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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!

JL

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Some residents have many risk factors for developing pressure ulcers. The nursing home has the responsibility to identify and evaluate these risk factors. They must then develop interventions to address the risk factors so a pressure ulcer does not develop. When you become involved with your loved ones care in a nursing home, you too should be aware of these risk factors, and ensure the staff are aware of any that your loved one has. Some of the risk factors include:

  • Impaired/decreased mobility and decreased functional ability;
  • Medical conditions, such as end stage renal disease, thyroid disease or diabetes mellitus;
  • Drugs such as steroids that may affect wound healing;
  • Impaired blood flow
  • Resident refusal of some aspects of care and treatment;
  • Cognitive impairment;
  • Exposure of skin to urinary and fecal incontinence;
  • Poor nutrition, malnutrition, and hydration deficits; and
  • A history of a healed pressure ulcer and its stage [if known] is important, since areas of healed Stage III or IV pressure ulcers are more likely to have recurrent breakdown.
  • Diabetic Neuropathy
  • An acute illness such as an upper respiratory infection, pneumonia, or congestive heart failure

Not all the risk factors can be modified or changed and some of those that can be changed, such as poor-nutrition, take time to be corrected even when there is immediate identification of the risk and appropriate interventions established. On the other hand, some risk factors can be removed promptly, such as pressure on a site.

A Nursing Home Surveyor will look to see if the nursing home staffs who are responsible for the resident’s care review each risk factor and its potential cause(s). They should identify those risk factors that increase the potential for pressure ulcers. The nursing home staff needs to decide what factor(s) can be modified, stabilized, or removed. Then the staff should determine what protocols need to be implemented for each individual resident.

Be safe and be informed!

JL

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A pressure ulcer can occur wherever circulation to the tissues of the body has been compromised by pressure. The staff in a nursing home must identify the individual resident at risk for developing pressure ulcers. The staff must also identify and evaluate each resident’s risk factors and changes in the resident’s condition. They must identify and evaluate factors that can be removed or modified and they must implement interventions to attempt to stabilize, reduce, or remove underlying risk factors. These interventions are to be individualized to each resident’s needs. The staff must monitor the impact of the interventions that were developed and then change or adjust the interventions if they don’t work and when they need to be modified. The nursing home staff must recognize and evaluate each resident’s risk factors and identify and evaluate all areas at risk of constant pressure.

In order to do this the nursing home should have a complete assessment program for an effective pressure ulcer prevention and treatment program. A comprehensive individual evaluation helps the facility to identify residents at risk of developing pressure ulcers, identify the level and nature of risk(s), and identify the presence of pressure ulcers. The nursing home can then use the information to develop and implement a comprehensive care plan that reflects each resident’s identified needs.

A Nursing Home Surveyor will look for a system or process to assure: assessments and interventions are appropriate, timely, implemented, monitored, and changed as needed. They will look for a process that ensures any change in condition is recognized, evaluated, reported to the doctor or Nurse Practitioner, and that the change is addressed. In addition, the Nursing Home Surveyor will look to see if the quality assessment and assurance committee helps the nursing home in the development and monitoring of processes and ensuring they follow accepted standards of practice.

Be safe and be informed!

JL

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