ST FRANCIS HEALTHCARE CAMPUS (BRECKENRIDGE, MN) Detailed Hospital Profile

Complaint Deficiency

Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
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: Few
A two-hour-resistant firewall in common walls
- 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
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
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Many
A two-hour-resistant firewall in common walls
- 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: Some
Provide proof that all residents' personal money which is deposited with the nursing home, is secure
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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 that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- 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
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
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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: 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: 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: Some
1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day
- 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: 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
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
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: Some
Post nurse staffing information/data on a daily basis
- Harm: Potential for minimal harm
- Scope: Many
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are free from obstructions and can be used at all times
- Harm: Potential for minimal harm
- Scope: Many
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Potential for minimal harm
- Scope: Many
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
Check and assess each resident's assessment at least every 3 months
- 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: 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 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 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: Some
Post nurse staffing information/data on a daily basis
- Harm: Potential for minimal harm
- Scope: Many
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: Few

Quality Measures

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

Here:	11.2%
State:	15.5%

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

Here:	13.2%
State:	12.5%

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

Here:	5.9%
State:	4.1%

Percent of long-stay residents who lose too much weight

Here:	10.9%
Minnesota:	7.6%

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

Here:	49.0%
State:	47.8%

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

This Hospital:	5.7%
State:	4.1%

Percent of long-stay residents with a urinary tract infection

This Hospital:	12.9%
State:	5.2%

Percent of long-stay residents who have depressive symptoms

Here:	29.9%
Minnesota:	7.4%

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

This Hospital:	1.0%
State:	3.9%

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

This Hospital:	100.0%
State:	97.0%

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

This Hospital:	100.0%
Minnesota:	96.8%

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

This Hospital:	50.0%
Minnesota:	26.2%

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

This Hospital:	100.0%
Minnesota:	87.6%

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

Here:	93.3%
State:	86.3%

Percent of long-stay residents who received an antipsychotic medication

This Hospital:	24.5%
State:	17.4%

Use of Medical Imaging

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

Here:	6.500%
State:	6.118%

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

Here:	0.061%
State:	0.072%

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

This Hospital:	0.100%
State:	0.011%

Outpatients with brain CT scans who got a sinus CT scan at the same time

Here:	1.100%
Minnesota:	2.414%

Process of Care

Heart Attack

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

Here:	8
State:	7

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

This Hospital:	96.0%
Minnesota:	96.6%

Heart Failure

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

Here:	100.0%
State:	97.5%

Percent of Patients Given Discharge Instructions

Here:	100.0%
State:	88.6%

Pneumonia

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

Here:	98.0%
State:	97.1%

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

This Hospital:	100.0%
Minnesota:	96.1%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	100.0%
Minnesota:	96.0%

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

This Hospital:	86.0%
State:	92.8%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	100.0%
State:	93.0%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	100.0%
Minnesota:	94.9%

Surgery

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

This Hospital:	95.0%
Minnesota:	97.4%

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

Here:	95.0%
Minnesota:	97.6%

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

This Hospital:	100.0%
State:	97.9%

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

This Hospital:	77.0%
State:	96.7%

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

This Hospital:	77.0%
Minnesota:	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%
Minnesota:	99.8%

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

This Hospital:	100.0%
Minnesota:	99.3%

Outcome of Care

30-Day Mortality Rates from Heart Attack

This Hospital:	15.9%
Minnesota:	14.7%

30-Day Mortality Rates from Heart Failure

Here:	12.4%
State:	11.2%

30-Day Mortality Rates from Pneumonia

Here:	11.5%
State:	11.4%

30-Day Readmission Rates from Heart Failure

This Hospital:	23.8%
State:	24.3%

30-Day Readmission Rates from Pneumonia

This Hospital:	18.6%
State:	18.3%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: Between 100 and 299
Survey Response Rate: 38%

How often did nurses communicate well with patients?

Sometimes or never

Here:	3%
Minnesota:	3%

Usually

This Hospital:	18%
State:	18%

Always

This Hospital:	79%
State:	79%

How often did doctors communicate well with patients?

Sometimes or never

Here:	1%
State:	3%

Usually

Here:	12%
Minnesota:	14%

Always

Here:	87%
State:	83%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	7%
State:	6%

Usually

Here:	28%
Minnesota:	22%

Always

This Hospital:	65%
State:	72%

How often was patients' pain well controlled?

Sometimes or never

This Hospital:	5%
Minnesota:	5%

Usually

Here:	28%
State:	25%

Always

This Hospital:	67%
State:	70%

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

Sometimes or never

This Hospital:	13%
Minnesota:	16%

Usually

Here:	17%
State:	20%

Always

This Hospital:	70%
State:	64%

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

Sometimes or never

Here:	5%
State:	6%

Usually

Here:	19%
State:	18%

Always

This Hospital:	76%
Minnesota:	76%

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

Sometimes or never

Here:	6%
Minnesota:	7%

Usually

Here:	29%
Minnesota:	30%

Always

Here:	65%
Minnesota:	63%

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

Yes

Here:	88%
Minnesota:	86%

This Hospital:	12%
Minnesota:	14%

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

6 or lower

Here:	8%
Minnesota:	6%

7 or 8

Here:	19%
State:	22%

9 or 10

This Hospital:	73%
Minnesota:	72%

Would patients recommend the hospital to friends and family?

Here:	5%
State:	3%

Yes, probably

Here:	21%
State:	24%

Yes, definitely

This Hospital:	74%
State:	73%

ST FRANCIS HEALTHCARE CAMPUS - BRECKENRIDGE, MN

Complaint Deficiency

Quality Measures

Use of Medical Imaging

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Hospital Consumer Assessment of Healthcare Providers

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