HANYS’ Continuing Care
Issues Forum
Nursing Home Surveyor Guidance
for Incontinence and Catheters
Debbie LeBarron, Director
New F Tag 315
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Premise- Urinary incontinence is not normal
aging
Collapses current F Tags 315 and 316
Effective date – June 27, 2005
Contains
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Interpretative Guidance
New Investigative Protocol
Compliance and Severity Guidance
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New F Tag 315
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§483.25(d)(1) - A resident who enters the facility without
an indwelling catheter is not catheterized unless the
resident’s clinical condition demonstrates that
catheterization was necessary; and
§483.25(d)(2) - A resident who is incontinent of bladder
receives appropriate treatment and services to prevent
urinary tract infections and to restore as much normal
bladder function as possible.
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New F Tag 315 Intent
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Each incontinent resident is identified, assessed and
provided appropriate treatment and services to achieve
or maintain as much normal urinary function as
possible;
An indwelling catheter is not used without valid
medical justification;
An indwelling catheter which is not medically justified
is discontinued as soon as clinically warranted;
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New F Tag 315 Intent(cont.)
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Services are provided to restore or improve normal
bladder function to the extent possible, after the
catheter; and •
A resident receives the appropriate care and services to
prevent infections to the extent possible.
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New F Tag 315
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Definitions
Resources
Resident choice
Presence of Advanced Directive
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Urinary Incontinence
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“…resident receives appropriate treatment
and services…”
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Identify resident at-risk-for or with
incontinence
Accurate, thorough assessment
Appropriate, individualized interventions
Monitor effectiveness
Modify plan as necessary
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Urinary Incontinence
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Risk factors
Types of Incontinence
Interventions – physiological and
functional; measured by least to most
invasive
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Catheters
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Resident admitted Without – no catheter until/ unless
clinical condition demonstrates it was necessary
Resident admitted With - comprehensive assessment
should include underlying factors supporting the medical
justification for the initiation and continuing need for
catheter use, determination of which factors can be
modified or reversed (or rationale for why those factors
should not be modified), and the development of a plan for
removal.
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Catheters
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“Because of the risk of substantial
complications with the use of indwelling
urinary catheters, they should be reserved
primarily for short-term decompression of
acute urinary retention.”
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Catheters
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Intermittent- New onset incontinence, from transient
hypo-atonic bladder (e.g.- post Hospital catheter use)
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Until bladder tone returns – up to7 days
As evidenced by voiding trial and post void residual
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Catheters
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Indwelling- Appropriate indications for continuing use of an
indwelling catheter beyond 14 days may include:
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Urinary retention and no treatment
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Documented post void residual (PVR) volumes in a range over
200 milliliters (ml);
Inability to manage the retention/incontinence w/ intermittent
catheterization; and
Persistent overflow incontinence, symptomatic infections,
and/or renal dysfunction.
Contamination of Stage III or IV pressure ulcer w/
impeded healing; and
Terminal illness or severe impairment, with intractable
pain
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Catheters
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Complications
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Must assess/document for risk
Must monitor/document for signs
Bacteriuria and UTIs/Urosepsis
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indwelling catheters for more than 7 days
(>2 to 4 weeks) increases the chances of having a
symptomatic UTI and urosepsis.
Urine C&S from catheterized resident
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Catheters
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Acute UTI (symptomatic/not chronic)
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Lab tests w/ clinical findings
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fever with hematuria
+ urine culture
presence of pyuria or nitrites (indicating the
presence of Enterobacteriaceae).
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UTI
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Indications to treat - No catheter & three of the
following present…
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Fever (increase in temp >2 degrees F (1.1 degrees C) or rectal
temperature >99.5 degrees F (37.5 degrees C) or single
measurement of temperature >100 degrees F (37.8 degrees C)
);14
New or increased burning pain on urination, frequency or
urgency;
New flank or suprapubic pain or tenderness;
Change in character of urine (e.g., new bloody urine, foul
smell, or amount of sediment) or as reported by the laboratory
(new pyuria or microscopic hematuria); and/or
Worsening of mental or functional status (e.g., confusion,
decreased appetite, unexplained falls, incontinence of recent
onset, lethargy, decreased activity).
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UTI
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Indications to treat – w/ catheter & two of the following
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Fever or chills;
New flank pain or suprapubic pain or tenderness;
Change in character of urine (e.g., new bloody urine, foul
smell, or amount of sediment) or as reported by the laboratory
(new pyuria or microscopic hematuria); and/or
Worsening of mental or functional status.
Local findings such as obstruction, leakage, or mucosal trauma
(hematuria) may also be present.
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UTI Follow up
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Recurrent UTIs
Predisposing Factors
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structural abnormalities - a referral to a
urologist
poor perineal hygiene
PRIMARY - reconsider the relative risks
and benefits of continuing the use of an
indwelling catheter.
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Investigative Protocol
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Objectives
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To determine whether the initial insertion or continued
use of an indwelling catheter is based upon clinical
indication for use of a urinary catheter;
To determine the adequacy of interventions to prevent,
improve, and/or manage urinary incontinence; and
To determine whether appropriate treatment and
services have been provided to prevent and/or treat
UTIs.
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Investigative Protocol
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Process - for a sampled resident with an
indwelling urinary catheter or for a resident
with urinary incontinence.
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Observation
Interviews
Record Review
Interviews with Health Care Practitioners and
Professionals
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Investigative Protocol
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Observation
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Staff Understanding and Implementation of
care plan
Delivery of care – Infection Control/Skin Care
Staff approach/resident dignity & privacy
Awareness of complications >observations
>reporting
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Investigative Protocol
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Interviews - resident, family or responsible
party about….
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Care plan development
Education and involvement in care
Awareness of resident issues/illnesses/response
to care
Staff accommodations to need for resident
changes to plan
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Investigative Protocol
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Record Review
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Assessment and Evaluation.
Care Plan.
Care Plan Revision.
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Investigative Protocol
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Surveyors: Do interviews with Health Care
Practitioners and Professionals…
“If inconsistencies in care or potential
negative outcomes have been identified, or
care is not in accord with standards of
practice, interview the nurse responsible for
coordinating or overseeing the resident’s
care.”
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For the Nurse Overseeing Care
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For inconsistencies…
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How the staff monitor use of the care plan, changes in
continence, skin condition, and the status of UTIs;
If the resident resists toileting, how staff have been
taught to respond;
Types of interventions that have been attempted to
promote continence (i.e., special clothing, devices,
types and frequency of assistance, change in toileting
schedule, environmental modifications);
If the resident is not on a restorative program, how it
was determined that the resident could not benefit from
interventions such as a scheduled toileting program;
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For the Nurse Overseeing Care
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For resident on toileting program…
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type of incontinence;
interventions to address that specific type;
How it is determined that the schedule and program is
effective (i.e., how continence is maintained or if there
has been a decline or improvement in continence, how
the program is revised to address the changes); and
Whether the resident has any physical or cognitive
limitations that influence potential improvement of
his/her continence;
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For the Nurse Overseeing Care
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For residents with urinary catheters,
whether the nursing staff:
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Can provide appropriate justification for the use
of the catheter;
Can identify previous attempts made (and the
results of the attempts) to remove a catheter;
Can identify a history of UTIs (if present), and
interventions to try to prevent recurrence.
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Investigative Protocol
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Surveyors: Do interviews with Health Care
Practitioners and Professionals…
Interventions/care inconsistent with recognized
standards of practice interview one or more health
care practitioners and professionals as necessary
(e.g., physician, charge nurse, director of nursing)
who, by virtue of training and knowledge of the
resident, should be able to provide information
about the causes, treatment and evaluation of the
resident’s condition or problem.
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For the Physician, Medical Director,
Charge Nurse or DoN
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Depending on the issue, ask about:
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How it was determined that the chosen interventions
were appropriate;
Risks identified for which there were no interventions;
Changes in condition that may justify additional or
different interventions; or how they validated the
effectiveness of current interventions; and
How they monitor the approaches to continence
programs
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F Tag Non-Compliance
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Areas of Evaluation
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Indwelling catheter upon or after admission
Incontinence
Symptomatic UTI
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Failure to …
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Prevent or improve incont.
Medically justify/care for catheter
Assess/Prevent/Rx UTI
Assess Resident Continence status
Identify/address Risk Factors
Implement interventions
Clinically justify
Manage symptomatic UTIs
Manage Indwelling Catheters
Follow relevant policies and procedures
Notify Physician
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Potential Additional Tags
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F157, Notification of Changes
F241, Dignity
F272, Comprehensive Assessments
F279, Comprehensive Care Plans
F280, Comprehensive Care Plan Revision
F281, Services Provided Meet Professional
Standards
F309, Quality of Care
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Potential Additional Tags
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F312, Quality of Care
F385, Physician Supervision
F444, Infection Control: Hand Washing
F498, Proficiency of Nurse Aides
F353, Sufficient Staff
F501, Medical Director
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Severity Determination
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Elements
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Presence of HARM
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Incontinence not result of clinical condition
Complications of catheters
Complications of incontinence
Negative changes in Psychosocial func.
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Severity Determination
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Elements
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Degree of HARM
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Occurred
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Serious injury, impairment, death, discomfort
Not yet occurred
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Potential for…
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Severity Determination
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Immediacy of Correction
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Level 4
Level 3
Level 2
Level 1 – not an option for this requirement
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Resources
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Survey and Certification letter
http://www.cms.hhs.gov/medicaid/surveycert/sc0523.pdf
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