SOUTHAMPTON MEMORIAL HOSPITAL (FRANKLIN, VA) Detailed Hospital Profile

Complaint Deficiency

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
Give or get x-rays and other tests in a timely manner to meet the needs of residents
- 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: 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
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep all essential equipment working safely
- 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
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few

Quality Measures

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

This Hospital:	26.9%
State:	18.8%

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

This Hospital:	11.9%
State:	10.6%

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

Here:	5.6%
State:	7.0%

Percent of long-stay residents who lose too much weight

Here:	7.8%
State:	7.6%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

Here:	29.3%
Virginia:	51.2%

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

Here:	2.1%
Virginia:	3.2%

Percent of long-stay residents with a urinary tract infection

This Hospital:	3.9%
Virginia:	7.9%

Percent of long-stay residents who have depressive symptoms

Here:	3.2%
Virginia:	4.7%

Percent of long-stay residents who were physically restrained

Here:	1.0%
Virginia:	1.0%

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

Here:	2.0%
State:	3.2%

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

This Hospital:	100.0%
Virginia:	93.7%

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

Here:	100.0%
Virginia:	94.6%

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

Here:	23.0%
State:	19.3%

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

This Hospital:	1.3%
Virginia:	1.3%

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

Here:	95.7%
Virginia:	85.3%

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

This Hospital:	95.9%
State:	83.6%

Percent of long-stay residents who received an antipsychotic medication

This Hospital:	16.3%
State:	22.2%

Process of Care

Heart Attack

Percent of Patients Given Aspirin at Arrival

Here:	100.0%
Virginia:	99.5%

Percent of Patients Given Aspirin at Discharge

This Hospital:	100.0%
State:	99.3%

Percent of Patients Given Beta Blocker at Discharge

This Hospital:	100.0%
State:	99.1%

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

This Hospital:	3
State:	9

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

Here:	98.0%
Virginia:	98.1%

Patients Given a Prescription for a Statin at Discharge

This Hospital:	93.0%
Virginia:	97.9%

Heart Failure

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

This Hospital:	100.0%
State:	99.5%

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

This Hospital:	94.0%
State:	97.3%

Percent of Patients Given Discharge Instructions

This Hospital:	93.0%
State:	94.7%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	100.0%
Virginia:	99.7%

Pneumonia

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

This Hospital:	98.0%
Virginia:	97.0%

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

Here:	98.0%
State:	97.5%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	100.0%
State:	99.4%

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

Here:	97.0%
Virginia:	95.5%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	97.0%
State:	94.9%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	100.0%
Virginia:	96.9%

Surgery

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

Here:	99.0%
State:	98.4%

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

Here:	97.0%
State:	97.7%

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

Here:	96.0%
Virginia:	98.9%

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

This Hospital:	100.0%
State:	97.1%

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

Here:	100.0%
Virginia:	97.9%

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

Here:	100.0%
Virginia:	100.0%

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

This Hospital:	86.0%
State:	95.0%

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

Here:	89.0%
State:	97.7%

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

Here:	94.0%
State:	96.9%

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

This Hospital:	100.0%
State:	99.9%

Outcome of Care

30-Day Mortality Rates from Heart Attack

This Hospital:	15.3%
Virginia:	15.2%

30-Day Mortality Rates from Heart Failure

Here:	11.3%
Virginia:	11.6%

30-Day Mortality Rates from Pneumonia

Here:	13.2%
Virginia:	12.2%

30-Day Readmission Rates from Heart Attack

Here:	19.0%
Virginia:	20.0%

30-Day Readmission Rates from Heart Failure

This Hospital:	27.3%
State:	24.6%

30-Day Readmission Rates from Pneumonia

This Hospital:	18.9%
Virginia:	19.2%

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

Acute Myocardial Infarction, Discharged Alive with Major Complications

Average Covered Charges

Here:	$42,350
State:	$36,558

Average Total Payments

Here:	$11,636
State:	$11,483

Number of discharges: 12

This Hospital:	1.66%
State:	0.87%

Cardiac Arrhythmia and Conduction Disorders with Complications

Average Covered Charges

This Hospital:	$23,068
State:	$16,713

Average Total Payments

Here:	$5,366
Virginia:	$5,355

Number of discharges: 15

This Hospital:	2.07%
Virginia:	1.46%

Cardiac Arrhythmia and Conduction Disorders without Complications

Average Covered Charges

This Hospital:	$20,278
Virginia:	$11,985

Average Total Payments

This Hospital:	$3,649
Virginia:	$3,674

Number of discharges: 42

This Hospital:	5.81%
Virginia:	1.66%

Cellulitis without Major Complications

Average Covered Charges

This Hospital:	$18,189
State:	$16,080

Average Total Payments

Here:	$5,360
Virginia:	$5,268

Number of discharges: 27

Here:	3.73%
State:	1.88%

Chest Pain

Average Covered Charges

Here:	$17,227
State:	$13,309

Average Total Payments

Here:	$3,519
Virginia:	$3,508

Number of discharges: 37

Here:	5.12%
State:	2.02%

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

This Hospital:	$35,582
State:	$22,971

Average Total Payments

This Hospital:	$7,492
State:	$7,375

Number of discharges: 22

Here:	3.04%
State:	2.01%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

This Hospital:	$21,301
State:	$14,677

Average Total Payments

Here:	$4,620
State:	$4,562

Number of discharges: 19

This Hospital:	2.63%
Virginia:	1.55%

Diabetes with Complications

Average Covered Charges

This Hospital:	$27,750
State:	$16,675

Average Total Payments

Here:	$5,148
Virginia:	$5,442

Number of discharges: 16

This Hospital:	2.21%
State:	0.73%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

This Hospital:	$20,814
State:	$16,267

Average Total Payments

Here:	$4,590
Virginia:	$4,677

Number of discharges: 24

This Hospital:	3.32%
State:	3.33%

Heart Failure and Shock with Complications

Average Covered Charges

Here:	$28,658
Virginia:	$18,524

Average Total Payments

This Hospital:	$6,487
State:	$6,409

Number of discharges: 28

Here:	3.87%
State:	3.24%

Heart Failure and Shock with Major Complications

Average Covered Charges

Here:	$38,984
State:	$27,627

Average Total Payments

This Hospital:	$9,411
Virginia:	$9,254

Number of discharges: 19

This Hospital:	2.63%
Virginia:	3.02%

Heart Failure and Shock without Complications

Average Covered Charges

This Hospital:	$22,429
State:	$13,642

Average Total Payments

This Hospital:	$4,385
Virginia:	$4,360

Number of discharges: 18

This Hospital:	2.49%
State:	1.17%

Intracranial Hemorrhage or Cerebral Infarction with Complications

Average Covered Charges

This Hospital:	$31,199
Virginia:	$23,909

Average Total Payments

Here:	$7,171
Virginia:	$7,314

Number of discharges: 17

Here:	2.35%
Virginia:	1.75%

Intracranial Hemorrhage or Cerebral Infarction without Complications

Average Covered Charges

Here:	$23,492
State:	$19,084

Average Total Payments

This Hospital:	$5,043
State:	$5,409

Number of discharges: 12

This Hospital:	1.66%
State:	0.95%

Kidney and Urinary Tract Infections with Major Complications

Average Covered Charges

This Hospital:	$28,670
Virginia:	$20,337

Average Total Payments

This Hospital:	$7,602
State:	$7,368

Number of discharges: 14

This Hospital:	1.94%
State:	1.05%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

Here:	$21,306
Virginia:	$15,209

Average Total Payments

This Hospital:	$5,021
Virginia:	$4,914

Number of discharges: 50

This Hospital:	6.92%
Virginia:	2.90%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

This Hospital:	$55,404
Virginia:	$47,709

Average Total Payments

This Hospital:	$13,302
State:	$13,248

Number of discharges: 45

Here:	6.22%
Virginia:	6.42%

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

Average Covered Charges

Here:	$16,673
State:	$14,229

Average Total Payments

This Hospital:	$4,425
Virginia:	$4,420

Number of discharges: 23

Here:	3.18%
State:	2.07%

Pulmonary Edema and Respiratory Failure

Average Covered Charges

Here:	$44,782
Virginia:	$25,878

Average Total Payments

Here:	$8,196
State:	$8,160

Number of discharges: 19

This Hospital:	2.63%
State:	1.90%

Red Blood Cell Disorders without Major Complications

Average Covered Charges

This Hospital:	$17,547
Virginia:	$16,210

Average Total Payments

This Hospital:	$5,091
State:	$5,305

Number of discharges: 13

This Hospital:	1.80%
Virginia:	1.21%

Renal Failure with Complications

Average Covered Charges

This Hospital:	$22,647
State:	$19,940

Average Total Payments

This Hospital:	$6,392
State:	$6,384

Number of discharges: 18

This Hospital:	2.49%
Virginia:	2.46%

Renal Failure without Complications

Average Covered Charges

This Hospital:	$24,767
State:	$14,169

Average Total Payments

Here:	$4,215
State:	$4,300

Number of discharges: 11

This Hospital:	1.52%
State:	0.31%

Respiratory Infections and Inflammations with Complications

Average Covered Charges

Here:	$39,091
State:	$26,604

Average Total Payments

This Hospital:	$9,007
State:	$9,105

Number of discharges: 17

This Hospital:	2.35%
Virginia:	0.77%

Respiratory Infections and Inflammations with Major Complications

Average Covered Charges

This Hospital:	$40,517
Virginia:	$37,946

Average Total Payments

Here:	$11,142
Virginia:	$12,347

Number of discharges: 11

This Hospital:	1.52%
Virginia:	1.03%

Respiratory System Diagnosis with Ventilator Support <96 Hours

Average Covered Charges

Here:	$52,604
Virginia:	$51,609

Average Total Payments

Here:	$13,572
Virginia:	$15,311

Number of discharges: 12

Here:	1.66%
State:	0.85%

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

Average Covered Charges

This Hospital:	$35,518
State:	$36,847

Average Total Payments

Here:	$11,784
State:	$12,110

Number of discharges: 24

Here:	3.32%
Virginia:	5.11%

Signs and Symptoms without Major Complications

Average Covered Charges

This Hospital:	$17,801
State:	$15,097

Average Total Payments

This Hospital:	$4,393
Virginia:	$4,461

Number of discharges: 15

Here:	2.07%
Virginia:	0.65%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

Here:	$35,779
Virginia:	$19,305

Average Total Payments

Here:	$6,489
State:	$6,423

Number of discharges: 39

Here:	5.39%
Virginia:	2.58%

Simple Pneumonia and Pleurisy with Major Complications

Average Covered Charges

Here:	$44,257
State:	$27,841

Average Total Payments

Here:	$9,265
State:	$9,090

Number of discharges: 41

This Hospital:	5.67%
State:	1.96%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

This Hospital:	$22,715
Virginia:	$14,202

Average Total Payments

Here:	$4,534
State:	$4,467

Number of discharges: 22

This Hospital:	3.04%
Virginia:	1.02%

Syncope and Collapse

Average Covered Charges

Here:	$22,607
State:	$15,506

Average Total Payments

This Hospital:	$4,597
State:	$4,539

Number of discharges: 25

This Hospital:	3.46%
State:	2.14%

Transient Ischemia

Average Covered Charges

Here:	$19,866
Virginia:	$16,483

Average Total Payments

Here:	$4,907
State:	$4,621

Number of discharges: 16

Here:	2.21%
Virginia:	1.34%

Hospital Acquired Conditions

Infection from a Urinary Catheter

This Hospital:	0.412%
State:	0.546%

Use of Medical Imaging

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

This Hospital:	4.200%
Virginia:	7.783%

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

Here:	0.257%
State:	0.107%

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

Here:	0.047%
Virginia:	0.028%

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

Here:	3.900%
State:	5.232%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 27%

How often did nurses communicate well with patients?

Sometimes or never

This Hospital:	5%
Virginia:	6%

Usually

Here:	14%
Virginia:	17%

Always

This Hospital:	81%
Virginia:	77%

How often did doctors communicate well with patients?

Sometimes or never

Here:	3%
State:	5%

Usually

This Hospital:	11%
State:	15%

Always

Here:	86%
Virginia:	80%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	12%
Virginia:	11%

Usually

Here:	22%
State:	26%

Always

Here:	66%
Virginia:	63%

How often was patients' pain well controlled?

Sometimes or never

This Hospital:	9%
State:	8%

Usually

Here:	20%
State:	23%

Always

Here:	71%
State:	69%

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

Sometimes or never

This Hospital:	19%
Virginia:	21%

Usually

Here:	15%
State:	18%

Always

This Hospital:	66%
Virginia:	61%

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

Sometimes or never

Here:	8%
Virginia:	10%

Usually

This Hospital:	16%
Virginia:	20%

Always

This Hospital:	76%
Virginia:	70%

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

Sometimes or never

Here:	10%
State:	11%

Usually

Here:	26%
State:	30%

Always

This Hospital:	64%
State:	59%

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

Yes

Here:	87%
Virginia:	84%

Here:	13%
State:	16%

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

6 or lower

Here:	7%
State:	9%

7 or 8

This Hospital:	21%
State:	25%

9 or 10

This Hospital:	72%
Virginia:	66%

Would patients recommend the hospital to friends and family?

This Hospital:	5%
Virginia:	6%

Yes, probably

Here:	30%
State:	26%

Yes, definitely

Here:	65%
State:	68%

SOUTHAMPTON MEMORIAL HOSPITAL - FRANKLIN, VA

Complaint Deficiency

Quality Measures

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

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

Hospital Acquired Conditions

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

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