Quality Report


Quality Report

Cookeville Regional Medical Center
HCO ID: 7821
1 Medical Center Boulevard
Cookeville, TN, 38501
(931) 528-2541
www.crmchealth.org
Summary of Quality Information

Accreditation Programs

View Accreditation History
Gold Seal
Hospital
Accreditation Decision
Effective Date
1/26/2024
Last Full Survey Date
1/26/2024
Last On-Site Survey Date
3/5/2024

The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.

  • Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
  • A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
  • Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
  • The hospital has policies and procedures that guide and support patient care, treatment, and services.
  • The hospital honors the patient's right to give or withhold informed consent.
  • The hospital inspects, tests, and maintains medical equipment.
  • The hospital maintains fire safety equipment and fire safety building features. Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
  • The hospital safely administers medications.

Advanced Certification Programs

View Certification History
Gold Seal
Advanced Total Hip and Total Knee Replacement
Certification Decision
Effective Date
12/6/2022
Last Full Survey Date
10/14/2022
Last On-Site Survey Date
10/14/2022
Gold Seal
Primary Stroke Center
Certification Decision
Effective Date
4/22/2023
Last Full Survey Date
4/21/2023
Last On-Site Survey Date
4/21/2023

Core Certification Programs

Gold Seal
Hip Fracture
Certification Decision
Effective Date
5/14/2022
Last Full Survey Date
5/13/2022
Last On-Site Survey Date
5/13/2022
Gold Seal
Sepsis
Certification Decision
Effective Date
5/11/2023
Last Full Survey Date
5/10/2023
Last On-Site Survey Date
5/10/2023

Sites

Advanced Wound Center at Cookeville Regional Medical Center
DBA: Advanced Wound Center at Cookeville Regional Medical Center
250 N. Cedar Avenue
Cookeville, TN, 38501

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Cardiac & Pulmonary Rehabilitation Center
228 West 4th Street, Suite 100
Cookeville, TN, 38501

Available Services

  • Outpatient Clinics (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Cookeville Regional Medical Center Authority
DBA: Cookeville Regional Medical Center Authority
1 Medical Center Boulevard
Cookeville, TN, 38501

Available Services

  • Cardiac Catheterization Lab (Surgical Services )
  • Cardiac Surgery (Surgical Services )
  • Cardiothoracic Surgery (Surgical Services )
  • Cardiovascular Unit (Inpatient )
  • Coronary Care Unit (Inpatient )
  • CT Scanner (Imaging/Diagnostic Services )
  • Dialysis Unit (Inpatient )
  • Ear/Nose/Throat Surgery (Surgical Services )
  • EEG/EKG/EMG Lab (Imaging/Diagnostic Services )
  • Gastroenterology (Surgical Services )
  • GI or Endoscopy Lab (Imaging/Diagnostic Services )
  • Gynecological Surgery (Surgical Services )
  • Gynecology (Inpatient )
  • Hazardous Medication Compounding (Inpatient )
  • Hematology/Oncology Unit (Inpatient )
  • Inpatient Unit (Inpatient )
  • Interventional Radiology (Imaging/Diagnostic Services )
  • Labor & Delivery (Inpatient )
  • Magnetic Resonance Imaging (Imaging/Diagnostic Services )
  • Medical /Surgical Unit (Inpatient )
  • Medical ICU (Intensive Care Unit )
  • Neuro/Spine Unit (Inpatient )
  • Neurosurgery (Surgical Services )
  • Non-Sterile Medication Compounding (Inpatient )
  • Normal Newborn Nursery (Inpatient )
  • Nuclear Medicine (Imaging/Diagnostic Services )
  • Orthopedic Surgery (Surgical Services )
  • Orthopedic/Spine Unit (Inpatient )
  • Outpatient Clinics (Outpatient )
  • Pediatric Unit (Inpatient )
  • Perform Invasive Procedure (Outpatient )
  • Positron Emission Tomography (PET) (Imaging/Diagnostic Services )
  • Post Anesthesia Care Unit (PACU) (Inpatient )
  • Radiation Oncology (Imaging/Diagnostic Services )
  • Sterile Medication Compounding (Inpatient )
  • Surgical ICU (Intensive Care Unit )
  • Surgical Unit (Inpatient )
  • Teleradiology (Imaging/Diagnostic Services )
  • Thoracic Surgery (Surgical Services )
  • Ultrasound (Imaging/Diagnostic Services )
  • Urology (Surgical Services )
  • Vascular Surgery (Surgical Services )

Certification Programs

  • Advanced Total Hip and Total Knee Replacement
  • Hip Fracture
  • Primary Stroke Center
  • Sepsis

CRMC Surgery Center - Whitney
DBA: CRMC Surgery Center - Whitney
467 North Whitney Avenue
Cookeville, TN, 38501

Available Services

  • Administration of Blood Product (Outpatient )
  • Administration of High Risk Medications (Outpatient )
  • Ambulatory Surgery Center (Outpatient )
  • Anesthesia (Outpatient )
  • Perform Invasive Procedure (Outpatient )

Outpatient Physical Therapy Department
215 West 6th Street
Cookeville, TN, 38501

Available Services

  • Outpatient Clinics (Outpatient )

Rehab Center
215 West 6th Street
Cookeville, TN, 38501

Available Services

  • Inpatient Unit (Inpatient )
  • Medical /Surgical Unit (Inpatient )
  • Rehabilitation Unit (Inpatient )
  • Rehabilitation Unit (24-hour Acute Care/Crisis Stabilization )

The Sleep Center at CRMC
DBA: The Sleep Center at CRMC
100 West 4th Street Suite 350
Cookeville, TN, 38501

Available Services

  • Outpatient Clinics (Outpatient )

Cooperative Agreements

Hospital - Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)

National Patient Safety Goals and National Quality Improvement Goals

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range /value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.
  12. The measure rate is within optimal range.

Symbol Key

  • starThis organization achieved the best possible results
  • plusThis organization's performance is better than the target range/value
  • checkThis organization's performance is similar to the target range/value
  • minusThis organization's performance is worse than the target range/value
  • naThis measure is not applicable for this organization
  • ndNot displayed

Measures Footnote Key

  1. The measure or measure set was not reported.
  2. The measure set does not have an overall result.
  3. The number is not enough for comparison purposes.
  4. The measure meets the Privacy Disclosure Threshold rule.
  5. The organization scored above 90% but was below most other organizations.
  6. The measure results are not statistically valid.
  7. The measure results are based on a sample of patients.
  8. The number of months with measure data is below the reporting requirement.
  9. The measure results are temporarily suppressed pending resubmission of updated data.
  10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
  11. There were no eligible patients that met the denominator criteria.
  12. The measure rate is within optimal range.

* This information can also be viewed at Hospital Compare.

**      Indicates per 1000 hours of patient care.
***   The measure was not in effect for this quarter.
----   Null value or data not displayed.

Hospital 2024 National Patient Safety Goals Nationwide Comparison: check Statewide Comparison: na
Reporting Period: January 2022 - December 2022
Perinatal Care National Comparison: nd 2 Statewide Comparison: nd 2

New Changes to Quarterly Measure

Download Quarterly Measure Results

* State results are not calculated for the National Patient Safety Goals.