MADISON LUTHERAN HOME (MADISON, MN) Detailed Nursing Home Profile

Quality Measures

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

This Nursing Home:	6.3%
State:	15.5%

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

This Nursing Home:	3.2%
Minnesota:	12.5%

Percent of long-stay residents who lose too much weight

This Nursing Home:	6.3%
State:	7.6%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

This Nursing Home:	61.1%
Minnesota:	47.8%

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

Here:	4.3%
State:	4.1%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	17.2%
Minnesota:	5.2%

Percent of long-stay residents who have depressive symptoms

Here:	9.7%
Minnesota:	7.4%

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

This Nursing Home:	9.1%
Minnesota:	3.9%

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

This Nursing Home:	100.0%
Minnesota:	97.0%

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

Here:	100.0%
State:	96.8%

Percent of long-stay residents who received an antipsychotic medication

Here:	17.2%
State:	17.4%

Process of Care

Heart Failure

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

Here:	23.0%
State:	97.5%

Pneumonia

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

This Nursing Home:	86.0%
Minnesota:	97.1%

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

Here:	27.0%
State:	92.8%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	66.0%
State:	94.9%

Outcome of Care

30-Day Mortality Rates from Pneumonia

This Nursing Home:	10.2%
Minnesota:	11.4%

30-Day Readmission Rates from Pneumonia

This Nursing Home:	20.4%
Minnesota:	18.3%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: Fewer than 100
Survey Response Rate: 44%

How often did nurses communicate well with patients?

Sometimes or never

Here:	3%
State:	3%

Usually

This Nursing Home:	31%
State:	18%

Always

This Nursing Home:	66%
State:	79%

How often did doctors communicate well with patients?

Sometimes or never

This Nursing Home:	4%
Minnesota:	3%

Usually

Here:	21%
Minnesota:	14%

Always

Here:	75%
State:	83%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	9%
Minnesota:	6%

Usually

Here:	32%
Minnesota:	22%

Always

This Nursing Home:	59%
Minnesota:	72%

How often was patients' pain well controlled?

Sometimes or never

Here:	14%
Minnesota:	5%

Usually

Here:	24%
Minnesota:	25%

Always

This Nursing Home:	62%
State:	70%

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

Sometimes or never

This Nursing Home:	15%
Minnesota:	16%

Usually

Here:	23%
Minnesota:	20%

Always

This Nursing Home:	62%
State:	64%

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

Sometimes or never

This Nursing Home:	3%
State:	6%

Usually

This Nursing Home:	17%
Minnesota:	18%

Always

This Nursing Home:	80%
State:	76%

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

Sometimes or never

This Nursing Home:	5%
State:	7%

Usually

Here:	28%
State:	30%

Always

Here:	67%
Minnesota:	63%

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

Yes

Here:	84%
Minnesota:	86%

Here:	16%
Minnesota:	14%

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

6 or lower

This Nursing Home:	9%
State:	6%

7 or 8

Here:	36%
Minnesota:	22%

9 or 10

Here:	55%
Minnesota:	72%

Would patients recommend the hospital to friends and family?

Here:	2%
State:	3%

Yes, probably

This Nursing Home:	33%
Minnesota:	24%

Yes, definitely

Here:	65%
State:	73%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.570
Minnesota:	0.794

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

Here:	0.780
State:	0.750

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.350
Minnesota:	1.543

Use of Medical Imaging

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

This Nursing Home:	1.300%
State:	6.118%

Complaint Deficiency

Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Review or revise the resident's care plan after any major change in a resident's physical or mental health
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Check and assess each resident's assessment at least every 3 months
- 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
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
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
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Immediate jeopardy to resident health or safety
- 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 the right treatment and services to residents who have mental or psychosocial problems adjusting
- 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: Immediate jeopardy to resident health or safety
- 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
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
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
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
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Record of quarterly fire drills for each shift under varying conditions
- 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
Store, cook, and serve food in a safe and clean way
- 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
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Keep each resident's personal and medical records private and confidential
- 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
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Check and assess each resident's assessment at least every 3 months
- 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
Provide care by qualified persons according to each resident's written plan of care
- 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
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
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
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
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few

MADISON LUTHERAN HOME - MADISON, MN

Quality Measures

Process of Care

Heart Failure

Pneumonia

Outcome of Care

Hospital Consumer Assessment of Healthcare Providers

Staff Information

Use of Medical Imaging

Complaint Deficiency

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