MITCHELL COUNTY HOSPITAL HEALTH SYSTEMS LTCU (BELOIT, KS) Detailed Nursing Home Profile

Quality Measures

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

This Nursing Home:	15.6%
State:	14.7%

Percent of long-stay residents who lose too much weight

Here:	11.4%
Kansas:	7.3%

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

This Nursing Home:	3.5%
Kansas:	3.6%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	8.6%
State:	8.2%

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

Here:	5.7%
Kansas:	5.1%

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

Here:	97.1%
State:	95.7%

Percent of long-stay residents who received an antipsychotic medication

Here:	26.5%
State:	23.1%

Process of Care

Heart Attack

Percent of Patients Given Aspirin at Arrival

This Nursing Home:	100.0%
Kansas:	99.1%

Percent of Patients Given Aspirin at Discharge

This Nursing Home:	100.0%
Kansas:	99.1%

Percent of Patients Given Beta Blocker at Discharge

This Nursing Home:	100.0%
State:	98.7%

Heart Failure

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

This Nursing Home:	100.0%
State:	96.1%

Pneumonia

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

Here:	95.0%
State:	96.4%

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

Here:	100.0%
State:	97.9%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Nursing Home:	73.0%
State:	97.0%

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

Here:	69.0%
Kansas:	90.7%

Percent of Patients Assessed and Given Influenza Vaccination

This Nursing Home:	77.0%
State:	92.6%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Nursing Home:	81.0%
State:	93.5%

Surgery

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

This Nursing Home:	100.0%
State:	99.9%

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

Here:	15.1%
Kansas:	15.3%

30-Day Mortality Rates from Heart Failure

Here:	11.9%
State:	12.0%

30-Day Mortality Rates from Pneumonia

This Nursing Home:	12.3%
State:	12.2%

30-Day Readmission Rates from Heart Failure

Here:	26.2%
State:	24.3%

30-Day Readmission Rates from Pneumonia

This Nursing Home:	20.4%
Kansas:	18.2%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.520
Kansas:	0.703

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

This Nursing Home:	0.990
State:	0.645

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.510
State:	1.346

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.480
Kansas:	0.050

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.480
State:	0.059

Complaint Deficiency

Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- 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
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 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 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
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: 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
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
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: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Emergency lighting that can last at least 1 1/2 hours
- 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: Few
Exits that are free from obstructions and can be used at all times
- 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
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves
- 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
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
Develop policies and procedures for influenza and pneumococcal immunizations
- Harm: Potential for minimal harm
- Scope: Many
Make sure that doctors visit residents regularly, as required
- 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: Some
Have a program that investigates, controls and keeps infection from spreading
- 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
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper backup exit lighting
- 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
Proper medical gas storage and administration areas
- 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
Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Allow residents to easily view the results of the nursing home's most recent survey
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give the resident the right to receive visitors
- 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
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 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: Minimal harm or potential for actual harm
- 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
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
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few

MITCHELL COUNTY HOSPITAL HEALTH SYSTEMS LTCU - BELOIT, KS