HANYS’ Continuing Care Issues Forum

1. HANYS’ Continuing Care Issues Forum Nursing Home Surveyor Guidance for Incontinence and Catheters Debbie LeBarron, Director

2. New F Tag 315 • Premise- Urinary incontinence is not normal aging • Collapses current F Tags 315 and 316 • Effective date – June 27, 2005 • Contains • Interpretative Guidance • New Investigative Protocol • Compliance and Severity Guidance

3. New F Tag 315 • §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.

4. New F Tag 315 Intent • 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;

5. New F Tag 315 Intent(cont.) • 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.

6. New F Tag 315 • Definitions • Resources • Resident choice • Presence of Advanced Directive

7. Urinary Incontinence • “…resident receives appropriate treatment and services…” • Identify resident at-risk-for or with incontinence • Accurate, thorough assessment • Appropriate, individualized interventions • Monitor effectiveness • Modify plan as necessary

8. Urinary Incontinence • Risk factors • Types of Incontinence • Interventions – physiological and functional; measured by least to most invasive

9. Catheters • 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.

10. Catheters • “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.”

11. Catheters • Intermittent-New onset incontinence, from transient hypo-atonic bladder (e.g.- post Hospital catheter use) • Until bladder tone returns – up to7 days • As evidenced by voiding trial and post void residual

12. Catheters • Indwelling-Appropriate indications for continuing use of an indwelling catheter beyond 14 days may include: • Urinary retention and no treatment • 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

13. Catheters • Complications • Must assess/document for risk • Must monitor/document for signs • Bacteriuria and UTIs/Urosepsis • 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

14. Catheters • Acute UTI (symptomatic/not chronic) • Lab tests w/ clinical findings • fever with hematuria • + urine culture • presence of pyuria or nitrites (indicating the presence of Enterobacteriaceae).

15. UTI • Indications to treat -No catheter & three of the following present… • 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).

16. UTI • Indications to treat – w/ catheter & two of the following • 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.

17. UTI Follow up • Recurrent UTIs • Predisposing Factors • 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.

18. Investigative Protocol • Objectives • 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.

19. Investigative Protocol • Process - for a sampled resident with an indwelling urinary catheter or for a resident with urinary incontinence. • Observation • Interviews • Record Review • Interviews with Health Care Practitioners and Professionals

20. Investigative Protocol • Observation • Staff Understanding and Implementation of care plan • Delivery of care – Infection Control/Skin Care • Staff approach/resident dignity & privacy • Awareness of complications >observations >reporting

21. Investigative Protocol • Interviews - resident, family or responsible party about…. • 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

22. Investigative Protocol • Record Review • Assessment and Evaluation. • Care Plan. • Care Plan Revision.

23. Investigative Protocol • 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.”

24. For the Nurse Overseeing Care • For inconsistencies… • 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;

25. For the Nurse Overseeing Care • For resident on toileting program… • 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;

26. For the Nurse Overseeing Care • For residents with urinary catheters, whether the nursing staff: • 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.

27. Investigative Protocol • 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.

28. For the Physician, Medical Director, Charge Nurse or DoN • Depending on the issue, ask about: • 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

29. F Tag Non-Compliance • Areas of Evaluation • Indwelling catheter upon or after admission • Incontinence • Symptomatic UTI

30. Failure to … • 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

31. Potential Additional Tags • 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

32. Potential Additional Tags • F312, Quality of Care • F385, Physician Supervision • F444, Infection Control: Hand Washing • F498, Proficiency of Nurse Aides • F353, Sufficient Staff • F501, Medical Director

33. Severity Determination • Elements • Presence of HARM • Incontinence not result of clinical condition • Complications of catheters • Complications of incontinence • Negative changes in Psychosocial func.

34. Severity Determination • Elements • Degree of HARM • Occurred • Serious injury, impairment, death, discomfort • Not yet occurred • Potential for…

35. Severity Determination • Immediacy of Correction • Level 4 • Level 3 • Level 2 • Level 1 – not an option for this requirement

36. Resources • Survey and Certification letter http://www.cms.hhs.gov/medicaid/survey-cert/sc0523.pdf