MEMORIAL HOSPITAL AND PHYSICIAN GROUP (FREDERICK, OK) Detailed Hospital Profile

Process of Care

Heart Failure

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

Here:	77.0%
State:	96.0%

Percent of Patients Given Discharge Instructions

This Hospital:	95.0%
Oklahoma:	88.1%

Pneumonia

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

Here:	75.0%
Oklahoma:	95.1%

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

This Hospital:	100.0%
State:	97.1%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	91.0%
Oklahoma:	96.5%

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

Here:	93.0%
Oklahoma:	92.1%

Percent of Patients Assessed and Given Influenza Vaccination

This Hospital:	89.0%
Oklahoma:	92.0%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	81.0%
Oklahoma:	92.6%

Outcome of Care

30-Day Mortality Rates from Heart Failure

Here:	9.9%
Oklahoma:	11.8%

30-Day Mortality Rates from Pneumonia

This Hospital:	9.9%
Oklahoma:	12.5%

30-Day Readmission Rates from Heart Failure

This Hospital:	23.7%
Oklahoma:	25.1%

30-Day Readmission Rates from Pneumonia

This Hospital:	20.6%
Oklahoma:	18.6%

Hospital Acquired Conditions

Falls and injuries

This Hospital:	1.274%
Oklahoma:	1.316%

Complaint Deficiency

Back-up procedures in place for a faulty automatic sprinkler system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
A two-hour-resistant firewall in common walls
- 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: 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: Some
Proper backup exit lighting
- 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: 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
Provide care by qualified persons according to each resident's written plan of care
- 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: Immediate jeopardy to resident health or safety
- 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: 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: Some
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
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: Some
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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: Some
Corridor and hallway doors that block smoke
- 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
Exits that are free from obstructions and can be used at all times
- 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: 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: Minimal harm or potential for actual harm
- Scope: Some
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: Some

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: Fewer than 100
Survey Response Rate: 27%

How often did nurses communicate well with patients?

Sometimes or never

This Hospital:	3%
Oklahoma:	5%

Usually

Here:	15%
Oklahoma:	17%

Always

Here:	82%
Oklahoma:	78%

How often did doctors communicate well with patients?

Sometimes or never

This Hospital:	1%
Oklahoma:	4%

Usually

Here:	11%
Oklahoma:	12%

Always

Here:	88%
State:	84%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	2%
State:	8%

Usually

This Hospital:	25%
Oklahoma:	23%

Always

Here:	73%
State:	69%

How often was patients' pain well controlled?

Sometimes or never

Here:	5%
State:	6%

Usually

Here:	19%
Oklahoma:	22%

Always

This Hospital:	76%
Oklahoma:	72%

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

Sometimes or never

Here:	24%
Oklahoma:	19%

Usually

Here:	21%
State:	18%

Always

This Hospital:	55%
Oklahoma:	63%

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

Sometimes or never

This Hospital:	10%
Oklahoma:	9%

Usually

Here:	21%
Oklahoma:	18%

Always

Here:	69%
State:	73%

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

Sometimes or never

Here:	7%
State:	7%

Usually

Here:	23%
Oklahoma:	26%

Always

Here:	70%
State:	67%

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

Yes

Here:	75%
Oklahoma:	82%

This Hospital:	25%
State:	18%

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

6 or lower

This Hospital:	9%
State:	9%

7 or 8

Here:	17%
State:	20%

9 or 10

Here:	74%
State:	71%

Would patients recommend the hospital to friends and family?

This Hospital:	4%
State:	5%

Yes, probably

This Hospital:	28%
State:	25%

Yes, definitely

Here:	68%
State:	70%

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

Chronic Obstructive Pulmonary Disease with Complications

Average Covered Charges

This Hospital:	$7,685
Oklahoma:	$20,357

Average Total Payments

This Hospital:	$6,019
State:	$5,990

Number of discharges: 16

Here:	10.74%
State:	2.45%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

This Hospital:	$9,037
State:	$16,855

Average Total Payments

Here:	$4,755
State:	$4,488

Number of discharges: 18

This Hospital:	12.08%
State:	3.38%

Heart Failure and Shock with Complications

Average Covered Charges

This Hospital:	$8,599
State:	$20,023

Average Total Payments

Here:	$6,469
State:	$6,322

Number of discharges: 23

This Hospital:	15.44%
State:	3.05%

Heart Failure and Shock with Major Complications

Average Covered Charges

This Hospital:	$11,304
Oklahoma:	$31,963

Average Total Payments

Here:	$9,381
Oklahoma:	$9,065

Number of discharges: 14

This Hospital:	9.40%
Oklahoma:	2.05%

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

Average Covered Charges

This Hospital:	$5,187
Oklahoma:	$12,842

Average Total Payments

This Hospital:	$4,582
Oklahoma:	$4,286

Number of discharges: 14

Here:	9.40%
Oklahoma:	2.85%

Renal Failure with Complications

Average Covered Charges

This Hospital:	$6,874
State:	$21,220

Average Total Payments

This Hospital:	$6,638
Oklahoma:	$6,390

Number of discharges: 13

Here:	8.72%
State:	2.07%

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

Average Covered Charges

Here:	$11,505
State:	$41,402

Average Total Payments

Here:	$11,908
State:	$11,891

Number of discharges: 38

This Hospital:	25.50%
Oklahoma:	5.07%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

Here:	$8,955
Oklahoma:	$21,487

Average Total Payments

Here:	$6,565
Oklahoma:	$6,233

Number of discharges: 13

This Hospital:	8.72%
State:	3.70%

Use of Medical Imaging

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

This Hospital:	7.800%
Oklahoma:	2.081%

Quality Measures

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

Here:	6.7%
State:	5.0%

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

Here:	100.0%
State:	95.3%

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

This Hospital:	90.0%
State:	90.0%

MEMORIAL HOSPITAL AND PHYSICIAN GROUP - FREDERICK, OK

Process of Care

Heart Failure

Pneumonia

Outcome of Care

Hospital Acquired Conditions

Complaint Deficiency

Hospital Consumer Assessment of Healthcare Providers

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

Use of Medical Imaging

Quality Measures

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