JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Southeastern Regional Medical Center

2 / 5

At a glance

Southeastern Regional Medical Center carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 6 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 Limit0.596Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit3.057Same as national
Central Line Associated Bloodstream Infection: Number of Device Days5151Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases4.082Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases6Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)1.470Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence Limit0.011Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit1.115Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days5071Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.424Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases1Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.226Same as national
SSI - Colon Surgery: Lower Confidence Limit0.274Same as national
SSI - Colon Surgery: Upper Confidence Limit5.403Same as national
SSI - Colon Surgery: Number of Procedures44Same as national
SSI - Colon Surgery: Predicted Cases1.223Same as national
SSI - Colon Surgery: Observed Cases2Same as national
SSI - Colon Surgery1.635Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures84Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.751Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.021Same as national
MRSA Bacteremia: Upper Confidence Limit2.044Same as national
MRSA Bacteremia: Patient Days48792Same as national
MRSA Bacteremia: Predicted Cases2.413Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.414Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.018Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.346Better than national
Clostridium Difficile (C.Diff): Patient Days45298Better than national
Clostridium Difficile (C.Diff): Predicted Cases19.093Better than national
Clostridium Difficile (C.Diff): Observed Cases2Better than national
Clostridium Difficile (C.Diff)0.105Better 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 Rate4.4Same as national589
Death rate for heart attack patients13.8Same as national100
Death rate for CABG surgery patientsNot available
Death rate for COPD patients11.4Same as national122
Death rate for heart failure patients11.6Same as national239
Death rate for pneumonia patients19.8Same as national265
Death rate for stroke patients14.1Same as national117
Pressure ulcer rate0.26Same as national2633
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.23Same as national3189
In-hospital fall-associated fracture rate0.37Same as national3331
Postoperative hemorrhage or hematoma rate2.44Same as national366
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rateNot available
Perioperative pulmonary embolism or deep vein thrombosis rate3.47Same as national381
Postoperative sepsis rateNot available
Postoperative wound dehiscence rate1.73Same as national66
Abdominopelvic accidental puncture or laceration rate1.00Same as national381
CMS Medicare PSI 90: Patient safety and adverse events composite0.90Same 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 patients-15.9Not available74
Hospital return days for heart failure patients44.1Not available288
Hospital return days for pneumonia patients14.9Not available268
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)16.1Same as national1004
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)13.2Same as national226
Rate of inpatient admissions for patients receiving outpatient chemotherapy11.2Same as national78
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy5.3Same as national78
Ratio of unplanned hospital visits after hospital outpatient surgery0.9Same as national105
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13Same as national74
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients18.8Same as national127
Heart failure (HF) 30-Day Readmission Rate22.1Same as national288
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.1Same as national268

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 rating3611
Doctor communication - star rating3611
Communication about medicines - star rating3611
Discharge information - star rating3611
Cleanliness - star rating4611
Quietness - star rating4611
Overall hospital rating - star rating3611
Recommend hospital - star rating3611
Summary star rating3611

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 Events04812
Healthcare workers given influenza vaccination1002506
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 better258370
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 better248338
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better37119
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better47213
Left before being seen253381
Head CT results7023
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients92348
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing122135
Appropriate care for severe sepsis and septic shock70304
Septic Shock 3-Hour Bundle78133
Septic Shock 6-Hour Bundle8876
Severe Sepsis 3-Hour Bundle86305
Severe Sepsis 6-Hour Bundle98187
Discharged on Antithrombotic Therapy97153
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 292154
Venous Thromboembolism Prophylaxis
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 Southeastern Regional Medical Center rated?
Southeastern Regional Medical Center has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Southeastern Regional Medical Center have emergency services?
Yes. Southeastern Regional Medical Center operates a 24/7 emergency department.
Where is Southeastern Regional Medical Center located?
Southeastern Regional Medical Center is located at 300 W 27 St Po Box 1408, Lumberton, NC 28359.
What type of hospital is Southeastern Regional Medical Center?
Southeastern Regional Medical Center is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

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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