Pateint Safety is important in the nursing home, hospital and any healthcare facility. Nursing Home and Hospital Surveyors do look at patient safety as they do surveys and investigations in those healthcare facilities. Processes change as we become more knowledgable about healthcare issues. Here is a historical look at scientific improvements over the last 2,000 years related to patient safety, the lack of which happens to be the 5th leading cause of death in the United States.

The Evolution of Patient Safety
Source: Accelerated Nursing Degrees

Remember, you must be your own advocate in order to stay safe in a healthcare facility.



One thing that is becoming more prevalent is healthcare consumers becoming more aware. The Internet has a wealth of information for consumers, and  sorting through and making use of that information is how each of us can be more active in directing our own healthcare. Healthwatch MD put out a video on the concept of patient as part of the healthcare team. No longer is the team just the doctor and nurses, now it is everyone, doctors, nurses, social workers, clergy, therapists, family and patients, to name just a few. Take a few moments to watch Dr. Leigh Hamby, chief medical officer for Piedmont Healthcare, discuss this concept.

Hospital Safety: You are Part of Your Healthcare Team

Remember, to be your own advocate!


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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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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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