GRAHAM HOSPITAL ASSOCIATION (CANTON, IL) Detailed Hospital Profile

Complaint Deficiency

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
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: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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: Some
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Proper construction of ducts through walls designed to prevent smoke passage
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Record of quarterly fire drills for each shift under varying conditions
- Harm: Potential for minimal harm
- Scope: Many
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly maintained smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed hallway dispensers for alcohol-based hand rub
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
- Harm: Immediate jeopardy to resident health or safety
- 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: Some
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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: Some
Provide activities to meet the interests and needs of each resident
- 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
Conduct initial and periodic assessments of each resident's functional capacity
- 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: Immediate jeopardy to resident health or safety
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- 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 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: Immediate jeopardy to resident health or safety
- 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: Immediate jeopardy to resident health or safety
- 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
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
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: Actual harm
- Scope: Many
Keep all essential equipment working safely
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Potential for minimal 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
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: Many

Hospital Acquired Conditions

Blood infection from a catheter in a large vein

This Hospital:	0.506%
State:	0.445%

Use of Medical Imaging

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

This Hospital:	56.300%
State:	37.406%

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

This Hospital:	4.800%
State:	8.337%

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

Here:	0.573%
State:	0.171%

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

Here:	0.571%
State:	0.056%

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

Here:	5.000%
Illinois:	5.573%

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

This Hospital:	4.900%
Illinois:	2.790%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 32%

How often did nurses communicate well with patients?

Sometimes or never

Here:	4%
State:	5%

Usually

Here:	18%
State:	18%

Always

Here:	78%
State:	77%

How often did doctors communicate well with patients?

Sometimes or never

Here:	2%
Illinois:	4%

Usually

This Hospital:	13%
Illinois:	16%

Always

This Hospital:	85%
State:	80%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	9%
Illinois:	11%

Usually

Here:	29%
State:	25%

Always

This Hospital:	62%
State:	64%

How often was patients' pain well controlled?

Sometimes or never

Here:	5%
Illinois:	7%

Usually

Here:	21%
Illinois:	24%

Always

Here:	74%
Illinois:	69%

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

Sometimes or never

Here:	23%
State:	21%

Usually

This Hospital:	18%
Illinois:	19%

Always

Here:	59%
State:	60%

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

Sometimes or never

Here:	7%
Illinois:	9%

Usually

This Hospital:	18%
State:	19%

Always

Here:	75%
Illinois:	72%

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

Sometimes or never

This Hospital:	12%
Illinois:	12%

Usually

This Hospital:	33%
State:	31%

Always

This Hospital:	55%
Illinois:	57%

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

Yes

This Hospital:	83%
Illinois:	83%

Here:	17%
State:	17%

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

6 or lower

Here:	9%
State:	9%

7 or 8

This Hospital:	25%
State:	24%

9 or 10

This Hospital:	66%
Illinois:	67%

Would patients recommend the hospital to friends and family?

This Hospital:	4%
Illinois:	5%

Yes, probably

This Hospital:	34%
Illinois:	27%

Yes, definitely

Here:	62%
Illinois:	68%

Process of Care

Heart Attack

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

This Hospital:	7
Illinois:	8

Average number of minutes before outpatients with chest pain or possible heart attack were transferred to another hospital

This Hospital:	47
State:	66

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

Here:	98.0%
Illinois:	96.6%

Heart Failure

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

Here:	96.0%
State:	99.0%

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

Here:	84.0%
State:	96.7%

Percent of Patients Given Discharge Instructions

Here:	100.0%
State:	94.0%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	100.0%
State:	99.3%

Pneumonia

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

This Hospital:	100.0%
State:	96.2%

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

This Hospital:	99.0%
Illinois:	97.5%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	96.0%
State:	98.5%

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

This Hospital:	94.0%
Illinois:	93.1%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	83.0%
Illinois:	94.4%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	95.0%
State:	95.5%

Surgery

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

This Hospital:	97.0%
State:	98.2%

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

Here:	98.0%
Illinois:	97.1%

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

Here:	99.0%
Illinois:	98.4%

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

Here:	97.0%
Illinois:	96.7%

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

Here:	97.0%
Illinois:	97.4%

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

Here:	98.0%
Illinois:	99.9%

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

Here:	92.0%
Illinois:	94.3%

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

This Hospital:	96.0%
State:	96.8%

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

Here:	97.0%
State:	96.3%

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

This Hospital:	98.0%
Illinois:	96.5%

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

This Hospital:	100.0%
Illinois:	99.7%

Outcome of Care

30-Day Mortality Rates from Heart Failure

This Hospital:	11.5%
Illinois:	11.0%

30-Day Mortality Rates from Pneumonia

This Hospital:	15.7%
Illinois:	11.7%

30-Day Readmission Rates from Heart Failure

Here:	25.9%
Illinois:	25.6%

30-Day Readmission Rates from Pneumonia

This Hospital:	20.0%
State:	19.4%

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

Cardiac Arrhythmia and Conduction Disorders with Complications

Average Covered Charges

This Hospital:	$16,173
Illinois:	$21,268

Average Total Payments

Here:	$5,633
Illinois:	$5,793

Number of discharges: 14

This Hospital:	2.14%
Illinois:	1.46%

Cardiac Arrhythmia and Conduction Disorders without Complications

Average Covered Charges

This Hospital:	$11,463
Illinois:	$15,251

Average Total Payments

This Hospital:	$4,074
Illinois:	$4,043

Number of discharges: 30

Here:	4.59%
Illinois:	1.56%

Cellulitis without Major Complications

Average Covered Charges

This Hospital:	$10,956
Illinois:	$18,733

Average Total Payments

This Hospital:	$5,826
State:	$5,908

Number of discharges: 31

Here:	4.75%
Illinois:	2.24%

Chronic Obstructive Pulmonary Disease with Complications

Average Covered Charges

This Hospital:	$14,463
Illinois:	$24,404

Average Total Payments

Here:	$6,919
State:	$6,718

Number of discharges: 21

This Hospital:	3.22%
Illinois:	2.13%

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

Here:	$16,520
State:	$30,400

Average Total Payments

This Hospital:	$8,357
Illinois:	$8,130

Number of discharges: 23

Here:	3.52%
Illinois:	2.07%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

Here:	$11,381
State:	$17,974

Average Total Payments

Here:	$5,095
Illinois:	$5,059

Number of discharges: 75

Here:	11.49%
Illinois:	1.69%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

This Hospital:	$13,400
State:	$19,895

Average Total Payments

Here:	$5,075
State:	$5,151

Number of discharges: 34

Here:	5.21%
State:	3.69%

G.I. Hemorrhage without Complications

Average Covered Charges

Here:	$13,880
State:	$18,250

Average Total Payments

Here:	$4,960
Illinois:	$5,012

Number of discharges: 16

This Hospital:	2.45%
State:	0.52%

Heart Failure and Shock with Complications

Average Covered Charges

Here:	$14,245
State:	$24,443

Average Total Payments

This Hospital:	$7,031
State:	$7,163

Number of discharges: 25

Here:	3.83%
State:	3.19%

Heart Failure and Shock without Complications

Average Covered Charges

This Hospital:	$10,980
Illinois:	$16,995

Average Total Payments

Here:	$4,865
State:	$4,812

Number of discharges: 32

Here:	4.90%
Illinois:	1.36%

Intracranial Hemorrhage or Cerebral Infarction without Complications

Average Covered Charges

This Hospital:	$14,343
State:	$24,632

Average Total Payments

This Hospital:	$5,579
Illinois:	$5,882

Number of discharges: 17

This Hospital:	2.60%
State:	0.75%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

Here:	$10,898
State:	$19,533

Average Total Payments

This Hospital:	$5,660
Illinois:	$5,411

Number of discharges: 64

This Hospital:	9.80%
Illinois:	2.92%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

This Hospital:	$40,713
State:	$53,071

Average Total Payments

This Hospital:	$15,746
State:	$14,841

Number of discharges: 43

This Hospital:	6.58%
Illinois:	5.56%

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

Average Covered Charges

Here:	$12,023
Illinois:	$17,353

Average Total Payments

This Hospital:	$4,884
Illinois:	$4,937

Number of discharges: 40

This Hospital:	6.13%
Illinois:	2.56%

Red Blood Cell Disorders without Major Complications

Average Covered Charges

Here:	$12,632
Illinois:	$19,956

Average Total Payments

This Hospital:	$5,457
Illinois:	$5,858

Number of discharges: 12

This Hospital:	1.84%
Illinois:	1.62%

Renal Failure with Complications

Average Covered Charges

Here:	$11,828
State:	$24,747

Average Total Payments

Here:	$7,006
State:	$7,044

Number of discharges: 12

Here:	1.84%
State:	1.98%

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

Average Covered Charges

This Hospital:	$17,226
Illinois:	$48,201

Average Total Payments

Here:	$12,722
State:	$13,223

Number of discharges: 14

This Hospital:	2.14%
State:	4.32%

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

Average Covered Charges

This Hospital:	$16,541
State:	$28,109

Average Total Payments

Here:	$7,657
State:	$7,726

Number of discharges: 21

This Hospital:	3.22%
State:	1.38%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

This Hospital:	$14,646
Illinois:	$25,731

Average Total Payments

Here:	$7,220
State:	$6,879

Number of discharges: 60

Here:	9.19%
State:	2.78%

Simple Pneumonia and Pleurisy with Major Complications

Average Covered Charges

This Hospital:	$23,062
Illinois:	$39,486

Average Total Payments

This Hospital:	$9,239
Illinois:	$9,878

Number of discharges: 16

This Hospital:	2.45%
State:	1.64%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

Here:	$11,796
State:	$17,950

Average Total Payments

Here:	$5,070
State:	$4,908

Number of discharges: 34

Here:	5.21%
Illinois:	1.13%

Syncope and Collapse

Average Covered Charges

This Hospital:	$13,692
State:	$19,781

Average Total Payments

Here:	$5,031
State:	$5,089

Number of discharges: 19

This Hospital:	2.91%
State:	2.34%

Quality Measures

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

Here:	38.6%
State:	19.2%

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

This Hospital:	3.6%
Illinois:	1.9%

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

Here:	94.8%
Illinois:	81.0%

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

This Hospital:	96.0%
Illinois:	80.2%

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

This Hospital:	1.1%
State:	2.5%

GRAHAM HOSPITAL ASSOCIATION - CANTON, IL

Complaint Deficiency

Hospital Acquired Conditions

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

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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