SPECTRUM HEALTH REHAB AND NSG CTRS-KELSEY HOSPITAL (LAKEVIEW, MI) Detailed Nursing Home Profile

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	1.140
Michigan:	0.749

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

Here:	0.690
Michigan:	0.782

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.840
Michigan:	1.525

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.100
State:	0.109

Number Therapy Hours Per Resident Per Day

Here:	0.100
Michigan:	0.112

Quality Measures

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

This Nursing Home:	3.7%
State:	1.6%

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

This Nursing Home:	100.0%
Michigan:	84.1%

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

This Nursing Home:	91.4%
Michigan:	82.9%

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

This Nursing Home:	4.0%
Michigan:	1.9%

Use of Medical Imaging

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

This Nursing Home:	6.200%
Michigan:	7.381%

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

This Nursing Home:	0.029%
State:	0.111%

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

This Nursing Home:	1.000%
Michigan:	2.361%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: Fewer than 100
Survey Response Rate: 37%

How often did nurses communicate well with patients?

Usually

Here:	9%
Michigan:	18%

Always

Here:	91%
State:	78%

How often did doctors communicate well with patients?

Sometimes or never

Here:	4%
State:	4%

Usually

This Nursing Home:	12%
Michigan:	17%

Always

Here:	84%
Michigan:	79%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Nursing Home:	2%
Michigan:	8%

Usually

This Nursing Home:	12%
Michigan:	24%

Always

This Nursing Home:	86%
Michigan:	68%

How often was patients' pain well controlled?

Sometimes or never

This Nursing Home:	3%
Michigan:	6%

Usually

This Nursing Home:	13%
Michigan:	23%

Always

Here:	84%
Michigan:	71%

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

Sometimes or never

Here:	17%
Michigan:	20%

Usually

This Nursing Home:	13%
Michigan:	19%

Always

Here:	70%
Michigan:	61%

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

Sometimes or never

This Nursing Home:	3%
State:	9%

Usually

This Nursing Home:	10%
Michigan:	20%

Always

Here:	87%
State:	71%

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

Sometimes or never

Here:	7%
Michigan:	12%

Usually

Here:	27%
Michigan:	31%

Always

Here:	66%
State:	57%

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

Yes

This Nursing Home:	97%
State:	86%

Here:	3%
Michigan:	14%

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

6 or lower

Here:	6%
State:	8%

7 or 8

Here:	11%
State:	22%

9 or 10

Here:	83%
State:	70%

Would patients recommend the hospital to friends and family?

This Nursing Home:	3%
Michigan:	5%

Yes, probably

This Nursing Home:	18%
State:	25%

Yes, definitely

Here:	79%
Michigan:	70%

Process of Care

Heart Attack

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

Here:	9
State:	9

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

Here:	99.0%
State:	95.4%

Heart Failure

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

This Nursing Home:	100.0%
State:	99.5%

Pneumonia

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

Here:	100.0%
Michigan:	96.5%

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

Here:	93.0%
State:	97.1%

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

Here:	100.0%
State:	95.7%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	100.0%
State:	95.8%

Outcome of Care

30-Day Mortality Rates from Pneumonia

Here:	9.8%
State:	11.4%

30-Day Readmission Rates from Heart Failure

Here:	23.6%
Michigan:	25.2%

30-Day Readmission Rates from Pneumonia

Here:	16.5%
Michigan:	18.7%

Complaint Deficiency

Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Weekly inspections and monthly testing of generators
- 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
Give the resident's representative the ability to exercise the resident's rights
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide access to a telephone for resident to use in private
- 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
Reasonably accommodate the needs and preferences 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
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 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
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
Make sure that residents are safe from serious medication errors
- 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
Make sure that doctors visit residents regularly, as required
- Harm: Potential for minimal 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: Some
Have a program that investigates, controls and keeps infection from spreading
- 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: Many
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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
Provide necessary care and services to maintain the highest well being of each resident
- 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: Some
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Many

SPECTRUM HEALTH REHAB AND NSG CTRS-KELSEY HOSPITAL - LAKEVIEW, MI

Staff Information

Quality Measures

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

Process of Care

Heart Attack

Heart Failure

Pneumonia

Outcome of Care

Complaint Deficiency

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