SUMMERSVILLE REGIONAL MEDICAL CENTER (SUMMERSVILLE, WV) Detailed Hospital Profile

Hospital Acquired Conditions

Falls and injuries

This Hospital:	0.581%
State:	0.833%

Infection from a Urinary Catheter

This Hospital:	0.581%
West Virginia:	0.325%

Process of Care

Heart Attack

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

This Hospital:	15
State:	11

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

Here:	97.0%
State:	96.9%

Outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival

This Hospital:	70
West Virginia:	68

Median Time to Fibrinolysis

Here:	26
State:	27

Heart Failure

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

Here:	93.0%
State:	98.4%

Percent of Patients Given Discharge Instructions

This Hospital:	78.0%
West Virginia:	91.6%

Pneumonia

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

Here:	94.0%
State:	95.2%

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

This Hospital:	65.0%
West Virginia:	96.0%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	82.0%
State:	98.3%

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

This Hospital:	80.0%
West Virginia:	93.3%

Percent of Patients Assessed and Given Influenza Vaccination

This Hospital:	76.0%
State:	93.2%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	78.0%
West Virginia:	95.7%

Surgery

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

This Hospital:	100.0%
West Virginia:	98.3%

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

This Hospital:	71.0%
State:	96.1%

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

This Hospital:	89.0%
State:	98.2%

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

Here:	92.0%
West Virginia:	95.5%

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

This Hospital:	92.0%
West Virginia:	96.5%

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

Here:	100.0%
West Virginia:	99.8%

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

Here:	88.0%
State:	94.5%

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

Here:	100.0%
State:	95.9%

Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)

Here:	81.0%
West Virginia:	94.8%

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

This Hospital:	98.0%
West Virginia:	93.8%

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

This Hospital:	87.0%
West Virginia:	98.9%

Outcome of Care

30-Day Mortality Rates from Heart Failure

Here:	11.6%
State:	11.6%

30-Day Mortality Rates from Pneumonia

Here:	12.3%
State:	12.3%

30-Day Readmission Rates from Heart Failure

This Hospital:	22.3%
State:	25.6%

30-Day Readmission Rates from Pneumonia

This Hospital:	17.3%
West Virginia:	19.6%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 34%

How often did nurses communicate well with patients?

Sometimes or never

Here:	7%
West Virginia:	6%

Usually

Here:	18%
West Virginia:	17%

Always

Here:	75%
West Virginia:	77%

How often did doctors communicate well with patients?

Sometimes or never

This Hospital:	4%
State:	4%

Usually

Here:	11%
State:	14%

Always

Here:	85%
West Virginia:	82%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Hospital:	13%
State:	12%

Usually

This Hospital:	25%
State:	23%

Always

Here:	62%
State:	65%

How often was patients' pain well controlled?

Sometimes or never

Here:	10%
State:	8%

Usually

Here:	25%
State:	23%

Always

This Hospital:	65%
State:	69%

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

Sometimes or never

Here:	21%
West Virginia:	20%

Usually

Here:	17%
West Virginia:	18%

Always

This Hospital:	62%
State:	62%

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

Sometimes or never

Here:	10%
State:	9%

Usually

Here:	21%
State:	18%

Always

Here:	69%
State:	73%

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

Sometimes or never

This Hospital:	12%
West Virginia:	13%

Usually

Here:	38%
State:	32%

Always

Here:	50%
State:	55%

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

Yes

This Hospital:	79%
West Virginia:	83%

This Hospital:	21%
State:	17%

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

6 or lower

This Hospital:	11%
State:	11%

7 or 8

This Hospital:	30%
West Virginia:	24%

9 or 10

This Hospital:	59%
State:	65%

Would patients recommend the hospital to friends and family?

Here:	6%
State:	6%

Yes, probably

Here:	37%
West Virginia:	29%

Yes, definitely

Here:	57%
State:	65%

Use of Medical Imaging

Outpatients with low back pain who had an MRI without trying recommended treatments first, such as physical therapy.

Here:	45.200%
State:	42.623%

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

Here:	5.800%
State:	8.958%

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

This Hospital:	0.047%
State:	0.275%

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

This Hospital:	0.068%
State:	0.071%

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

Here:	4.100%
State:	5.768%

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

Here:	2.100%
State:	3.183%

Quality Measures

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

Here:	10.9%
State:	19.9%

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

Here:	6.1%
West Virginia:	7.1%

Percent of long-stay residents who lose too much weight

This Hospital:	10.0%
State:	8.9%

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

This Hospital:	7.0%
West Virginia:	4.3%

Percent of long-stay residents with a urinary tract infection

Here:	16.0%
State:	9.4%

Percent of long-stay residents who have depressive symptoms

Here:	8.2%
West Virginia:	7.3%

Percent of long-stay residents who were physically restrained

Here:	6.0%
West Virginia:	2.5%

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

Here:	6.0%
State:	5.1%

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

Here:	100.0%
State:	96.1%

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

This Hospital:	98.0%
West Virginia:	94.0%

Percent of long-stay residents who received an antipsychotic medication

Here:	14.9%
State:	21.3%

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

Cardiac Arrhythmia and Conduction Disorders with Complications

Average Covered Charges

Here:	$10,960
State:	$12,030

Average Total Payments

This Hospital:	$5,142
State:	$5,051

Number of discharges: 14

This Hospital:	3.27%
State:	1.55%

Cardiac Arrhythmia and Conduction Disorders without Complications

Average Covered Charges

Here:	$9,289
West Virginia:	$8,528

Average Total Payments

This Hospital:	$3,790
West Virginia:	$3,482

Number of discharges: 17

This Hospital:	3.97%
State:	1.87%

Cellulitis without Major Complications

Average Covered Charges

Here:	$8,116
West Virginia:	$9,955

Average Total Payments

This Hospital:	$5,136
West Virginia:	$4,934

Number of discharges: 15

Here:	3.50%
State:	2.14%

Chronic Obstructive Pulmonary Disease with Complications

Average Covered Charges

This Hospital:	$11,102
State:	$12,902

Average Total Payments

This Hospital:	$6,091
West Virginia:	$5,791

Number of discharges: 26

Here:	6.07%
West Virginia:	3.65%

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

Here:	$11,863
State:	$16,204

Average Total Payments

Here:	$7,183
West Virginia:	$7,123

Number of discharges: 43

Here:	10.05%
West Virginia:	3.14%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

This Hospital:	$7,598
West Virginia:	$9,702

Average Total Payments

Here:	$4,358
State:	$4,286

Number of discharges: 22

This Hospital:	5.14%
State:	3.30%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

Here:	$8,139
State:	$11,121

Average Total Payments

Here:	$4,397
West Virginia:	$4,399

Number of discharges: 18

This Hospital:	4.21%
State:	3.99%

G.I. Hemorrhage with Complications

Average Covered Charges

Here:	$8,280
West Virginia:	$15,574

Average Total Payments

Here:	$6,350
West Virginia:	$6,146

Number of discharges: 22

This Hospital:	5.14%
State:	1.88%

Heart Failure and Shock with Complications

Average Covered Charges

This Hospital:	$9,774
State:	$13,518

Average Total Payments

Here:	$5,866
State:	$6,064

Number of discharges: 17

Here:	3.97%
State:	3.11%

Heart Failure and Shock with Major Complications

Average Covered Charges

This Hospital:	$13,375
State:	$20,887

Average Total Payments

This Hospital:	$8,717
State:	$8,936

Number of discharges: 15

Here:	3.50%
State:	2.50%

Heart Failure and Shock without Complications

Average Covered Charges

Here:	$8,627
State:	$9,106

Average Total Payments

This Hospital:	$4,201
State:	$4,047

Number of discharges: 12

This Hospital:	2.80%
State:	1.40%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

This Hospital:	$7,893
State:	$10,257

Average Total Payments

This Hospital:	$4,791
State:	$4,701

Number of discharges: 18

Here:	4.21%
State:	3.45%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

This Hospital:	$18,206
State:	$33,555

Average Total Payments

This Hospital:	$12,901
West Virginia:	$12,548

Number of discharges: 15

This Hospital:	3.50%
West Virginia:	4.22%

Pulmonary Edema and Respiratory Failure

Average Covered Charges

Here:	$12,474
State:	$18,551

Average Total Payments

Here:	$7,850
West Virginia:	$7,863

Number of discharges: 18

Here:	4.21%
State:	1.77%

Renal Failure with Complications

Average Covered Charges

This Hospital:	$9,651
West Virginia:	$13,699

Average Total Payments

This Hospital:	$6,278
West Virginia:	$6,153

Number of discharges: 17

This Hospital:	3.97%
West Virginia:	2.20%

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

Average Covered Charges

This Hospital:	$14,685
West Virginia:	$30,150

Average Total Payments

Here:	$11,358
State:	$12,053

Number of discharges: 21

Here:	4.91%
West Virginia:	3.24%

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

Average Covered Charges

This Hospital:	$9,270
West Virginia:	$15,708

Average Total Payments

This Hospital:	$7,076
State:	$6,916

Number of discharges: 12

This Hospital:	2.80%
State:	1.35%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

This Hospital:	$11,561
State:	$14,392

Average Total Payments

This Hospital:	$6,137
State:	$6,029

Number of discharges: 54

Here:	12.62%
West Virginia:	3.71%

Simple Pneumonia and Pleurisy with Major Complications

Average Covered Charges

Here:	$14,232
State:	$21,145

Average Total Payments

This Hospital:	$9,144
West Virginia:	$8,863

Number of discharges: 23

This Hospital:	5.37%
State:	2.15%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

Here:	$9,221
State:	$9,911

Average Total Payments

This Hospital:	$4,640
State:	$4,263

Number of discharges: 29

This Hospital:	6.78%
State:	1.55%

Complaint Deficiency

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 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
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: Few
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- 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
Hire sufficient dietary support personnel
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Protected exits that allow the resident to escape the building
- 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
Exit stairways and towers that are smoke proof
- Harm: Potential for minimal harm
- Scope: Many
Exit stairways and towers that are smoke proof
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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: Potential for minimal harm
- Scope: Many
Allow residents to easily view the results of the nursing home's most recent survey
- Harm: Potential for minimal harm
- Scope: Many
Provide enough notice before discharging or transferring a resident
- Harm: Potential for minimal harm
- Scope: Many
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
Properly maintained smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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: Some
Smoke barrier doors that can resist smoke for at least 20 minutes
- 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
Rooms that can be unlocked from inside without a key
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly located and lighted Exit signs
- Harm: Potential for minimal harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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: Potential for minimal harm
- Scope: Some
Make sure each resident receives an accurate assessment by a qualified health professional
- 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
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
Develop policies and procedures for influenza and pneumococcal immunizations
- 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
Provide or obtain dental services for each resident
- 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: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that a working call system is available in each resident's room or bathroom and bathing area
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Potential for minimal harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Potential for minimal harm
- Scope: Many
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Potential for minimal harm
- Scope: Some
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Many
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Potential for minimal harm
- Scope: Many
Properly protected cooking facilities
- Harm: Potential for minimal harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Potential for minimal harm
- Scope: Some
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: Potential for minimal 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: Some
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
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
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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 the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Actual harm
- Scope: Some
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
- 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
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: Some
Be administered in an acceptable way that maintains the well-being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
- Harm: Actual harm
- Scope: Some

SUMMERSVILLE REGIONAL MEDICAL CENTER - SUMMERSVILLE, WV

Hospital Acquired Conditions

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Hospital Consumer Assessment of Healthcare Providers

Use of Medical Imaging

Quality Measures

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

Complaint Deficiency

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