HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF (HOLLISTER, CA) Detailed Nursing Home Profile

Quality Measures

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

Here:	42.6%
California:	13.1%

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

This Nursing Home:	9.4%
California:	8.9%

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

Here:	15.2%
California:	7.5%

Percent of long-stay residents who lose too much weight

Here:	4.9%
California:	6.3%

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

This Nursing Home:	2.3%
California:	4.0%

Percent of long-stay residents with a urinary tract infection

Here:	8.1%
California:	6.7%

Percent of long-stay residents who have depressive symptoms

Here:	1.1%
State:	2.4%

Percent of long-stay residents who were physically restrained

This Nursing Home:	3.3%
State:	3.6%

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

This Nursing Home:	4.4%
State:	93.0%

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

Here:	100.0%
California:	94.0%

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

This Nursing Home:	13.3%
State:	21.2%

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

Here:	1.2%
State:	1.2%

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

Here:	33.8%
California:	81.9%

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

This Nursing Home:	89.6%
State:	79.7%

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

Here:	3.6%
California:	2.2%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	14.8%
State:	19.0%

Complaint Deficiency

Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Portable fire extinguishers
- 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: Few
A separate and independent backup electrical power source
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Other fire safety features required by fire safety codes
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly constructed linen or trash chutes
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- 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: Few
Properly installed electrical wiring and equipment
- 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
Restrictions on the use of highly flammable materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide special eating equipment and utensils for each resident who needs them
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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: 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
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
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
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
Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents are safe from serious medication errors
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- 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: Potential for minimal harm
- Scope: Some
Approved construction type or materials
- 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: Some
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
Properly located and lighted Exit signs
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Restrictions on the use of highly flammable materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- 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
Properly installed hallway dispensers for alcohol-based hand rub
- 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: Potential for minimal harm
- Scope: Many
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
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Potential for minimal harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep all essential equipment working safely
- Harm: Potential for minimal harm
- Scope: Some
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
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors
- 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
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly sized and located linen or trash receptacles
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper medical gas storage and administration areas
- 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: 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: Potential for minimal 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
Conduct initial and periodic assessments of each resident's functional capacity
- 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 menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- 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
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep all essential equipment working safely
- 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
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly maintained smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Portable fire extinguishers
- 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: Few

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	1.120
California:	0.748

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.530
California:	0.900

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.650
California:	1.608

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.090
California:	0.118

Number Therapy Hours Per Resident Per Day

Here:	0.090
California:	0.126

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

Cardiac Arrhythmia and Conduction Disorders with Complications

Average Covered Charges

This Nursing Home:	$30,579
State:	$39,980

Average Total Payments

This Nursing Home:	$8,453
State:	$7,146

Number of discharges: 12

Here:	2.92%
State:	1.30%

Cardiac Arrhythmia and Conduction Disorders without Complications

Average Covered Charges

Here:	$20,973
California:	$28,713

Average Total Payments

Here:	$5,639
State:	$4,819

Number of discharges: 20

Here:	4.87%
California:	1.18%

Cellulitis without Major Complications

Average Covered Charges

Here:	$40,192
California:	$36,707

Average Total Payments

Here:	$8,234
California:	$7,245

Number of discharges: 17

Here:	4.14%
California:	2.08%

Chest Pain

Average Covered Charges

This Nursing Home:	$19,807
California:	$29,034

Average Total Payments

This Nursing Home:	$5,543
State:	$4,742

Number of discharges: 32

This Nursing Home:	7.79%
California:	2.11%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

Here:	$24,787
State:	$36,899

Average Total Payments

This Nursing Home:	$7,142
State:	$6,233

Number of discharges: 34

Here:	8.27%
California:	3.09%

G.I. Hemorrhage with Complications

Average Covered Charges

Here:	$34,788
State:	$46,039

Average Total Payments

This Nursing Home:	$10,249
California:	$8,685

Number of discharges: 14

This Nursing Home:	3.41%
California:	1.95%

Heart Failure and Shock with Complications

Average Covered Charges

This Nursing Home:	$35,733
California:	$47,292

Average Total Payments

Here:	$9,995
California:	$8,831

Number of discharges: 25

This Nursing Home:	6.08%
California:	2.91%

Heart Failure and Shock with Major Complications

Average Covered Charges

Here:	$69,523
California:	$70,963

Average Total Payments

This Nursing Home:	$17,156
State:	$13,159

Number of discharges: 12

Here:	2.92%
State:	3.03%

Heart Failure and Shock without Complications

Average Covered Charges

This Nursing Home:	$35,229
California:	$32,995

Average Total Payments

Here:	$6,907
California:	$5,851

Number of discharges: 14

This Nursing Home:	3.41%
State:	1.02%

Hip and Femur Procedures Except Major Joint without Complications

Average Covered Charges

This Nursing Home:	$64,279
California:	$68,603

Average Total Payments

Here:	$15,460
California:	$12,359

Number of discharges: 11

This Nursing Home:	2.68%
California:	0.32%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

This Nursing Home:	$26,164
State:	$36,114

Average Total Payments

Here:	$7,926
State:	$6,728

Number of discharges: 22

This Nursing Home:	5.35%
State:	2.98%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

This Nursing Home:	$74,769
State:	$88,239

Average Total Payments

Here:	$21,206
State:	$17,187

Number of discharges: 12

This Nursing Home:	2.92%
State:	6.26%

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

Average Covered Charges

Here:	$23,722
State:	$32,446

Average Total Payments

Here:	$6,971
State:	$5,975

Number of discharges: 15

Here:	3.65%
State:	2.21%

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

Average Covered Charges

This Nursing Home:	$51,649
California:	$90,173

Average Total Payments

Here:	$17,943
California:	$16,748

Number of discharges: 25

Here:	6.08%
California:	7.21%

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

Average Covered Charges

This Nursing Home:	$31,453
State:	$50,385

Average Total Payments

This Nursing Home:	$11,431
State:	$9,612

Number of discharges: 22

Here:	5.35%
California:	2.35%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

This Nursing Home:	$45,838
California:	$48,755

Average Total Payments

This Nursing Home:	$10,222
California:	$8,695

Number of discharges: 48

This Nursing Home:	11.68%
California:	2.75%

Simple Pneumonia and Pleurisy with Major Complications

Average Covered Charges

Here:	$58,182
State:	$70,362

Average Total Payments

This Nursing Home:	$14,853
California:	$12,496

Number of discharges: 14

This Nursing Home:	3.41%
State:	1.89%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

Here:	$29,674
State:	$34,477

Average Total Payments

This Nursing Home:	$7,152
California:	$5,838

Number of discharges: 17

Here:	4.14%
State:	0.97%

Syncope and Collapse

Average Covered Charges

Here:	$24,472
California:	$37,038

Average Total Payments

Here:	$7,141
State:	$6,233

Number of discharges: 30

Here:	7.30%
California:	1.60%

Transient Ischemia

Average Covered Charges

This Nursing Home:	$24,085
California:	$37,396

Average Total Payments

Here:	$7,369
California:	$6,120

Number of discharges: 15

This Nursing Home:	3.65%
California:	0.94%

Hospital Acquired Conditions

Falls and injuries

This Nursing Home:	0.553%
State:	0.625%

Severe pressure sores (bed sores)

This Nursing Home:	0.553%
California:	0.321%

Use of Medical Imaging

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

This Nursing Home:	9.000%
California:	8.180%

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

Here:	0.463%
California:	0.170%

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

Here:	5.600%
State:	1.898%

Process of Care

Heart Failure

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

This Nursing Home:	98.0%
California:	98.9%

Percent of Patients Given Discharge Instructions

This Nursing Home:	83.0%
California:	93.5%

Pneumonia

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

Here:	96.0%
State:	96.1%

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

This Nursing Home:	91.0%
California:	96.7%

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

This Nursing Home:	95.0%
California:	95.9%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	73.0%
State:	94.3%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	85.0%
California:	95.8%

Surgery

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

Here:	91.0%
California:	98.1%

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

Here:	93.0%
California:	96.3%

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

This Nursing Home:	98.0%
California:	98.2%

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

Here:	76.0%
California:	96.0%

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

Here:	77.0%
State:	96.9%

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

This Nursing Home:	100.0%
California:	99.8%

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

Here:	84.0%
California:	93.9%

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

This Nursing Home:	100.0%
California:	99.6%

Outcome of Care

30-Day Mortality Rates from Heart Attack

This Nursing Home:	13.9%
State:	14.9%

30-Day Mortality Rates from Heart Failure

This Nursing Home:	11.7%
California:	10.9%

30-Day Mortality Rates from Pneumonia

This Nursing Home:	13.9%
State:	11.7%

30-Day Readmission Rates from Heart Failure

This Nursing Home:	25.2%
State:	24.4%

30-Day Readmission Rates from Pneumonia

Here:	20.0%
State:	18.3%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 23%

How often did nurses communicate well with patients?

Sometimes or never

Here:	9%
California:	7%

Usually

This Nursing Home:	20%
California:	21%

Always

Here:	71%
State:	72%

How often did doctors communicate well with patients?

Sometimes or never

Here:	7%
State:	6%

Usually

Here:	18%
State:	17%

Always

This Nursing Home:	75%
State:	77%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Nursing Home:	12%
California:	13%

Usually

Here:	24%
California:	28%

Always

This Nursing Home:	64%
State:	59%

How often was patients' pain well controlled?

Sometimes or never

This Nursing Home:	11%
California:	8%

Usually

This Nursing Home:	22%
State:	25%

Always

Here:	67%
State:	67%

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

Sometimes or never

This Nursing Home:	23%
State:	23%

Usually

This Nursing Home:	19%
California:	19%

Always

This Nursing Home:	58%
State:	58%

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

Sometimes or never

This Nursing Home:	9%
State:	10%

Usually

Here:	21%
State:	21%

Always

Here:	70%
State:	69%

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

Sometimes or never

Here:	23%
State:	18%

Usually

Here:	33%
State:	33%

Always

Here:	44%
California:	49%

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

Yes

This Nursing Home:	74%
State:	81%

Here:	26%
California:	19%

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

6 or lower

Here:	16%
State:	10%

7 or 8

This Nursing Home:	31%
State:	24%

9 or 10

Here:	53%
California:	66%

Would patients recommend the hospital to friends and family?

This Nursing Home:	12%
State:	7%

Yes, probably

This Nursing Home:	33%
California:	24%

Yes, definitely

Here:	55%
California:	69%

HAZEL HAWKINS MEMORIAL HOSPITAL D/P SNF - HOLLISTER, CA

Quality Measures

Complaint Deficiency

Staff Information

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

Hospital Acquired Conditions

Use of Medical Imaging

Process of Care

Heart Failure

Pneumonia

Surgery

Outcome of Care

Hospital Consumer Assessment of Healthcare Providers

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