JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Other

Decatur Memorial Hospital

3 / 5

At a glance

Decatur Memorial Hospital carries a 3-star CMS overall rating — in line with the national norm. On healthcare-associated infection measures, it performs better than the national average on 18 and worse on 0.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence LimitBetter than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit0.841Better than national
Central Line Associated Bloodstream Infection: Number of Device Days3938Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases3.563Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Better than national
Central Line Associated Bloodstream Infection (ICU + select Wards)0.000Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitBetter than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.643Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4717Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.659Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Better than national
SSI - Colon Surgery: Lower Confidence Limit0.568Same as national
SSI - Colon Surgery: Upper Confidence Limit4.313Same as national
SSI - Colon Surgery: Number of Procedures89Same as national
SSI - Colon Surgery: Predicted Cases2.237Same as national
SSI - Colon Surgery: Observed Cases4Same as national
SSI - Colon Surgery1.788Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures74Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.592Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitSame as national
MRSA Bacteremia: Upper Confidence Limit1.319Same as national
MRSA Bacteremia: Patient Days46773Same as national
MRSA Bacteremia: Predicted Cases2.271Same as national
MRSA Bacteremia: Observed Cases0Same as national
MRSA Bacteremia0.000Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.101Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.613Better than national
Clostridium Difficile (C.Diff): Patient Days45175Better than national
Clostridium Difficile (C.Diff): Predicted Cases18.089Better than national
Clostridium Difficile (C.Diff): Observed Cases5Better than national
Clostridium Difficile (C.Diff)0.276Better than national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.3Same as national1316
Death rate for heart attack patients12.4Same as national110
Death rate for CABG surgery patientsNot available
Death rate for COPD patients8.4Same as national215
Death rate for heart failure patients12Same as national357
Death rate for pneumonia patients17.6Same as national460
Death rate for stroke patients11.6Same as national178
Pressure ulcer rate1.05Same as national4464
Death rate among surgical inpatients with serious treatable complications195.17Same as national64
Iatrogenic pneumothorax rate0.18Same as national4907
In-hospital fall-associated fracture rate0.27Same as national4967
Postoperative hemorrhage or hematoma rate2.62Same as national985
Postoperative acute kidney injury requiring dialysis rate1.44Same as national338
Postoperative respiratory failure rate7.13Same as national320
Perioperative pulmonary embolism or deep vein thrombosis rate5.03Same as national1057
Postoperative sepsis rate4.14Same as national298
Postoperative wound dehiscence rate1.62Same as national234
Abdominopelvic accidental puncture or laceration rate1.05Same as national1026
CMS Medicare PSI 90: Patient safety and adverse events composite1.07Same as national

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patients30.8Not available88
Hospital return days for heart failure patients31.2Not available383
Hospital return days for pneumonia patients-11.2Not available441
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.9Same as national1980
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.2Same as national1792
Rate of inpatient admissions for patients receiving outpatient chemotherapy10.2Same as national77
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy4.9Same as national77
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national928
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate12.9Same as national88
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.5Same as national231
Heart failure (HF) 30-Day Readmission Rate19.3Same as national383
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate13.8Same as national441

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating2748
Doctor communication - star rating2748
Communication about medicines - star rating2748
Discharge information - star rating2748
Cleanliness - star rating2748
Quietness - star rating3748
Overall hospital rating - star rating2748
Recommend hospital - star rating3748
Summary star rating2748

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volumehigh
Global Malnutrition Composite Score
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented
Global Malnutrition Composite Score: Malnutrition Risk Screening
Global Malnutrition Composite Score: Nutrition Assessment
Global Malnutrition Composite Score: Nutritional Care Plan
Hospital Harm - Severe Hyperglycemia
Hospital Harm - Severe Hypoglycemia
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination742387
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better212883
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better205817
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better29853
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better37816
Left before being seen841643
Head CT results8335
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients10063
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing131587
Appropriate care for severe sepsis and septic shock41125
Septic Shock 3-Hour Bundle5048
Septic Shock 6-Hour Bundle5522
Severe Sepsis 3-Hour Bundle75125
Severe Sepsis 6-Hour Bundle8771
Discharged on Antithrombotic Therapy92172
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 297140
Venous Thromboembolism Prophylaxis693409
Intensive Care Unit Venous Thromboembolism Prophylaxis

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural MeasureYes

Frequently asked questions

How is Decatur Memorial Hospital rated?
Decatur Memorial Hospital has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Decatur Memorial Hospital have emergency services?
Yes. Decatur Memorial Hospital operates a 24/7 emergency department.
Where is Decatur Memorial Hospital located?
Decatur Memorial Hospital is located at 2300 North Edward Street, Decatur, IL 62526.
What type of hospital is Decatur Memorial Hospital?
Decatur Memorial Hospital is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Other).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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