Kelly’s Regulatory Corner 

This month let’s review F690 Bowel/Bladder Incontinence. This article is a long one because there is a lot tied to this regulation. The regulation states that providers are responsible for ensuring that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence, unless his/her clinical condition is/becomes such that it is no longer possible to maintain continence.

For residents with urinary incontinence:

If a resident has urinary incontinence, the facility must provide services based on the resident’s comprehensive assessment which ensure that:

• A resident who is admitted with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible, unless the resident’s clinical condition necessitates continued catheterization.
• A resident who is incontinent of bladder receives appropriate care and services to prevent urinary tract infections (UTIs) and, to the extent possible, restore continence.

Related to indwelling catheters, the regulatory intent is to ensure that an indwelling catheter is not used unless there is a valid medical justification for catheterization and that use is discontinued as soon as it is clinically warranted.

For residents with fecal incontinence:

• Providers are responsible for ensuring a resident with fecal incontinence receives appropriate treatment and services to restore as much normal bowel function as possible, based on the resident’s comprehensive assessment.

Types of Urinary Incontinence

Understanding the nature of incontinence helps with assessment and identification of appropriate interventions. Here are some common types of urinary incontinence:

• Urge Incontinence is the most common cause of urinary incontinence in older adults. It is associated with detrusor muscle over activity (excessive contraction of the smooth muscle in the wall of the urinary bladder) resulting in a sudden, strong urge (also known as urgency) to expel moderate to large amounts of urine before the bladder is full). The resident can feel the need to void, but is unable to inhibit voiding long enough to reach and sit on the commode.
• Stress Incontinence is the second most common type of urinary incontinence in older women. It is associated with impaired urethral closure (malfunction of the urethral sphincter), which allows small amounts of urine leakage when pressure on the bladder is increased. This can occur when laughing, standing from a sitting position, sneezing or laughing.
• Mixed Incontinence is a combination of the above types of incontinence. Many older adults, especially women, may experience both stress and urge incontinence symptoms.
• Overflow Incontinence may mimic urge or stress incontinence, but is less common than either of those types of incontinence. It is associated with leakage of small amounts of urine when the bladder has reached its maximum capacity and has become distended due to urinary retention. Symptoms may include weak stream, hesitancy, intermittency, nocturia, incomplete voiding, constant dribbling or dysuria. There are multiple factors that can contribute to this form of incontinence.
• Transient Incontinence is related to a potentially improvable or reversible cause. It is temporary or occasional incontinence that could be due to many causes, including infection, delirium, atrophic urethritis or vaginitis, restricted mobility, increased urine production or some medications.
• Functional Incontinence occurs when an individual whose urinary tract function is sufficiently intact that he/she should be able to maintain continence, but loss of urine occurs due to external factors. This may be due to staff response to a request for toileting assistance or the resident’s inability to utilize the toilet in time. Other possible contributing factors include poor physical weakness or poor mobility/dexterity, cognitive problems, medications or environmental impediments.

Example Survey Citation – F690 S/S: D

An alert and oriented resident who required staff assistance for ADL care did not receive morning care during the 7-3 shift until 12:15 because no CNA had been assigned to provide care to the resident. The surveyor observed the resident in bed, visibly upset and loudly saying that no one took care of them that morning. There was a strong urine odor in the room.
Admission/Readmission

As part of the comprehensive assessment, the resident’s continence status needs to be addressed on admission and whenever there is a change in status.

So . . . the resident is continent- are you done? No. You need to determine if and how much assistance is needed to get to the toilet – this is an area that can get you into trouble.

Surveyors are directed to observe for actual or potential harm as well as to observe for visual cues of psychosocial harm and distress:

• A resident who is continent but due to temporary functional limitations (i.e., recent TKR) needs assistance to the bathroom. The resident soils him/herself because staff do not respond to their call bell on a timely basis.
• A male resident uses a urinal. Staff leave it in the bathroom after emptying and the resident soils himself.
• A resident who is continent of urine asks to be assisted to the bathroom, but staff instead encourage them to “just go in the diaper.”
• Although many residents have used absorbent products prior to admission to the nursing home and the use of absorbent products may be appropriate, absorbent products should not be used as the primary long-term approach to continence management until the resident has been appropriately evaluated and other alternative approaches have been considered.

Any changes in status should be addressed when they occur and not wait for a routinely scheduled assessment i.e., resident previously continent is noted with episodes of incontinence, foley catheter removal.

Many tools do not capture all areas that should be considered in addressing urinary continence:

• The resident’s prior history of bladder functioning – i.e., were they continent prior to hospitalization?
• Pertinent diagnosis – DM, CHF, CVA
• Voiding patterns – i.e., frequency, nocturnal voiding
• Medication use – i.e., diuretics, narcotics
• Patterns of fluid intake i.e., consider limiting fluids after a certain hour
• Use of stimulants/irritants – caffeine
• Physical exam – enlarged prostate, prolapsed uterus
• Functional and cognitive needs – manual dexterity, need for task segmentation, pain
• Environmental factors – lighting, distance to the bathroom, use of bedside commodes
• Potential/actual skin breakdown

Interventions

Interventions need to be resident-specific, so an accurate and comprehensive assessment is needed to ensure all elements are addressed. Make sure there is monitoring of the interventions put in place – Are we following the plan of care? Some things to thing about:

• Behavioral programs such as bladder rehab/bladder retraining, pelvic floor muscle rehab require the resident’s cooperation and motivation.
• Prompted voiding and scheduled voiding are more staff-directed programs rather than dependent on resident function. Scheduled voiding is not considered to be a bladder retraining /rehab program.
• Proper sizing of products may impact on potential for skin breakdown i.e., blister formation.
• It is important that residents using absorbent products be checked (and changed as needed) on a schedule based upon the resident’s voiding pattern, professional standards of practice, and the manufacturer’s recommendations. Products may contain urine but checks and changes are still needed due to an increased risk of MASD.
• Intermittent catheterization may be an appropriate intervention for some residents. If the resident self-performs the task, make sure there is documentation to support ongoing ability and use of acceptable infection control practices.

Catheter Use

As previously noted, a resident who enters the facility without an indwelling catheter should not be catheterized unless the resident’s clinical condition demonstrates that this catheterization was necessary. If a resident enters the facility with an indwelling urinary catheter or subsequently has a catheter inserted, he/she is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary.

If a resident arrives at your facility with a catheter in place, it needs to be determined if continued use of the catheter is medically necessary. Supportive documentation by a urologist is the best acknowledgement of need. Documentation in the resident’s record must reflect the attending practitioner’s valid clinical indication to support the use of an indwelling catheter. This is because indwelling catheter use can be associated with various complications – especially UTI, as well as:

• Bacteremia
• Sepsis, pyelonephritis or chronic renal inflammation due to urinary tract infections
• Bladder stones
• Febrile episodes
• Fistula formulation
• Epididymitis
• Urethra erosion

Things to Think About

• Many facilities discontinue foley catheters the morning after admission unless medical necessity is clearly documented in the record.
• Monitoring of the resident post catheter removal should always be evident in the record.
• The ongoing use of a catheter may increase the risk of urinary tract infections including sepsis and may impact negatively on independence and dignity (don’t forget those privacy bags).
• A catheter should never remain in place for the purpose of specimen collection or convenience.

As far as documentation goes, the regulation spells out what needs to be included:

• How and when the resident/representative was involved and informed of care and treatment including the potential use and indications for the need for a catheter, how long use is anticipated, and when and why a catheter must be removed.
• Evidence that the resident/ representative was included in the development of the care plan, including the use of the catheter and associated interventions. Don’t forget – the resident/representative has the right to decline the treatment.
• Education of the resident/representative on the identification of risks and benefits for the use of a catheter. Also remember – the resident/ representative may choose to continue a catheter even if there is no clinical indication for use. If this occurs, the counseling provided by the physician and staff must be documented and this education/counseling should be periodically done while the catheter is in place.
• Physician’s valid clinical indication to support use of the catheter.

Example Survey Citation – F690 S/S: G (Actual Harm)

A resident was observed during survey to have an indwelling catheter draining dark urine. Review of the resident’s record found that the resident did not have a physician’s order, assessment or care plan for indwelling catheter use. The surveyor reviewed the resident’s TAR and identified there was a physician’s order on admission that if the patient has not voided during the shift, bladder scan and straight catheterize patient if retaining 300ml or more of urine. There were no notations on the TAR that a bladder scan or straight catheter use were done for the first ten days of admission however, there was a nursing progress note indicating that on the date of admission, the resident did not void so an indwelling catheter was inserted. There was no documentation that a bladder scan had been performed. Ten days later, the resident was transferred to the hospital after red blood was observed in the catheter bag and the resident stated he felt lightheaded and dizzy. There was no documentation indicating the date when the catheter had been inserted prior to the hospital transfer. The catheter remained in the resident after readmission for another two weeks, when it was observed by the surveyor. There are a number of issues here related to the facility’s practices related to catheter use, including the lack of evidence of nurse to physician communication.

Review Your Practices

• Do all staff members responsible for catheter insertion and/or catheter care have a current competency on file?
• Do you have a system in place to monitor follow-up visits for urology consults?
• Do orders and care plans capture the correct rationale for use/size of the catheter?
• Do MD progress notes include the reason for use and ongoing evaluation of use of the catheter? (It should be addressed in monthly/bimonthly comprehensive notes as well as on an interim basis.)
• Is the use of catheter/any precautionary measures noted on the caregiver assignment?
• Does nursing documentation reflect the resident’s response to the catheter?
• Is catheter care noted on the POC task/documented?

Urinary Tract Infection (UTI)

Let’s discuss one of the biggest issues related to UTIs – antibiotic use. Just because an individual has non-specific symptoms that could be related to a UTI, such as cloudy or foul-smelling urine, change in mental status, change in function or bacteriuria, the rule of thumb should not be to treat with antibiotics. The resident’s physician is expected to thoroughly evaluate and assess the resident to ensure use of an antibiotic is indicated.

Per the Interpretive Guidance in Appendix PP:

• For a non-catheterized resident with symptoms associated with a UTI, the attending practitioner should order a urine culture prior to the initiation of antibiotic therapy to help guide treatment.
• If the resident has a long-term indwelling urethral catheter, a specimen should be obtained from a freshly placed indwelling catheter.
• Post-treatment urine culture is not always necessary but may be helpful if the resident’s signs/symptoms of a UTI continue or do not respond to treatment with antibiotics.
• Continued bacteriuria without residual symptoms does not warrant repeat or continued antibiotic therapy.

It is important – including for Antibiotic Stewardship reasons – that UTIs are not treated unnecessarily with antibiotics. This can lead to the development of multi-drug resistant organisms (MDROs) and other complications which can pose a threat of infection to other residents or result in the resident potentially being hospitalized.

Recurrent UTIs

If an individual has two or more UTIs in a 6-month period, this is considered recurrent UTI. The guidance at F690 differs for individuals who are catheterized versus those who are not.

Non-catheterized individual

• When there is recurrent UTI, this may need to be evaluated further for issues such as a prolapsed bladder, tumors or enlarged prostate.

Catheterized individual

Recurrent UTIs should be reviewed to determine:

• If there is possible impairment of free urine flow through the catheter
• The need to reevaluate the techniques being used for catheter care and for perineal hygiene, including the proper technique to use for removal of fecal soiling
• The relative risks and benefits of continuing the use of an indwelling catheter

Please note — Changing catheters or urinary drainage bags at fixed intervals is not recommended.

Things to Think About

• Are your residents receiving sufficient fluids? The resident may need to be assessed for fluid needs and a fluid management program.
• Are your urine C&S results indicating contamination? Make sure staff are competent in specimen collection. When was the last time catheterization competencies were completed?
• Staff also need to ensure that the resident is kept clean of feces to minimize the potential for bacterial migration into the urethra and bladder. Are your staff completing checks of their assigned residents as per the plan of care and providing necessary brief changes accompanied with proper incontinence care?

Take a look at your catheters – literally.

• Are staff maintaining standard precautions? Don’t forget – the facility is expected to show that it employs appropriate infection prevention and control practices related to catheters.
• Are the bags in direct contact with the floor? This is routinely cited during a compliance survey – and something we see on most mock surveys. It’s a “gotcha” deficiency and is avoidable.
• Is the tubing looped? Have the potentially negative outcomes such as reduced flow rate, looping being a contributing cause of bacteriuria and urinary tract infection been discussed with staff?
• When residents are being transferred, do staff maintain the catheter bag below the level of the bladder? How often is the catheter drainage bag & excess tubing placed on the resident’s stomach by your staff so that the tubing doesn’t get pulled? When did you last do transfer competencies for a resident with a urinary catheter?

Fecal Incontinence

Let’s start with a review of some definitions:

Passive incontinence —the involuntary discharge of fecal matter or flatus without any awareness. This suggests a loss of perception and/or impaired recto anal reflexes, either with or without sphincter dysfunction.

Urge incontinence — the discharge of fecal matter or flatus despite active attempts to retain these contents. Here there is a predominant disruption of the sphincter function or the rectal capacity to retain stool.

Fecal seepage — the undesired leakage of stool, often after a bowel movement with otherwise normal continence and evacuation. This condition is mostly due to incomplete evacuation of stool and/or impaired rectal sensation. The sphincter function and pudendal nerve function are mostly intact.

Just as bladder incontinence needs to be assessed, fecal incontinence (FI) needs to be addressed as a part of the comprehensive resident assessment. There are many potential causes of fecal incontinence, including diarrhea, nerve damage, hemorrhoids or rectal prolapse. Since FI can create dignity concerns and loss of independence for a resident, it is important to attempt for the resident’s quality of life that attempts to address this incontinence are attempted. The IG notes that increased fiber consumption, use of medications to develop more solid stools and even pelvic floor exercises can improve bowel control. Are you using nutritional interventions as well as educating the resident on how to do pelvic floor exercises?  Do you even think about incorporating these interventions into the resident’s plan of care?

The resident’s plan of care should focus on enhancing the resident’s dignity and reducing potential embarrassment related to FI. The IG lists both emotional and physical complications related to fecal incontinence, including:

• Loss of self-esteem
• Social isolation
• Skin irritation/excoriation
• Pain
• Itching

Staff usually have a pretty good understanding of the physical complications, but they would likely benefit from a review of potential dignity and emotional concerns associated with FI.  Remember the evaluation of psychosocial harm to a resident is a component of the survey process. Lastly, the assessment and treatment plan for FI should also include infection control measures, including the appropriate use of personal protective equipment (PPE).

Kelly Dines
VP of Clinical Operations