9,143
New York:	$23,294

Average Total Payments

This Hospital:	$4,927
New York:	$7,529

Number of discharges: 14

Here:	3.25%
New York:	1.43%

Cardiac Arrhythmia and Conduction Disorders without Complications

Average Covered Charges

Here:	$8,887
New York:	$15,605

Average Total Payments

Here:	$3,467
State:	$4,967

Number of discharges: 13

Here:	3.02%
New York:	1.64%

Cellulitis without Major Complications

Average Covered Charges

Here:	$9,972
New York:	$21,478

Average Total Payments

This Hospital:	$5,314
State:	$7,326

Number of discharges: 20

Here:	4.64%
New York:	2.35%

Cervical Spinal Fusion without Complications

Average Covered Charges

Here:	$22,968
State:	$44,209

Average Total Payments

Here:	$12,412
State:	$16,866

Number of discharges: 15

This Hospital:	3.48%
State:	0.14%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

Here:	$9,000
State:	$16,960

Average Total Payments

This Hospital:	$4,434
State:	$6,071

Number of discharges: 15

This Hospital:	3.48%
New York:	1.51%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

This Hospital:	$10,045
State:	$18,668

Average Total Payments

This Hospital:	$4,269
State:	$6,361

Number of discharges: 19

Here:	4.41%
State:	3.99%

Heart Failure and Shock with Complications

Average Covered Charges

This Hospital:	$13,284
New York:	$26,907

Average Total Payments

This Hospital:	$6,156
New York:	$9,020

Number of discharges: 17

This Hospital:	3.94%
New York:	3.05%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

Here:	$9,552
New York:	$21,451

Average Total Payments

Here:	$4,693
State:	$7,036

Number of discharges: 16

This Hospital:	3.71%
State:	2.87%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

Here:	$24,630
New York:	$45,478

Average Total Payments

Here:	$12,904
State:	$17,066

Number of discharges: 176

Here:	40.84%
New York:	4.46%

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

Average Covered Charges

This Hospital:	$7,207
New York:	$18,413

Average Total Payments

Here:	$4,329
New York:	$6,139

Number of discharges: 16

Here:	3.71%
State:	2.44%

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

Average Covered Charges

Here:	$16,928
New York:	$47,465

Average Total Payments

Here:	$11,400
New York:	$17,315

Number of discharges: 12

This Hospital:	2.78%
New York:	5.04%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

This Hospital:	$12,255
New York:	$24,560

Average Total Payments

This Hospital:	$6,202
New York:	$8,494

Number of discharges: 34

This Hospital:	7.89%
New York:	2.61%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

This Hospital:	$8,782
State:	$17,401

Average Total Payments

Here:	$4,336
New York:	$5,941

Number of discharges: 23

This Hospital:	5.34%
State:	1.04%

Spinal Fusion Except Cervical without Major Complications

Average Covered Charges

This Hospital:	$57,794
New York:	$74,410

Average Total Payments

Here:	$25,810
New York:	$31,590

Number of discharges: 27

This Hospital:	6.26%
State:	0.50%

Syncope and Collapse

Average Covered Charges

Here:	$9,741
New York:	$19,174

Average Total Payments

Here:	$4,229
State:	$6,619

Number of discharges: 14

This Hospital:	3.25%
State:	3.39%

COMMUNITY MEMORIAL HOSPITAL, INC - HAMILTON, NY

Complaint Deficiency

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

Hospital Acquired Conditions

Quality Measures

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

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