MEMORIAL HOSPITAL, INC TOWANDA (TOWANDA, PA) Detailed Hospital Profile

Quality Measures

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

This Hospital:	16.3%
State:	15.9%

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

This Hospital:	8.9%
State:	10.2%

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

This Hospital:	17.0%
Pennsylvania:	5.9%

Percent of long-stay residents who lose too much weight

Here:	1.9%
Pennsylvania:	7.4%

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

Here:	9.7%
State:	3.9%

Percent of long-stay residents with a urinary tract infection

This Hospital:	5.6%
Pennsylvania:	5.3%

Percent of long-stay residents who have depressive symptoms

Here:	5.5%
State:	4.6%

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

This Hospital:	1.8%
Pennsylvania:	3.0%

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

This Hospital:	94.6%
Pennsylvania:	95.1%

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

This Hospital:	98.2%
State:	94.5%

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

This Hospital:	15.4%
Pennsylvania:	21.2%

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

Here:	6.2%
Pennsylvania:	1.6%

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

Here:	85.0%
Pennsylvania:	85.6%

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

Here:	76.0%
Pennsylvania:	84.4%

Percent of long-stay residents who received an antipsychotic medication

This Hospital:	17.9%
Pennsylvania:	22.2%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 35%

How often did nurses communicate well with patients?

Sometimes or never

This Hospital:	3%
State:	5%

Usually

This Hospital:	17%
Pennsylvania:	18%

Always

Here:	80%
Pennsylvania:	77%

How often did doctors communicate well with patients?

Sometimes or never

Here:	3%
Pennsylvania:	5%

Usually

Here:	15%
Pennsylvania:	16%

Always

This Hospital:	82%
Pennsylvania:	79%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Hospital:	4%
State:	10%

Usually

This Hospital:	28%
State:	26%

Always

This Hospital:	68%
Pennsylvania:	64%

How often was patients' pain well controlled?

Sometimes or never

Here:	3%
Pennsylvania:	7%

Usually

This Hospital:	24%
State:	24%

Always

This Hospital:	73%
Pennsylvania:	69%

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

Sometimes or never

Here:	16%
State:	21%

Usually

Here:	17%
Pennsylvania:	19%

Always

This Hospital:	67%
Pennsylvania:	60%

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

Sometimes or never

Here:	2%
State:	9%

Usually

This Hospital:	14%
State:	20%

Always

Here:	84%
State:	71%

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

Sometimes or never

Here:	9%
Pennsylvania:	14%

Usually

Here:	34%
State:	34%

Always

Here:	57%
Pennsylvania:	52%

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

Yes

Here:	82%
State:	83%

Here:	18%
State:	17%

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

6 or lower

Here:	6%
State:	10%

7 or 8

Here:	23%
State:	24%

9 or 10

This Hospital:	71%
Pennsylvania:	66%

Would patients recommend the hospital to friends and family?

This Hospital:	3%
State:	5%

Yes, probably

Here:	28%
State:	28%

Yes, definitely

This Hospital:	69%
Pennsylvania:	67%

Use of Medical Imaging

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

This Hospital:	4.300%
Pennsylvania:	8.255%

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

Here:	0.041%
Pennsylvania:	0.151%

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

This Hospital:	0.028%
State:	0.023%

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

This Hospital:	4.600%
State:	5.987%

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

Cellulitis without Major Complications

Average Covered Charges

Here:	$12,579
Pennsylvania:	$21,833

Average Total Payments

Here:	$5,201
State:	$5,569

Number of discharges: 13

This Hospital:	4.78%
Pennsylvania:	2.29%

Chronic Obstructive Pulmonary Disease with Complications

Average Covered Charges

This Hospital:	$12,017
State:	$29,850

Average Total Payments

This Hospital:	$6,182
State:	$6,479

Number of discharges: 16

Here:	5.88%
State:	2.15%

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

Here:	$17,746
Pennsylvania:	$35,841

Average Total Payments

This Hospital:	$7,446
State:	$7,862

Number of discharges: 28

Here:	10.29%
State:	1.99%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

This Hospital:	$9,949
State:	$21,975

Average Total Payments

This Hospital:	$4,546
Pennsylvania:	$4,841

Number of discharges: 18

Here:	6.62%
Pennsylvania:	1.72%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

This Hospital:	$9,564
Pennsylvania:	$24,456

Average Total Payments

Here:	$4,503
State:	$4,986

Number of discharges: 26

Here:	9.56%
Pennsylvania:	3.72%

Heart Failure and Shock with Complications

Average Covered Charges

Here:	$15,638
Pennsylvania:	$29,163

Average Total Payments

Here:	$6,466
State:	$6,918

Number of discharges: 13

Here:	4.78%
State:	3.75%

Heart Failure and Shock with Major Complications

Average Covered Charges

Here:	$15,264
Pennsylvania:	$40,714

Average Total Payments

Here:	$8,129
Pennsylvania:	$9,817

Number of discharges: 11

Here:	4.04%
State:	2.71%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

This Hospital:	$9,437
State:	$23,346

Average Total Payments

Here:	$5,013
Pennsylvania:	$5,274

Number of discharges: 24

Here:	8.82%
Pennsylvania:	2.94%

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

Average Covered Charges

Here:	$8,802
State:	$21,864

Average Total Payments

Here:	$4,398
Pennsylvania:	$4,771

Number of discharges: 25

This Hospital:	9.19%
Pennsylvania:	2.03%

Pulmonary Edema and Respiratory Failure

Average Covered Charges

Here:	$15,694
Pennsylvania:	$34,570

Average Total Payments

This Hospital:	$7,236
Pennsylvania:	$11,356

Number of discharges: 13

This Hospital:	4.78%
State:	1.07%

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

Average Covered Charges

This Hospital:	$22,083
Pennsylvania:	$50,114

Average Total Payments

This Hospital:	$11,915
State:	$12,705

Number of discharges: 14

This Hospital:	5.15%
State:	3.92%

Signs and Symptoms without Major Complications

Average Covered Charges

Here:	$9,817
Pennsylvania:	$24,920

Average Total Payments

Here:	$4,299
Pennsylvania:	$5,242

Number of discharges: 16

Here:	5.88%
State:	0.72%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

Here:	$13,372
State:	$29,567

Average Total Payments

This Hospital:	$5,990
Pennsylvania:	$6,703

Number of discharges: 26

Here:	9.56%
State:	2.73%

Simple Pneumonia and Pleurisy with Major Complications

Average Covered Charges

Here:	$21,758
Pennsylvania:	$41,229

Average Total Payments

This Hospital:	$9,068
State:	$9,510

Number of discharges: 17

This Hospital:	6.25%
Pennsylvania:	1.78%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

Here:	$11,248
Pennsylvania:	$21,186

Average Total Payments

This Hospital:	$4,444
Pennsylvania:	$4,668

Number of discharges: 12

Here:	4.41%
Pennsylvania:	1.11%

Complaint Deficiency

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
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: Minimal harm or potential for actual harm
- Scope: Some
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Approved construction type or materials
- 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: 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
Automatic sprinkler systems that have been maintained in working order
- 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: Some
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
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- 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
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 doctors visit residents regularly, as required
- 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
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: Few
Reasonably accommodate the needs and preferences of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide activities to meet the interests and needs of each resident
- 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: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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
1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews
- 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
Properly located and lighted Exit signs
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- 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: Many

Process of Care

Heart Attack

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

Here:	4
Pennsylvania:	9

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

Here:	98.0%
State:	96.6%

Heart Failure

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

This Hospital:	96.0%
State:	99.3%

Percent of Patients Given Discharge Instructions

Here:	100.0%
Pennsylvania:	93.4%

Pneumonia

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

This Hospital:	94.0%
Pennsylvania:	96.6%

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

Here:	98.0%
State:	97.4%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	100.0%
Pennsylvania:	98.9%

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

Here:	94.0%
Pennsylvania:	95.7%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	100.0%
Pennsylvania:	94.1%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	100.0%
Pennsylvania:	96.6%

Surgery

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

Here:	80.0%
Pennsylvania:	98.6%

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

Here:	79.0%
Pennsylvania:	97.5%

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

This Hospital:	100.0%
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

This Hospital:	89.0%
State:	98.0%

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

This Hospital:	89.0%
Pennsylvania:	98.6%

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%
State:	99.9%

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

This Hospital:	54.0%
Pennsylvania:	95.6%

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

Here:	100.0%
State:	99.8%

Outcome of Care

30-Day Mortality Rates from Heart Attack

This Hospital:	16.3%
Pennsylvania:	14.8%

30-Day Mortality Rates from Heart Failure

This Hospital:	13.0%
Pennsylvania:	10.9%

30-Day Mortality Rates from Pneumonia

This Hospital:	13.4%
Pennsylvania:	11.8%

30-Day Readmission Rates from Heart Failure

Here:	23.3%
State:	24.8%

30-Day Readmission Rates from Pneumonia

This Hospital:	18.3%
State:	18.6%

MEMORIAL HOSPITAL, INC TOWANDA - TOWANDA, PA

Quality Measures

Hospital Consumer Assessment of Healthcare Providers

Use of Medical Imaging

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

Complaint Deficiency

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

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