Long-Term Care Survey Alert

Revised survey guidance maps out assessment steps.

To manage urinary incontinence under the new F315 tag requires a mindset adjustment - one that starts with a heads up on how surveyors expect you to assess this common condition.

The new survey guidance for F315 (urinary incontinence/ catheters) was, at press time, set to go into effect on June 27. The Centers for Medicare & Medicaid Services released an advance copy of the final guidance in an April 2005 survey and certification letter.

The bottom line: You must perform a comprehensive assessment of residents' continence status at admission and when they have a change in condition, emphasizes the advance copy of the final survey guidance.

"The clinical staff have to figure out why the resident is incontinent and go to the care plan phase from there," counsels Reta Underwood, president of Consultants for Long Term Care Inc. in Buckner, KY. "The physician documentation should also back up the reason for the resident's incontinence." (Review the types of incontinence defined by the guidance, later in this issure.)

The survey guidance spells out expected assessment parameters in some detail. "Facilities should become familiar with the requirements and then determine the type of assessment tools that will work for their population - and what they will do with that assessment information to formulate [resident-centered] care plans," says nurse attorney Janet Feldcamp with Benesch Friedlander Coplan & Aronoff LLP in Columbus, OH.


Tip: The nursing and interdisciplinary staff should work with the medical director to determine the specific elements of the assessment and who will do what, including the attending physician's or prescribing clinician's part, suggests Feldcamp.

Cover the Basics

The assessment should include a pelvic and rectal exam to check for causes of incontinence, such as prolapsed uterus or bladder, prostate enlargement, significant constipation or fecal impaction, atrophic vaginitis, distended bladder or bladder spasms, according to the advance copy of the final guidelines.

Fecal impaction - a sentinel event and correctable cause of transient urinary incontinence - is on surveyors' radar screen, cautioned Diane Newman, MSN, RNC, FAAN, in a presentation at the March 2005 American Association of Nurse Assessment Coordinators conference in Chicago.

Don't let this happen in your facility: CNAs had been reporting that one resident had very dark urine and back pain, which sounds like an UTI. Turns out that the dark urine was really vaginal discharge resulting from a a vaginal pessary for incontinence. No one knew the resident had the pessary until a nurse practitioner performed a pelvic exam and removed it, according to Newman, who is co-director of the Penn Center for Continence and Pelvic Health in Philadelphia.

Get the 'Rest of the Story'

As part of the assessment, "look closely at the resident's continence level in the previous residential setting (home, assisted living, etc), which may require looking past the acute-care episode leading to nursing home admission," says Feldcamp.

Best practice tip: Once the resident stabilizes from an acute-care stay, staff should keep a "bladder diary" of the person's voiding patterns for at least three days.

The diary tracks the timing, frequency and amounts of urine, including continent and incontinent episodes, according to Newman's presentation. The information can provide invaluable clues about whether a person has urgency or frequency, urinary retention, constant dribbling due to overflow incontinence - or urine leakage that occurs primarily with sudden movement or standing up.

Also find out if the person is aware of the urge to void and can delay voiding, which means he may be a candidate for bladder retraining, advised Newman. If not, the bladder diary can help you individualize a toileting plan that accommodates a cognitively impaired resident's usualvoiding pattern. "Encouraging patients to toilet based on their usual pattern ... is in keeping with CMS' focus on resident-centered care," observes Karen Merk, RN, a clinical consultant with Briggs Corporation in Des Moines, IA.

Some nursing facilities use ultrasound bladder scans as part of the comprehensive continence assessment. For example, the ultrasound scan - which CNAs can be trained to perform - tells the nursing staff how much urine a person's bladder can hold before he has an incontinence episode, says Karen Johnson, RN, director of nursing at Minnewaska Lutheran Home in Starbuck, MN.

Look for Other Impediments

If the resident has impaired ADL functioning, the nurse should  observe the person toilet to identify ways to improve his independence, advised Newman. Also map the paths to every toilet to look for impediments, including lack of a picture symbol to let them know where to go. One facility got tagged when residents told a surveyor that the bathrooms in the halls were locked after 9 p.m. Another facility figured out residents were having toileting accidents (and falls) trying to traverse the rather long distance from the dining room to the closest bathroom.

Tip: Don't forget to consult with the pharmacist about meds that can cause or contribute to incontinence, advised Newman.