JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Government - Hospital District or Authority

Titus Regional Medical Center

3 / 5

At a glance

Titus Regional Medical Center carries a 3-star CMS overall rating — in line with the national norm.

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 LimitNot available
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence LimitNot available
Central Line Associated Bloodstream Infection: Number of Device Days451Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases0.383Not available
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases0Not available
Central Line Associated Bloodstream Infection (ICU + select Wards)Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence LimitNot available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days671Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases0.545Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases2Not available
Catheter Associated Urinary Tract Infections (ICU + select Wards)Not available
SSI - Colon Surgery: Lower Confidence LimitNot available
SSI - Colon Surgery: Upper Confidence LimitNot available
SSI - Colon Surgery: Number of Procedures36Not available
SSI - Colon Surgery: Predicted Cases0.945Not available
SSI - Colon Surgery: Observed Cases0Not available
SSI - Colon SurgeryNot available
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures78Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.629Not available
SSI - Abdominal Hysterectomy: Observed Cases0Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence LimitNot available
MRSA Bacteremia: Upper Confidence LimitNot available
MRSA Bacteremia: Patient Days10805Not available
MRSA Bacteremia: Predicted Cases0.294Not available
MRSA Bacteremia: Observed Cases0Not available
MRSA BacteremiaNot available
Clostridium Difficile (C.Diff): Lower Confidence Limit0.015Same as national
Clostridium Difficile (C.Diff): Upper Confidence Limit1.450Same as national
Clostridium Difficile (C.Diff): Patient Days9440Same as national
Clostridium Difficile (C.Diff): Predicted Cases3.402Same as national
Clostridium Difficile (C.Diff): Observed Cases1Same as national
Clostridium Difficile (C.Diff)0.294Same as 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 Rate3.7Same as national329
Death rate for heart attack patients11Same as national65
Death rate for CABG surgery patientsNot available
Death rate for COPD patients9.7Same as national62
Death rate for heart failure patients13Same as national88
Death rate for pneumonia patients14.8Same as national162
Death rate for stroke patients11.5Same as national78
Pressure ulcer rate0.41Same as national1076
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national1370
In-hospital fall-associated fracture rate0.35Same as national1306
Postoperative hemorrhage or hematoma rate2.23Same as national243
Postoperative acute kidney injury requiring dialysis rate1.66Same as national41
Postoperative respiratory failure rate11.60Same as national46
Perioperative pulmonary embolism or deep vein thrombosis rate3.10Same as national247
Postoperative sepsis rate5.14Same as national41
Postoperative wound dehiscence rate1.72Same as national32
Abdominopelvic accidental puncture or laceration rate1.02Same as national143
CMS Medicare PSI 90: Patient safety and adverse events composite0.98Same 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 patients2.9Not available55
Hospital return days for heart failure patients4.1Not available85
Hospital return days for pneumonia patients-13.8Not available172
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)15.2Same as national515
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)12.8Same as national347
Rate of inpatient admissions for patients receiving outpatient chemotherapy9.5Same as national36
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy4.9Same as national36
Ratio of unplanned hospital visits after hospital outpatient surgery1.2Same as national145
Acute Myocardial Infarction (AMI) 30-Day Readmission Rate13.1Same as national55
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients16.5Same as national69
Heart failure (HF) 30-Day Readmission Rate20Same as national85
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate16.3Same as national172

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 rating4379
Doctor communication - star rating4379
Communication about medicines - star rating3379
Discharge information - star rating4379
Cleanliness - star rating4379
Quietness - star rating4379
Overall hospital rating - star rating3379
Recommend hospital - star rating4379
Summary star rating4379

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 volumemedium
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 vaccination681217
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 better188368
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 better187344
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better28411
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better30213
Left before being seen122554
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients94227
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing9911
Appropriate care for severe sepsis and septic shock7370
Septic Shock 3-Hour Bundle10022
Septic Shock 6-Hour Bundle10011
Severe Sepsis 3-Hour Bundle8970
Severe Sepsis 6-Hour Bundle7850
Discharged on Antithrombotic Therapy97102
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 29591
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 Titus Regional Medical Center rated?
Titus Regional Medical Center has a 3 out of 5 CMS overall star rating as of the latest CMS release.
Does Titus Regional Medical Center have emergency services?
Yes. Titus Regional Medical Center operates a 24/7 emergency department.
Where is Titus Regional Medical Center located?
Titus Regional Medical Center is located at 2001 N Jefferson, Mount Pleasant, TX 75455.
What type of hospital is Titus Regional Medical Center?
Titus Regional Medical Center is classified by CMS as a Acute Care Hospitals facility (Government - Hospital District or Authority).

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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