JEFFERSON DAVIS COMMUNITY HOSPITAL ECF (PRENTISS, MS) Detailed Nursing Home Profile

Quality Measures

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

Here:	29.5%
State:	18.2%

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

This Nursing Home:	5.1%
State:	13.9%

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

This Nursing Home:	6.1%
Mississippi:	7.3%

Percent of long-stay residents who lose too much weight

Here:	8.0%
State:	7.8%

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

This Nursing Home:	3.6%
State:	3.2%

Percent of long-stay residents with a urinary tract infection

Here:	6.0%
Mississippi:	7.3%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	2.1%
Mississippi:	2.8%

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

This Nursing Home:	2.0%
State:	2.9%

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

Here:	100.0%
Mississippi:	94.9%

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

This Nursing Home:	100.0%
Mississippi:	96.7%

Percent of long-stay residents who received an antipsychotic medication

Here:	20.4%
State:	26.8%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.480
State:	0.625

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

Here:	0.820
State:	0.996

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.300
Mississippi:	1.616

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.010
State:	0.046

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.010
State:	0.049

Complaint Deficiency

Store, cook, and serve food in a safe and clean way
- 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
Exits that are accessible 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
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Actual harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Actual harm
- Scope: Some
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Actual harm
- Scope: Some
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Potential for minimal harm
- Scope: Many
Properly maintained smoke detectors
- Harm: Potential for minimal harm
- Scope: Many
Properly protected cooking facilities
- Harm: Potential for minimal harm
- Scope: Many
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible
- 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
Corridors or aisles that are unobstructed and are at least 8 feet in width
- 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
Properly working alarms on sprinkler valves
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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
Dispose of garbage and refuse properly
- 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
1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compensation
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Employ or obtain outside professional resources providing services in the nursing home that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Protect each resident from all abuse, physical punishment, and being separated from others
- Harm: Actual harm
- Scope: Few
Provide a safe, clean, comfortable and homelike environment
- 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: Actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: 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
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
Provide bedrooms that don't allow residents to see each other when privacy is needed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Put firmly secured handrails on each side of hallways
- Harm: Minimal harm or potential for actual harm
- Scope: Few

Process of Care

Heart Failure

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

Here:	83.0%
Mississippi:	97.3%

Percent of Patients Given Discharge Instructions

Here:	86.0%
State:	90.8%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Nursing Home:	25.0%
Mississippi:	99.2%

Pneumonia

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

Here:	100.0%
Mississippi:	96.2%

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

Here:	100.0%
Mississippi:	97.9%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Nursing Home:	50.0%
Mississippi:	97.9%

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

This Nursing Home:	87.0%
State:	93.2%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	100.0%
Mississippi:	92.1%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	64.0%
Mississippi:	93.8%

Outcome of Care

30-Day Mortality Rates from Heart Failure

Here:	12.6%
State:	12.2%

30-Day Mortality Rates from Pneumonia

This Nursing Home:	12.1%
Mississippi:	13.2%

30-Day Readmission Rates from Heart Failure

Here:	24.4%
State:	26.1%

30-Day Readmission Rates from Pneumonia

This Nursing Home:	19.6%
Mississippi:	19.6%

JEFFERSON DAVIS COMMUNITY HOSPITAL ECF - PRENTISS, MS