In the previous posts we started talking about how nursing home and hospital surveyors investigate issues surrounding incontinence in nursing homes. I continue that discussion here.

Another element to investigations is interviews.

Interviews: During the review and investigation the surveyor will be conducting interviews with the resident, family or responsible party when possible. These interviews will help identify:

  1. Involvement in care plan development including defining the approaches and goals, and whether interventions reflect preferences and choices;
  2. Awareness of the existing continence program and how to use devices or equipment;
  3. If timely assistance is provided as needed for toileting needs, hydration and personal hygiene and if continence care and/or catheter care is provided according to the care plan;
  4. If the resident comprehends and applies information and instructions to help improve or maintain continence;
  5. The presence of urinary tract-related pain, including causes and management;
  6. If interventions were refused, whether consequences and/or other alternative approaches were presented and discussed; and
  7. Awareness of any current Urinary Tract Infections (UTI), history of UTIs, or perineal skin problems.


Interviews of the nursing assistants will be conducted to determine if they:

  1. Are aware of, and understand, the interventions specific to this resident (such as the bladder or bowel restorative/management programs);
  2. Have been trained and know how to handle catheters, tubing and drainage bags and other devices used during the provision of care; and
  3. Know what, when, and to whom to report changes in status regarding bowel and bladder function, hydration status, urine characteristics, and complaints of urinary-related symptoms.

It is best for the nursing home surveyor to interview the direct care staff first rather than the Director of Nursing or other administrative staff. This allows the surveyor to see if the “front-line” staff, who provide the care, are knowledgeable about what is needed for each resident. The physician, medical director, charge nurse, director of nursing, and other administrative staff can be interviewed also, but many times the most valuable interviews come from the direct care staff.

We will continue this in the next post.

Be safe and informed!


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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!


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When surveying in a nursing facility, the Nursing Home Surveyor looks at specific issues. One of the most common issues a surveyor will look at is the continence status of a resident and the care the facility provides to residents related to continence. The nursing home surveyors use the regulations and guidance located in Appendix PP of the SOM at F315 (483.25(d)).

The regulation states: Based on the resident’s comprehensive assessment, the facility must ensure that —

  • 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.

The intent of this set of requirements is to ensure that:

  • Each resident who is incontinent of urine 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 unless there is valid medical justification;
  • An indwelling catheter for which continuing use is not medically justified is discontinued as soon as clinically warranted;
  • Services are provided to restore or improve normal bladder function to the extent possible, after the removal of the catheter; and
  • A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible.


The skilled nursing facility survey process, for both a regular survey as well as a complaint investigation survey, for incontinence issues is 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/or to determine whether appropriate treatment and services have been provided to prevent and/or treat Urinary Tract Infections.

When looking at the appropriateness of the use of an indwelling catheter or the adequacy of the facility’s care of a patient with urinary incontinence, the nursing home surveyor will review the “resident assessment”. The surveyor will also review the resident’s care plan and the physician orders in order to see what interventions the facility has planned to put into place. This review will help the nursing home surveyor know what observations he or she should make for that resident.

The facility staff are expected to assess and provide appropriate care from the day of admission, for residents with urinary incontinence or a condition that may contribute to incontinence or the presence of an indwelling urinary catheter. The surveyor will, therefore, corroborate the observations made by conducting interviews with the resident, staff, and family members or visitors. The surveyor will also look at the clinical record of the patients/residents.

The guidelines CMS has provided gives a suggested list of actions the surveyor should take when reviewing this issue for a resident. The list is not exhaustive, though, and there are often other avenues to explore. We will discuss that list in the next few posts.

Be safe and be informed!


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The staging system is one way of summarizing certain characteristics of pressure ulcers, including the extent of tissue damage. The best definitions for the stages of pressure ulcers are from the National Pressure Ulcer Advisory Panel. You will find much more information about Pressure Ulcers at their website. Nursing home and hospital surveyors will use this staging system as they look at pressure sores during a survey.

Stage I is a change in normal intact skin. The change can be seen and is a result of pressure on the skin. Some of the changed signs are: skin temperature (warmth or coolness); tissue consistency (firm or boggy); Sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Many times Stage I pressure ulcers may be difficult to identify because they are not readily visible and they present with greater variability. Advanced technology (not commonly available in nursing homes) has shown that a Stage I pressure ulcer may have minimal to substantial tissue damage in layers beneath the skin’s surface, even when there is no visible surface penetration. The Stage I will generally persist even after the pressure on the area has been removed for 30-45 minutes.

In Stage II part of the skin is lost. The ulcer is superficial and looks like an abrasion, blister, or shallow crater.

In Stage III there is skin loss involving damage to subcutaneous tissue that may extend down to, but not through, underlying tissues covering the muscle. It looks like a deep crater.

A Stage IV has extensive skin loss with destruction and/or tissue necrosis (dead tissue), or damage to muscle, and bone.

Although it may be difficult, it is important that you, as well as the nursing home and hospital surveyors, know about these stages and that you help to monitor your loved one for signs of a pressure ulcer. Prevention is the best thing, but if your loved one develops a pressure ulcer whether in a hospital, nursing home, or at home, check out the information available on the Internet and learn all you can about Pressure Ulcers. Learn what acceptable treatments there are, and then question the staff as to what treatment is being provided to your loved one. Ask questions and be proactive. In addition, report it to the local licensing and certification agency so an investigation can be conducted by a nursing home and hospital surveyor.

Be safe and be informed!


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