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I mentioned in Part I that CMS has guidelines for the Nursing Home Surveyor. We started discussing these guidelines, and the list of actions CMS expects a surveyor to take when investigating urinary incontinence issues in a nursing home. The first of these expectations is the need to do observations in a nursing home.

During the review and investigation during a survey or a complaint, the nursing home surveyor will be observing whether the facility staff implement the interventions indicated in the plan of care for that resident. The interventions need to be consistent and on all shifts and days. When needed, nursing home surveyors will go into the facility on “off-hours”, meaning during the evening and night shifts or during the weekend, in order to look at issues over all time frames. While making observations of the interventions, the nursing home surveyors will take note of and follow up on deviations from the plan of care or from current standards of practice, as well as potential negative outcomes.

Some observations made by the nursing home surveyor include whether staff make appropriate resident accommodations consistent with the assessment, such as placing the call bell within reach and responding to the call bell, in relation to meeting toileting needs; maintaining a clear pathway and ready access to toilet facilities; providing (where indicated) elevated toilet seats, grab bars, adequate lighting, and assistance needed to use devices such as urinals, bedpans and commodes. The nursing home surveyors will observe whether assistance is provided to try to prevent incontinence episodes, such as whether prompting, transfer, and/or stand-by assist to ambulate are provided for each resident who needs that type of assistance for toileting.

For some residents their assessment indicates they have the potential to regain some degree of continence. For those residents who are put on a program to restore continence the nursing home surveyor will gather information on the frequency of breakthrough or transient incontinence, how staff respond to the resident’s incontinence episodes, and whether the staff provide care in accord with current accepted standards of practice (including infection control practices). The nursing home investigator will also see if the staff provide care with respect for the resident’s dignity.

After the staff does a clinical assessment, some residents are found to be unable to participate in a program to restore continence or in a scheduled toileting program. These residents require care due to incontinence of urine. For these residents, the nursing home surveyor will see if the staff put the resident on a regularly scheduled check and change program, which is matched to the resident’s voiding pattern. (The nursing home staff should be determining what that pattern is. As you can imagine, people don’t all go to the bathroom at the same time; everyone has his or her own pattern.) The nursing home surveyors will check to see whether the nursing home staff check and change residents in a timely fashion.

If a resident has an incontinent episode the surveyor will observe a variety of things such as:

  1. the condition of the pads/sheets/clothing (a delay in providing continence care may be indicated by brown or yellowish rings/circles, saturated linens/clothing, odors, etc.),
  2. the resident’s physical condition, (such as the integrity of the skin, openings, rashes, redness, erosion, etc.,
  3. the psychosocial outcomes which could include such things as embarrassment or expressions of humiliation, or resignation about being incontinent,
  4. whether the nursing home staff provide appropriate hygiene measures including cleansing, rinsing, drying and applying protective moisture barriers or barrier films to try to prevent skin breakdown from prolonged exposure of the skin to urine, and
  5. the staff’s response to the resident’s incontinence episodes. All of the care provided by the nursing home staff should be consistent with current accepted standards of practice (including infection control practices) and with respect for the resident’s dignity.

Some residents end up with an indwelling catheter. In these cases the nursing home surveyor will be observing the care to evaluate:

  1. Whether staff use appropriate infection control practices regarding hand washing, catheter care, tubing, and the collection bag;
  2. Whether staff recognize and assess potential evidence of symptomatic Urinary Tract Infections or other related changes in urine condition;
  3. How staff manage and assess urinary leakage from the point of catheter insertion to the bag;
  4. How the staff assess and manage any catheter-related pain;
  5. What interventions the staff use to prevent inadvertent catheter removal or tissue injury from dislodging the catheter.

All residents who have continence have an indwelling or intermittent catheter should be well hydrated (i.e. receive enough fluids). To look at this the nursing home surveyor will observe to ensure enough fluids are provided and encouraged.

We will continue this discussion of urinary incontinence and how a nursing home and hospital surveyor looks at it.

Be safe and be informed!

JL

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