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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Nursing Home residents have guaranteed rights. These rights are spelled out in the Code of Federal Regulations at 483.10, 483.12, 483.13, and 483.15. The nursing home must actively promote these rights for all residents, regardless of any barriers the resident may face (such as communication issues or hearing/vision problems, etc.) This also includes residents who may not be competent, for whatever reason, to act upon or decide issues for him/herself.

These rights include the resident’s right to:

  • Exercise his or her rights; (Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility’s rules, as long as those rules do not violate a regulatory requirement) The facility must not hamper, compel, treat differentially, or retaliate against a resident for exercising his/her rights.
  • Be informed about what rights and responsibilities he or she has;
  • If he or she wishes, have the facility manage his personal funds;
  • Choose a physician and treatment and participate in decisions and care planning;
  • Privacy and confidentiality;
  • Voice grievances and have the facility respond to those grievances;
  • Examine survey results;
  • Work or not work;
  • Privacy in sending and receiving mail;
  • Visit and be visited by others from outside the facility;
  • Use a telephone in privacy;
  • Retain and use personal possessions to the maximum extent that space and safety permit;
  • Share a room with a spouse, if that is mutually agreeable;
  • Self-administer medication, if the facility’s interdisciplinary care planning team determines it is safe; and
  • Refuse a transfer from a distinct part, within the institution. (A distinct part is a part of another institution such as a hospital which is used as a nursing facility or skilled nursing facility – surveyors will often refer to this as a D/P SNF [distinct part skilled nursing facility].
  • Have access to current and old clinical records pertaining to him/her and at the community rate for copies.
  • Be fully informed in a language the resident can understand of his/her total health status
  • To be informed in advance of treatments & changes in care
  • To refuse treatment and make an advanced directive (Some state laws will also state that a resident who has the capacity to make a health care decision and who withholds consent to treatment or makes an explicit refusal of treatment either directly or through an advance directive, may not be treated against his/her wishes. In these cases a facility may not transfer or discharge a resident for refusing treatment unless the criteria for transfer or discharge are met. Refusal of treatment does not absolve the facility from providing care. The facility should make a care plan to address the residents refusal and try to address the reasons for the refusal.)

There are circumstances when a surrogate decision maker needs to be involved. But even when a surrogate decision maker is involved if the resident can understand the situation and express a preference, the resident should be informed and his/her wishes respected as much as possible. Remember, though, that the involvement of a surrogate or representative does not automatically relieve a facility of its duty to protect and promote the resident’s interests. For instance, a surrogate decision maker does not have the right to insist that a treatment be performed that is not medically appropriate. Also, state laws may also restrict the right of a surrogate to reject treatment or care for the resident.

This has been a quick review/summary of the information from the regulations related to Residents Rights. These are under F-tags 151 & 154.

Be informed, be safe!


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