MARLETTE COMM HOSP LTCU (MARLETTE, MI) Detailed Nursing Home Profile

Process of Care

Heart Attack

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

This Nursing Home:	10
State:	9

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

This Nursing Home:	124
Michigan:	51

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

Here:	92.0%
State:	95.4%

Heart Failure

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

Here:	89.0%
Michigan:	99.5%

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

This Nursing Home:	73.0%
State:	95.9%

Percent of Patients Given Discharge Instructions

This Nursing Home:	77.0%
State:	92.1%

Pneumonia

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

This Nursing Home:	88.0%
State:	96.5%

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

This Nursing Home:	92.0%
Michigan:	97.1%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	95.0%
Michigan:	98.8%

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

This Nursing Home:	86.0%
Michigan:	95.7%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	36.0%
Michigan:	92.3%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	58.0%
State:	95.8%

Surgery

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

This Nursing Home:	86.0%
State:	98.3%

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

This Nursing Home:	100.0%
State:	97.3%

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

Here:	73.0%
State:	98.5%

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

Here:	93.0%
Michigan:	97.5%

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

This Nursing Home:	93.0%
State:	98.4%

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

This Nursing Home:	83.0%
State:	99.8%

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

Here:	86.0%
State:	93.2%

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

This Nursing Home:	90.0%
Michigan:	93.9%

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

Here:	53.0%
Michigan:	95.7%

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

This Nursing Home:	94.0%
Michigan:	99.7%

Outcome of Care

30-Day Mortality Rates from Heart Failure

This Nursing Home:	10.4%
State:	10.8%

30-Day Mortality Rates from Pneumonia

This Nursing Home:	10.4%
State:	11.4%

30-Day Readmission Rates from Heart Failure

This Nursing Home:	24.1%
State:	25.2%

30-Day Readmission Rates from Pneumonia

This Nursing Home:	18.2%
Michigan:	18.7%

Quality Measures

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

This Nursing Home:	6.1%
State:	14.8%

Percent of long-stay residents who lose too much weight

This Nursing Home:	7.9%
Michigan:	7.4%

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

Here:	2.7%
State:	4.0%

Percent of long-stay residents with a urinary tract infection

Here:	2.6%
State:	6.2%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	14.3%
Michigan:	4.8%

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

This Nursing Home:	5.3%
Michigan:	2.8%

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

This Nursing Home:	100.0%
Michigan:	92.5%

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

Here:	89.5%
State:	94.6%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	5.3%
Michigan:	16.0%

Complaint Deficiency

Corridors that are separated from common areas by walls constructed to limit the passage of smoke
- 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
Did not have a written emergency evacuation plan
- 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
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 a safe, clean, comfortable and homelike environment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
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
Make sure medically necessary lab services/tests are ordered by the attending physician
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridors that are separated from common areas by walls constructed to limit the passage of smoke
- 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: Few
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: 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
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 housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
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
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: Many
Corridors that are separated from common areas by walls constructed to limit the passage of smoke
- 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 accessible at all times
- 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: Some
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
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many

Use of Medical Imaging

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

Here:	4.900%
State:	7.381%

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

Here:	0.004%
State:	0.111%

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

This Nursing Home:	3.500%
State:	5.222%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.820
Michigan:	0.749

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

This Nursing Home:	0.510
State:	0.782

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.330
Michigan:	1.525

MARLETTE COMM HOSP LTCU - MARLETTE, MI