WEBSTER GENERAL HOSPITAL/SWING BED (EUPORA, MS) Detailed Hospital Profile

Complaint Deficiency

An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper backup exit lighting
- 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: Few
An approved automatic sprinkler system connected to the fire alarm system
- 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 services provided by the nursing facility meet professional standards of quality
- 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
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give or get quality lab services/tests in a timely manner to meet the needs of residents
- 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: Potential for minimal harm
- Scope: Some
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Potential for minimal harm
- Scope: Many
Portable fire extinguishers
- Harm: Potential for minimal harm
- Scope: Many
Weekly inspections and monthly testing of generators
- Harm: Potential for minimal harm
- Scope: Many
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Record of quarterly fire drills for each shift under varying conditions
- 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: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- 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: 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
Provide a tasty and well-balanced diet that meets the nutritional needs of each resident
- 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: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give or get quality lab services/tests in a timely manner to meet the needs 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
Provide housekeeping and maintenance services
- 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: Few
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 with a urinary tract infection

Here:	8.6%
Mississippi:	7.3%

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

Here:	5.7%
State:	2.9%

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

This Hospital:	100.0%
Mississippi:	94.9%

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

Here:	100.0%
State:	96.7%

Percent of long-stay residents who received an antipsychotic medication

Here:	23.5%
Mississippi:	26.8%

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

Bronchitis and Asthma with Complications

Average Covered Charges

This Hospital:	$10,343
State:	$18,293

Average Total Payments

This Hospital:	$4,900
Mississippi:	$5,060

Number of discharges: 12

Here:	2.21%
Mississippi:	0.74%

Bronchitis and Asthma without Complications

Average Covered Charges

This Hospital:	$12,591
State:	$14,285

Average Total Payments

Here:	$3,524
Mississippi:	$3,693

Number of discharges: 15

Here:	2.76%
Mississippi:	0.54%

Cellulitis without Major Complications

Average Covered Charges

Here:	$12,979
State:	$17,224

Average Total Payments

This Hospital:	$4,848
Mississippi:	$5,050

Number of discharges: 37

Here:	6.81%
State:	1.90%

Chronic Obstructive Pulmonary Disease with Complications

Average Covered Charges

Here:	$13,610
State:	$21,305

Average Total Payments

Here:	$5,654
State:	$5,812

Number of discharges: 17

This Hospital:	3.13%
Mississippi:	2.37%

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

Here:	$18,383
Mississippi:	$26,679

Average Total Payments

Here:	$7,352
State:	$7,105

Number of discharges: 12

This Hospital:	2.21%
Mississippi:	2.30%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

Here:	$11,073
State:	$16,092

Average Total Payments

This Hospital:	$4,192
Mississippi:	$4,362

Number of discharges: 21

This Hospital:	3.87%
Mississippi:	2.34%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

Here:	$14,620
State:	$16,954

Average Total Payments

This Hospital:	$4,377
State:	$4,347

Number of discharges: 41

This Hospital:	7.55%
Mississippi:	4.02%

Heart Failure and Shock with Complications

Average Covered Charges

Here:	$15,355
Mississippi:	$20,890

Average Total Payments

Here:	$5,943
Mississippi:	$6,135

Number of discharges: 32

This Hospital:	5.89%
State:	3.46%

Heart Failure and Shock with Major Complications

Average Covered Charges

This Hospital:	$21,923
Mississippi:	$32,289

Average Total Payments

This Hospital:	$8,480
Mississippi:	$8,991

Number of discharges: 12

This Hospital:	2.21%
Mississippi:	2.92%

Heart Failure and Shock without Complications

Average Covered Charges

This Hospital:	$10,749
Mississippi:	$14,583

Average Total Payments

Here:	$3,998
State:	$4,098

Number of discharges: 20

Here:	3.68%
State:	1.73%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

This Hospital:	$16,276
State:	$16,244

Average Total Payments

Here:	$4,505
State:	$4,671

Number of discharges: 59

Here:	10.87%
State:	3.46%

Medical Back Problems without Major Complications

Average Covered Charges

Here:	$12,023
Mississippi:	$19,495

Average Total Payments

Here:	$4,727
State:	$5,016

Number of discharges: 13

Here:	2.39%
Mississippi:	0.65%

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

Average Covered Charges

Here:	$12,790
Mississippi:	$14,414

Average Total Payments

Here:	$4,303
Mississippi:	$4,193

Number of discharges: 50

Here:	9.21%
State:	2.58%

Red Blood Cell Disorders without Major Complications

Average Covered Charges

This Hospital:	$16,094
State:	$17,864

Average Total Payments

Here:	$4,630
State:	$4,971

Number of discharges: 14

This Hospital:	2.58%
State:	1.98%

Respiratory Infections and Inflammations with Complications

Average Covered Charges

This Hospital:	$21,606
Mississippi:	$31,040

Average Total Payments

Here:	$8,262
State:	$8,720

Number of discharges: 23

This Hospital:	4.24%
Mississippi:	0.80%

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

Average Covered Charges

Here:	$25,057
State:	$44,389

Average Total Payments

Here:	$11,297
State:	$11,997

Number of discharges: 14

Here:	2.58%
State:	3.82%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

This Hospital:	$19,490
State:	$22,633

Average Total Payments

This Hospital:	$5,860
Mississippi:	$6,078

Number of discharges: 84

Here:	15.47%
State:	3.08%

Simple Pneumonia and Pleurisy with Major Complications

Average Covered Charges

This Hospital:	$25,992
Mississippi:	$34,401

Average Total Payments

This Hospital:	$8,546
State:	$8,855

Number of discharges: 25

Here:	4.60%
Mississippi:	1.91%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

Here:	$13,223
State:	$16,650

Average Total Payments

Here:	$4,642
State:	$4,315

Number of discharges: 42

This Hospital:	7.73%
Mississippi:	1.59%

Use of Medical Imaging

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

Here:	36.300%
Mississippi:	40.903%

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

This Hospital:	1.000%
State:	8.123%

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

Here:	0.056%
Mississippi:	0.163%

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

This Hospital:	0.038%
Mississippi:	0.073%

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

This Hospital:	5.800%
Mississippi:	4.103%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: Between 100 and 299
Survey Response Rate: 25%

How often did nurses communicate well with patients?

Sometimes or never

This Hospital:	4%
State:	5%

Usually

This Hospital:	9%
Mississippi:	15%

Always

Here:	87%
Mississippi:	80%

How often did doctors communicate well with patients?

Sometimes or never

This Hospital:	1%
State:	4%

Usually

This Hospital:	2%
State:	11%

Always

This Hospital:	97%
Mississippi:	85%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Hospital:	9%
Mississippi:	11%

Usually

This Hospital:	15%
Mississippi:	22%

Always

This Hospital:	76%
State:	67%

How often was patients' pain well controlled?

Sometimes or never

Here:	2%
Mississippi:	8%

Usually

Here:	17%
Mississippi:	20%

Always

This Hospital:	81%
State:	72%

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

Sometimes or never

Here:	14%
State:	21%

Usually

Here:	16%
State:	17%

Always

Here:	70%
Mississippi:	62%

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

Sometimes or never

Here:	5%
Mississippi:	10%

Usually

This Hospital:	7%
State:	18%

Always

Here:	88%
State:	72%

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

Sometimes or never

Here:	9%
Mississippi:	7%

Usually

This Hospital:	19%
Mississippi:	24%

Always

Here:	72%
Mississippi:	69%

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

Yes

This Hospital:	84%
Mississippi:	79%

Here:	16%
Mississippi:	21%

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

6 or lower

This Hospital:	5%
Mississippi:	10%

7 or 8

Here:	15%
State:	22%

9 or 10

Here:	80%
State:	68%

Would patients recommend the hospital to friends and family?

This Hospital:	2%
State:	6%

Yes, probably

This Hospital:	23%
State:	26%

Yes, definitely

This Hospital:	75%
Mississippi:	68%

Process of Care

Heart Attack

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

This Hospital:	9
Mississippi:	12

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

Here:	91.0%
Mississippi:	93.9%

Heart Failure

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

Here:	88.0%
State:	97.3%

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

Here:	83.0%
State:	94.1%

Percent of Patients Given Discharge Instructions

This Hospital:	71.0%
State:	90.8%

Pneumonia

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

This Hospital:	94.0%
Mississippi:	96.2%

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

This Hospital:	97.0%
Mississippi:	97.9%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	87.0%
Mississippi:	97.9%

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

This Hospital:	86.0%
Mississippi:	93.2%

Percent of Patients Assessed and Given Influenza Vaccination

This Hospital:	94.0%
Mississippi:	92.1%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	98.0%
State:	93.8%

Outcome of Care

30-Day Mortality Rates from Heart Failure

Here:	10.2%
State:	12.2%

30-Day Mortality Rates from Pneumonia

Here:	11.2%
State:	13.2%

30-Day Readmission Rates from Heart Failure

This Hospital:	26.6%
State:	26.1%

30-Day Readmission Rates from Pneumonia

This Hospital:	22.1%
Mississippi:	19.6%

WEBSTER GENERAL HOSPITAL/SWING BED - EUPORA, MS

Complaint Deficiency

Quality Measures

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

Use of Medical Imaging

Hospital Consumer Assessment of Healthcare Providers

Process of Care

Heart Attack

Heart Failure

Pneumonia

Outcome of Care

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