MEMORIAL HOSPITAL AND MANOR (BAINBRIDGE, GA) Detailed Hospital Profile

Process of Care

Heart Attack

Percent of Patients Given Aspirin at Arrival

Here:	75.0%
Georgia:	99.2%

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

This Hospital:	13
State:	33

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

This Hospital:	91.0%
State:	95.8%

Heart Failure

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

This Hospital:	82.0%
State:	99.2%

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

This Hospital:	71.0%
State:	95.8%

Percent of Patients Given Discharge Instructions

This Hospital:	68.0%
Georgia:	89.3%

Pneumonia

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

This Hospital:	87.0%
Georgia:	96.3%

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

This Hospital:	81.0%
Georgia:	97.0%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	86.0%
State:	98.9%

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

This Hospital:	90.0%
State:	94.9%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	61.0%
State:	94.4%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	74.0%
Georgia:	96.2%

Surgery

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

Here:	87.0%
State:	98.2%

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

Here:	100.0%
State:	96.5%

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

Here:	97.0%
Georgia:	98.4%

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

Here:	88.0%
Georgia:	96.5%

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

This Hospital:	89.0%
State:	97.4%

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

This Hospital:	100.0%
Georgia:	99.6%

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

This Hospital:	52.0%
Georgia:	93.5%

Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on them

This Hospital:	83.0%
State:	95.9%

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

Here:	90.0%
State:	96.6%

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

This Hospital:	100.0%
State:	97.0%

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

This Hospital:	68.0%
State:	99.3%

Outcome of Care

30-Day Mortality Rates from Heart Attack

Here:	17.2%
Georgia:	15.6%

30-Day Mortality Rates from Heart Failure

Here:	10.8%
Georgia:	11.6%

30-Day Mortality Rates from Pneumonia

This Hospital:	14.8%
State:	12.6%

30-Day Readmission Rates from Heart Failure

This Hospital:	25.5%
State:	24.1%

30-Day Readmission Rates from Pneumonia

Here:	18.6%
State:	18.5%

Quality Measures

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

Here:	18.2%
Georgia:	15.5%

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

Here:	28.9%
State:	12.0%

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

This Hospital:	4.5%
Georgia:	7.3%

Percent of long-stay residents who lose too much weight

Here:	12.5%
Georgia:	8.1%

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

This Hospital:	1.8%
State:	2.7%

Percent of long-stay residents with a urinary tract infection

Here:	3.1%
State:	7.6%

Percent of long-stay residents who have depressive symptoms

This Hospital:	7.6%
State:	10.7%

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

This Hospital:	5.2%
Georgia:	3.6%

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

This Hospital:	84.2%
Georgia:	96.0%

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

Here:	76.3%
State:	95.5%

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

Here:	59.1%
State:	87.1%

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

This Hospital:	27.6%
Georgia:	84.7%

Percent of long-stay residents who received an antipsychotic medication

Here:	25.8%
Georgia:	28.2%

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

Bronchitis and Asthma without Complications

Average Covered Charges

Here:	$8,068
Georgia:	$14,069

Average Total Payments

This Hospital:	$3,778
State:	$4,045

Number of discharges: 13

Here:	4.02%
Georgia:	0.27%

Cellulitis without Major Complications

Average Covered Charges

Here:	$8,294
State:	$17,342

Average Total Payments

This Hospital:	$4,888
Georgia:	$5,372

Number of discharges: 18

This Hospital:	5.57%
Georgia:	1.61%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

This Hospital:	$10,312
State:	$15,346

Average Total Payments

Here:	$4,209
Georgia:	$4,587

Number of discharges: 38

Here:	11.76%
State:	1.80%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

Here:	$11,944
State:	$17,921

Average Total Payments

This Hospital:	$4,232
State:	$4,668

Number of discharges: 21

This Hospital:	6.50%
State:	3.05%

G.I. Obstruction without Complications

Average Covered Charges

Here:	$9,506
State:	$14,753

Average Total Payments

This Hospital:	$3,783
Georgia:	$4,083

Number of discharges: 17

Here:	5.26%
Georgia:	0.41%

Heart Failure and Shock with Complications

Average Covered Charges

This Hospital:	$16,035
State:	$19,560

Average Total Payments

Here:	$6,011
Georgia:	$6,481

Number of discharges: 18

Here:	5.57%
State:	3.50%

Heart Failure and Shock without Complications

Average Covered Charges

Here:	$9,293
State:	$13,448

Average Total Payments

This Hospital:	$3,999
Georgia:	$4,372

Number of discharges: 15

Here:	4.64%
State:	1.23%

Intracranial Hemorrhage or Cerebral Infarction with Complications

Average Covered Charges

This Hospital:	$14,984
State:	$25,991

Average Total Payments

Here:	$6,652
Georgia:	$7,265

Number of discharges: 22

This Hospital:	6.81%
Georgia:	1.73%

Intracranial Hemorrhage or Cerebral Infarction without Complications

Average Covered Charges

This Hospital:	$12,846
Georgia:	$20,289

Average Total Payments

Here:	$4,783
Georgia:	$5,383

Number of discharges: 16

Here:	4.95%
Georgia:	0.79%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

Here:	$10,165
State:	$16,440

Average Total Payments

Here:	$4,550
Georgia:	$4,869

Number of discharges: 14

Here:	4.33%
Georgia:	3.08%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

Here:	$38,310
State:	$46,857

Average Total Payments

This Hospital:	$12,347
Georgia:	$13,303

Number of discharges: 16

Here:	4.95%
State:	5.88%

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

Average Covered Charges

Here:	$8,534
Georgia:	$14,725

Average Total Payments

This Hospital:	$4,152
Georgia:	$4,421

Number of discharges: 20

This Hospital:	6.19%
State:	2.20%

Red Blood Cell Disorders without Major Complications

Average Covered Charges

Here:	$11,793
Georgia:	$17,108

Average Total Payments

This Hospital:	$4,643
State:	$5,275

Number of discharges: 18

This Hospital:	5.57%
State:	1.49%

Respiratory System Diagnosis with Ventilator Support <96 Hours

Average Covered Charges

This Hospital:	$15,049
Georgia:	$52,482

Average Total Payments

This Hospital:	$10,854
State:	$14,739

Number of discharges: 13

This Hospital:	4.02%
State:	1.05%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

Here:	$17,821
State:	$22,144

Average Total Payments

This Hospital:	$6,798
Georgia:	$6,410

Number of discharges: 25

Here:	7.74%
Georgia:	2.75%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

Here:	$12,486
State:	$16,155

Average Total Payments

Here:	$4,324
State:	$4,495

Number of discharges: 39

This Hospital:	12.07%
State:	1.11%

Use of Medical Imaging

Outpatients with low back pain who had an MRI without trying recommended treatments first, such as physical therapy.

This Hospital:	60.800%
State:	35.075%

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

Here:	3.700%
State:	8.789%

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

Here:	0.191%
State:	0.125%

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

Here:	0.018%
Georgia:	0.053%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 22%

How often did nurses communicate well with patients?

Sometimes or never

Here:	5%
Georgia:	5%

Usually

This Hospital:	18%
State:	18%

Always

Here:	77%
State:	77%

How often did doctors communicate well with patients?

Sometimes or never

Here:	5%
Georgia:	4%

Usually

This Hospital:	13%
State:	13%

Always

Here:	82%
State:	83%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	11%
State:	12%

Usually

This Hospital:	26%
Georgia:	24%

Always

This Hospital:	63%
Georgia:	64%

How often was patients' pain well controlled?

Sometimes or never

Here:	8%
Georgia:	7%

Usually

Here:	23%
State:	22%

Always

This Hospital:	69%
Georgia:	71%

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

Sometimes or never

Here:	20%
State:	21%

Usually

Here:	17%
State:	17%

Always

Here:	63%
Georgia:	62%

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

Sometimes or never

Here:	14%
State:	10%

Usually

Here:	24%
State:	19%

Always

This Hospital:	62%
State:	71%

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

Sometimes or never

Here:	9%
State:	8%

Usually

This Hospital:	27%
Georgia:	27%

Always

This Hospital:	64%
Georgia:	65%

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

Yes

This Hospital:	76%
State:	81%

This Hospital:	24%
State:	19%

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

6 or lower

Here:	15%
Georgia:	9%

7 or 8

This Hospital:	26%
Georgia:	22%

9 or 10

Here:	59%
State:	69%

Would patients recommend the hospital to friends and family?

Here:	8%
Georgia:	6%

Yes, probably

Here:	38%
Georgia:	25%

Yes, definitely

Here:	54%
Georgia:	69%

Complaint Deficiency

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
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Potential for minimal harm
- Scope: Some
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Potential for minimal harm
- Scope: Some
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide a safe, clean, comfortable and homelike environment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure each resident receives an accurate assessment by a qualified health professional
- Harm: Potential for minimal harm
- Scope: Some
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 gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- 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: Immediate jeopardy to resident health or safety
- Scope: Few
Try to resolve each resident's complaints quickly
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Listen to the resident or family groups or act on their complaints or suggestions
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
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: Immediate jeopardy to resident health or safety
- 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: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each residents' abilities in activities of daily living do not decline, unless unavoidable
- 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
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 residents with reduced range of motion get proper treatment and services to increase range of motion
- 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: Minimal harm or potential for actual harm
- Scope: Few
Give each resident enough fluids to keep them healthy and prevent dehydration
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
- 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
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
- 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: Few
Give or get quality lab services/tests in a timely manner to meet the needs of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Quickly tell the resident's doctor the results of lab tests
- Harm: Immediate jeopardy to resident health or safety
- 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: 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: Immediate jeopardy to resident health or safety
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
- 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
Give each resident enough fluids to keep them healthy and prevent dehydration
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that doctors visit residents regularly, as required
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give or get quality lab services/tests in a timely manner to meet the needs of residents
- 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

MEMORIAL HOSPITAL AND MANOR - BAINBRIDGE, GA

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Quality Measures

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

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

Complaint Deficiency

User Contributions:

Comment about this article, ask questions, or add new information about this topic: