THOMAS MEMORIAL HOSPITAL (SOUTH CHARLESTON, WV) Detailed Hospital Profile

Process of Care

Heart Attack

Percent of Patients Given Aspirin at Arrival

Here:	93.0%
West Virginia:	98.6%

Percent of Patients Given Aspirin at Discharge

Here:	97.0%
State:	98.8%

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

Here:	92.0%
West Virginia:	97.7%

Percent of Patients Given Beta Blocker at Discharge

This Hospital:	96.0%
State:	98.9%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	100.0%
West Virginia:	99.9%

Percent of Patients Given PCI Within 90 Minutes Of Arrival

Here:	100.0%
West Virginia:	91.8%

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

Here:	10
West Virginia:	11

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

This Hospital:	94.0%
West Virginia:	96.9%

Patients Given a Prescription for a Statin at Discharge

Here:	90.0%
West Virginia:	96.3%

Heart Failure

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

This Hospital:	100.0%
State:	98.4%

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

This Hospital:	94.0%
State:	95.0%

Percent of Patients Given Discharge Instructions

Here:	96.0%
State:	91.6%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	100.0%
West Virginia:	99.4%

Pneumonia

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

This Hospital:	95.0%
West Virginia:	95.2%

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

This Hospital:	98.0%
State:	96.0%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	100.0%
West Virginia:	98.3%

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

This Hospital:	95.0%
State:	93.3%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	98.0%
West Virginia:	93.2%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	97.0%
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

Here:	100.0%
West Virginia:	98.3%

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

Here:	95.0%
West Virginia:	96.1%

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

This Hospital:	99.0%
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:	95.0%
West Virginia:	95.5%

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

This Hospital:	96.0%
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

This Hospital:	100.0%
State:	99.8%

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

Here:	92.0%
State:	94.5%

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

This Hospital:	97.0%
West Virginia:	95.9%

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

Here:	96.0%
West Virginia:	94.8%

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

This Hospital:	97.0%
State:	93.8%

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

This Hospital:	100.0%
State:	98.9%

Outcome of Care

30-Day Mortality Rates from Heart Attack

Here:	18.2%
State:	15.5%

30-Day Mortality Rates from Heart Failure

Here:	12.3%
West Virginia:	11.6%

30-Day Mortality Rates from Pneumonia

Here:	16.1%
West Virginia:	12.3%

30-Day Readmission Rates from Heart Attack

Here:	18.5%
West Virginia:	20.2%

30-Day Readmission Rates from Heart Failure

Here:	24.2%
State:	25.6%

30-Day Readmission Rates from Pneumonia

Here:	16.7%
State:	19.6%

Hospital Acquired Conditions

Falls and injuries

Here:	1.146%
State:	0.833%

Blood infection from a catheter in a large vein

Here:	0.286%
West Virginia:	0.393%

Severe pressure sores (bed sores)

Here:	0.430%
State:	0.363%

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

Acute Myocardial Infarction, Discharged Alive with Complications

Average Covered Charges

Here:	$17,894
State:	$17,489

Average Total Payments

This Hospital:	$6,211
State:	$7,136

Number of discharges: 21

This Hospital:	0.83%
West Virginia:	0.80%

Acute Myocardial Infarction, Discharged Alive with Major Complications

Average Covered Charges

This Hospital:	$29,179
State:	$27,957

Average Total Payments

Here:	$9,690
State:	$10,950

Number of discharges: 26

Here:	1.03%
West Virginia:	1.04%

Acute Myocardial Infarction, Discharged Alive without Complications

Average Covered Charges

This Hospital:	$10,989
State:	$13,287

Average Total Payments

Here:	$4,219
West Virginia:	$4,689

Number of discharges: 14

This Hospital:	0.56%
State:	0.43%

Atherosclerosis without Major Complications

Average Covered Charges

This Hospital:	$8,922
West Virginia:	$9,106

Average Total Payments

This Hospital:	$3,132
West Virginia:	$3,675

Number of discharges: 11

Here:	0.44%
State:	0.90%

Bronchitis and Asthma without Complications

Average Covered Charges

Here:	$15,012
State:	$8,699

Average Total Payments

This Hospital:	$3,184
West Virginia:	$3,776

Number of discharges: 12

Here:	0.48%
West Virginia:	0.20%

Cardiac Arrhythmia and Conduction Disorders with Complications

Average Covered Charges

Here:	$11,184
State:	$12,030

Average Total Payments

Here:	$4,582
West Virginia:	$5,051

Number of discharges: 44

Here:	1.75%
West Virginia:	1.55%

Cardiac Arrhythmia and Conduction Disorders with Major Complications

Average Covered Charges

This Hospital:	$25,468
State:	$18,920

Average Total Payments

This Hospital:	$7,023
State:	$7,620

Number of discharges: 13

Here:	0.52%
State:	0.78%

Cardiac Arrhythmia and Conduction Disorders without Complications

Average Covered Charges

Here:	$7,009
State:	$8,528

Average Total Payments

Here:	$3,061
West Virginia:	$3,482

Number of discharges: 31

Here:	1.23%
West Virginia:	1.87%

Cellulitis without Major Complications

Average Covered Charges

Here:	$9,769
West Virginia:	$9,955

Average Total Payments

This Hospital:	$4,387
West Virginia:	$4,934

Number of discharges: 46

Here:	1.83%
West Virginia:	2.14%

Chest Pain

Average Covered Charges

This Hospital:	$12,300
State:	$10,553

Average Total Payments

Here:	$3,055
State:	$3,462

Number of discharges: 69

This Hospital:	2.74%
West Virginia:	2.41%

Chronic Obstructive Pulmonary Disease with Complications

Average Covered Charges

This Hospital:	$20,386
West Virginia:	$12,902

Average Total Payments

This Hospital:	$5,777
West Virginia:	$5,791

Number of discharges: 111

This Hospital:	4.40%
West Virginia:	3.65%

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

This Hospital:	$23,470
State:	$16,204

Average Total Payments

This Hospital:	$6,732
State:	$7,123

Number of discharges: 84

Here:	3.33%
West Virginia:	3.14%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

This Hospital:	$15,748
State:	$9,702

Average Total Payments

Here:	$3,961
West Virginia:	$4,286

Number of discharges: 110

This Hospital:	4.37%
West Virginia:	3.30%

Circulatory Disorders Except Acute Myocardial Infarction, with Card Cath without Major Complications

Average Covered Charges

This Hospital:	$17,134
State:	$18,767

Average Total Payments

This Hospital:	$5,755
State:	$6,630

Number of discharges: 41

Here:	1.63%
State:	1.98%

Degenerative Nervous System Disorders without Major Complications

Average Covered Charges

Here:	$8,537
West Virginia:	$13,894

Average Total Payments

Here:	$4,794
State:	$5,686

Number of discharges: 19

Here:	0.75%
State:	0.31%

Diabetes with Complications

Average Covered Charges

Here:	$13,505
West Virginia:	$12,547

Average Total Payments

Here:	$4,457
State:	$5,103

Number of discharges: 16

Here:	0.63%
West Virginia:	0.69%

Disorders of Pancreas Except Malignancy with Complications

Average Covered Charges

This Hospital:	$25,203
West Virginia:	$17,713

Average Total Payments

This Hospital:	$6,118
West Virginia:	$6,737

Number of discharges: 11

Here:	0.44%
State:	0.36%

Dysequilibrium

Average Covered Charges

Here:	$9,518
State:	$11,026

Average Total Payments

Here:	$3,433
West Virginia:	$3,910

Number of discharges: 12

This Hospital:	0.48%
West Virginia:	0.19%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders with Major Complications

Average Covered Charges

This Hospital:	$20,854
West Virginia:	$19,325

Average Total Payments

Here:	$6,269
State:	$7,172

Number of discharges: 20

Here:	0.79%
State:	0.50%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

Here:	$14,046
West Virginia:	$11,121

Average Total Payments

Here:	$4,030
State:	$4,399

Number of discharges: 125

Here:	4.96%
State:	3.99%

Extracranial Procedures without Complications

Average Covered Charges

Here:	$11,611
West Virginia:	$16,944

Average Total Payments

This Hospital:	$5,470
West Virginia:	$5,962

Number of discharges: 20

Here:	0.79%
West Virginia:	0.55%

G.I. Hemorrhage with Complications

Average Covered Charges

Here:	$14,740
West Virginia:	$15,574

Average Total Payments

This Hospital:	$5,510
State:	$6,146

Number of discharges: 55

Here:	2.18%
West Virginia:	1.88%

G.I. Hemorrhage with Major Complications

Average Covered Charges

Here:	$28,941
State:	$29,334

Average Total Payments

This Hospital:	$9,652
West Virginia:	$11,046

Number of discharges: 17

Here:	0.67%
State:	0.59%

G.I. Hemorrhage without Complications

Average Covered Charges

This Hospital:	$11,520
State:	$10,350

Average Total Payments

This Hospital:	$3,836
West Virginia:	$4,318

Number of discharges: 21

This Hospital:	0.83%
State:	0.56%

G.I. Obstruction with Complications

Average Covered Charges

This Hospital:	$13,380
West Virginia:	$13,242

Average Total Payments

Here:	$4,927
State:	$5,632

Number of discharges: 17

Here:	0.67%
State:	0.68%

Heart Failure and Shock with Complications

Average Covered Charges

Here:	$18,488
State:	$13,518

Average Total Payments

Here:	$5,547
State:	$6,064

Number of discharges: 69

Here:	2.74%
West Virginia:	3.11%

Heart Failure and Shock with Major Complications

Average Covered Charges

This Hospital:	$26,084
State:	$20,887

Average Total Payments

This Hospital:	$8,707
West Virginia:	$8,936

Number of discharges: 66

This Hospital:	2.62%
West Virginia:	2.50%

Heart Failure and Shock without Complications

Average Covered Charges

Here:	$12,302
State:	$9,106

Average Total Payments

This Hospital:	$3,724
State:	$4,047

Number of discharges: 35

This Hospital:	1.39%
State:	1.40%

Hip and Femur Procedures Except Major Joint with Complications

Average Covered Charges

Here:	$32,319
West Virginia:	$30,759

Average Total Payments

Here:	$10,881
State:	$11,523

Number of discharges: 24

Here:	0.95%
West Virginia:	0.91%

Hip and Femur Procedures Except Major Joint with Major Complications

Average Covered Charges

This Hospital:	$38,129
State:	$55,097

Average Total Payments

This Hospital:	$16,721
West Virginia:	$20,155

Number of discharges: 11

Here:	0.44%
West Virginia:	0.22%

Hip and Femur Procedures Except Major Joint without Complications

Average Covered Charges

Here:	$21,198
State:	$24,595

Average Total Payments

This Hospital:	$8,245
State:	$9,283

Number of discharges: 23

This Hospital:	0.91%
State:	0.31%

Intracranial Hemorrhage or Cerebral Infarction with Complications

Average Covered Charges

This Hospital:	$14,722
State:	$17,560

Average Total Payments

Here:	$5,801
State:	$7,265

Number of discharges: 14

Here:	0.56%
West Virginia:	1.39%

Intracranial Hemorrhage or Cerebral Infarction without Complications

Average Covered Charges

Here:	$12,624
State:	$13,951

Average Total Payments

Here:	$4,399
West Virginia:	$5,203

Number of discharges: 19

Here:	0.75%
West Virginia:	0.73%

Kidney and Urinary Tract Infections with Major Complications

Average Covered Charges

Here:	$26,033
State:	$18,419

Average Total Payments

This Hospital:	$6,901
West Virginia:	$7,511

Number of discharges: 25

Here:	0.99%
State:	0.83%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

This Hospital:	$10,602
West Virginia:	$10,257

Average Total Payments

Here:	$4,176
State:	$4,701

Number of discharges: 89

This Hospital:	3.53%
State:	3.45%

Laparoscopic Cholecystectomy without C.D.E. with Complications

Average Covered Charges

Here:	$28,416
West Virginia:	$25,843

Average Total Payments

This Hospital:	$9,123
West Virginia:	$9,980

Number of discharges: 12

This Hospital:	0.48%
West Virginia:	0.28%

Laparoscopic Cholecystectomy without C.D.E. without Complications

Average Covered Charges

Here:	$20,472
West Virginia:	$20,392

Average Total Payments

Here:	$6,620
State:	$7,170

Number of discharges: 15

This Hospital:	0.60%
State:	0.22%

Major Gastrointestinal Disorders and Peritoneal Infections with Complications

Average Covered Charges

This Hospital:	$21,262
West Virginia:	$16,093

Average Total Payments

Here:	$6,945
West Virginia:	$7,566

Number of discharges: 13

This Hospital:	0.52%
State:	0.30%

Major Joint Replacement or Reattachment of Lower Extremity without Major Complications

Average Covered Charges

Here:	$28,342
State:	$33,555

Average Total Payments

This Hospital:	$11,592
West Virginia:	$12,548

Number of discharges: 180

This Hospital:	7.14%
State:	4.22%

Major Small and Large Bowel Procedures with Complications

Average Covered Charges

This Hospital:	$46,138
State:	$42,201

Average Total Payments

This Hospital:	$14,474
State:	$16,275

Number of discharges: 12

This Hospital:	0.48%
West Virginia:	0.53%

Major Small and Large Bowel Procedures with Major Complications

Average Covered Charges

This Hospital:	$87,803
State:	$84,532

Average Total Payments

Here:	$30,433
State:	$33,996

Number of discharges: 19

This Hospital:	0.75%
West Virginia:	0.40%

Medical Back Problems without Major Complications

Average Covered Charges

This Hospital:	$13,335
State:	$12,767

Average Total Payments

Here:	$4,206
West Virginia:	$5,026

Number of discharges: 24

This Hospital:	0.95%
West Virginia:	0.85%

Misc Disorders of Nutrition, Metabolism, Fluids or Electrolytes with Major Complications

Average Covered Charges

This Hospital:	$18,513
State:	$19,476

Average Total Payments

Here:	$7,269
State:	$7,750

Number of discharges: 14

Here:	0.56%
West Virginia:	0.45%

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

Average Covered Charges

Here:	$9,572
West Virginia:	$9,782

Average Total Payments

Here:	$3,832
State:	$4,200

Number of discharges: 56

Here:	2.22%
West Virginia:	1.96%

Other Circulatory System Diagnoses with Major Complications

Average Covered Charges

This Hospital:	$14,568
West Virginia:	$27,314

Average Total Payments

This Hospital:	$9,047
State:	$11,962

Number of discharges: 11

This Hospital:	0.44%
West Virginia:	0.45%

Other Digestive System Diagnoses with Complications

Average Covered Charges

Here:	$16,793
West Virginia:	$14,413

Average Total Payments

This Hospital:	$5,196
West Virginia:	$6,090

Number of discharges: 17

Here:	0.67%
West Virginia:	0.42%

Percutaneous Cardiovascular Procedures with Drug-Eluting Stent without Major Complications

Average Covered Charges

This Hospital:	$38,580
State:	$41,116

Average Total Payments

Here:	$10,441
West Virginia:	$12,246

Number of discharges: 21

Here:	0.83%
West Virginia:	1.69%

Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent without Major Complications

Average Covered Charges

Here:	$34,735
West Virginia:	$39,243

Average Total Payments

This Hospital:	$9,477
West Virginia:	$10,556

Number of discharges: 14

This Hospital:	0.56%
State:	0.39%

Peripheral Vascular Disorders with Complications

Average Covered Charges

This Hospital:	$11,979
West Virginia:	$13,396

Average Total Payments

Here:	$5,207
West Virginia:	$5,969

Number of discharges: 28

This Hospital:	1.11%
West Virginia:	0.79%

Peripheral Vascular Disorders without Complications

Average Covered Charges

Here:	$7,272
West Virginia:	$9,434

Average Total Payments

Here:	$3,555
West Virginia:	$3,940

Number of discharges: 14

Here:	0.56%
West Virginia:	0.34%

Permanent Cardiac Pacemaker Implant with Complications

Average Covered Charges

This Hospital:	$35,863
State:	$39,675

Average Total Payments

Here:	$14,241
State:	$16,100

Number of discharges: 15

Here:	0.60%
West Virginia:	0.30%

Poisoning and Toxic Effects of Drugs without Major Complications

Average Covered Charges

Here:	$9,645
State:	$8,892

Average Total Payments

Here:	$3,318
West Virginia:	$3,936

Number of discharges: 13

Here:	0.52%
State:	0.48%

Psychoses

Average Covered Charges

Here:	$11,798
State:	$9,461

Average Total Payments

This Hospital:	$5,566
West Virginia:	$5,928

Number of discharges: 14

Here:	0.56%
State:	0.22%

Pulmonary Edema and Respiratory Failure

Average Covered Charges

Here:	$27,970
West Virginia:	$18,551

Average Total Payments

Here:	$6,961
State:	$7,863

Number of discharges: 34

This Hospital:	1.35%
State:	1.77%

Red Blood Cell Disorders without Major Complications

Average Covered Charges

This Hospital:	$14,219
State:	$11,327

Average Total Payments

This Hospital:	$4,434
State:	$4,774

Number of discharges: 27

This Hospital:	1.07%
State:	1.34%

Renal Failure with Complications

Average Covered Charges

Here:	$14,704
West Virginia:	$13,699

Average Total Payments

Here:	$5,452
State:	$6,153

Number of discharges: 58

This Hospital:	2.30%
West Virginia:	2.20%

Renal Failure with Major Complications

Average Covered Charges

Here:	$19,855
State:	$23,118

Average Total Payments

Here:	$9,447
West Virginia:	$10,082

Number of discharges: 36

This Hospital:	1.43%
West Virginia:	1.22%

Respiratory Infections and Inflammations with Complications

Average Covered Charges

Here:	$30,726
West Virginia:	$19,617

Average Total Payments

Here:	$8,881
West Virginia:	$8,860

Number of discharges: 23

This Hospital:	0.91%
State:	0.85%

Respiratory Infections and Inflammations with Major Complications

Average Covered Charges

This Hospital:	$36,167
West Virginia:	$27,963

Average Total Payments

Here:	$11,030
West Virginia:	$12,086

Number of discharges: 25

Here:	0.99%
State:	0.88%

Respiratory System Diagnosis with Ventilator Support 96+ Hours

Average Covered Charges

This Hospital:	$70,941
West Virginia:	$77,185

Average Total Payments

Here:	$28,680
State:	$33,155

Number of discharges: 21

Here:	0.83%
State:	0.49%

Respiratory System Diagnosis with Ventilator Support <96 Hours

Average Covered Charges

This Hospital:	$34,875
West Virginia:	$36,399

Average Total Payments

Here:	$12,411
West Virginia:	$14,359

Number of discharges: 40

This Hospital:	1.59%
State:	1.30%

Seizures without Major Complications

Average Covered Charges

Here:	$14,026
State:	$11,443

Average Total Payments

Here:	$3,985
State:	$5,131

Number of discharges: 22

This Hospital:	0.87%
West Virginia:	0.74%

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

Average Covered Charges

This Hospital:	$31,343
West Virginia:	$30,150

Average Total Payments

Here:	$10,548
West Virginia:	$12,053

Number of discharges: 38

This Hospital:	1.51%
State:	3.24%

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

Average Covered Charges

Here:	$11,663
State:	$15,708

Average Total Payments

Here:	$6,203
State:	$6,916

Number of discharges: 11

This Hospital:	0.44%
State:	1.35%

Signs and Symptoms without Major Complications

Average Covered Charges

This Hospital:	$10,775
State:	$10,973

Average Total Payments

This Hospital:	$3,609
State:	$4,245

Number of discharges: 38

Here:	1.51%
West Virginia:	0.87%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

This Hospital:	$17,424
West Virginia:	$14,392

Average Total Payments

This Hospital:	$5,496
State:	$6,029

Number of discharges: 123

Here:	4.88%
West Virginia:	3.71%

Simple Pneumonia and Pleurisy with Major Complications

Average Covered Charges

This Hospital:	$32,478
State:	$21,145

Average Total Payments

This Hospital:	$8,060
State:	$8,863

Number of discharges: 42

This Hospital:	1.67%
State:	2.15%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

This Hospital:	$14,675
State:	$9,911

Average Total Payments

This Hospital:	$4,150
State:	$4,263

Number of discharges: 53

Here:	2.10%
West Virginia:	1.55%

Syncope and Collapse

Average Covered Charges

This Hospital:	$10,824
State:	$11,188

Average Total Payments

This Hospital:	$3,973
West Virginia:	$4,415

Number of discharges: 66

Here:	2.62%
West Virginia:	1.99%

Transient Ischemia

Average Covered Charges

Here:	$15,802
West Virginia:	$11,701

Average Total Payments

Here:	$4,870
West Virginia:	$4,522

Number of discharges: 30

This Hospital:	1.19%
West Virginia:	1.31%

Complaint Deficiency

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
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- 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
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
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: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly protected cooking facilities
- Harm: Potential for minimal harm
- Scope: Some
Provide enough notice before discharging or transferring a resident
- Harm: Potential for minimal harm
- Scope: Many
Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home
- 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 residents' abilities in activities of daily living do not decline, unless unavoidable
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that special or therapeutic diets are ordered by the attending doctor
- 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
Record of quarterly fire drills for each shift under varying conditions
- Harm: Potential for minimal harm
- Scope: Many
Give the resident's representative the ability to exercise the resident's rights
- 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: Potential for minimal harm
- Scope: Many
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Potential for minimal harm
- Scope: Many
Provide activities to meet the interests and needs of each resident
- 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
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: 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 services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Provide necessary care and services to maintain the highest well being of each resident
- 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: Some
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
Give each resident enough fluids to keep them healthy and prevent dehydration
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Be administered in an acceptable way that maintains the well-being of each resident
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Operate and provide services according to Federal, State, and local laws and professional standards
- Harm: Potential for minimal harm
- Scope: Many
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few

Use of Medical Imaging

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

This Hospital:	40.900%
State:	42.623%

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

Here:	9.800%
West Virginia:	8.958%

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

This Hospital:	0.040%
West Virginia:	0.275%

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

This Hospital:	7.200%
West Virginia:	5.768%

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

Here:	4.700%
State:	3.183%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 31%

How often did nurses communicate well with patients?

Sometimes or never

Here:	8%
State:	6%

Usually

Here:	19%
West Virginia:	17%

Always

Here:	73%
West Virginia:	77%

How often did doctors communicate well with patients?

Sometimes or never

Here:	4%
State:	4%

Usually

This Hospital:	14%
West Virginia:	14%

Always

This Hospital:	82%
State:	82%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Hospital:	15%
West Virginia:	12%

Usually

This Hospital:	27%
State:	23%

Always

This Hospital:	58%
State:	65%

How often was patients' pain well controlled?

Sometimes or never

This Hospital:	7%
State:	8%

Usually

Here:	22%
State:	23%

Always

Here:	71%
State:	69%

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

Sometimes or never

Here:	28%
State:	20%

Usually

This Hospital:	15%
State:	18%

Always

This Hospital:	57%
State:	62%

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

Sometimes or never

Here:	14%
State:	9%

Usually

Here:	21%
West Virginia:	18%

Always

This Hospital:	65%
West Virginia:	73%

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

Sometimes or never

This Hospital:	8%
State:	13%

Usually

Here:	32%
State:	32%

Always

This Hospital:	60%
West Virginia:	55%

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

Yes

Here:	82%
West Virginia:	83%

This Hospital:	18%
State:	17%

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

6 or lower

This Hospital:	9%
West Virginia:	11%

7 or 8

Here:	22%
State:	24%

9 or 10

Here:	69%
West Virginia:	65%

Would patients recommend the hospital to friends and family?

Here:	6%
State:	6%

Yes, probably

Here:	22%
West Virginia:	29%

Yes, definitely

Here:	72%
West Virginia:	65%

THOMAS MEMORIAL HOSPITAL - SOUTH CHARLESTON, WV

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Hospital Acquired Conditions

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

Complaint Deficiency

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

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