As mentioned in the other posts talking of this issue, CMS has guidance in the SOM for nursing home surveyors to follow. The third piece of the investigation is the review of the resident’s record and other facility documents. The nursing home surveyor will review the resident’s assessment, the history and physical and other portions of the clinical record. These items should include the information needed to determine the resident’s needs and the interventions needed to meet the resident’s needs. The surveyor should be looking for consistency among the various parts of the record as well as with the observations that have been made and the interviews that were conducted.

The plan of care should be reviewed to see if it contains the detail needed to meet the resident’s needs. Each care plan should be individualized to each resident, so the surveyor is going to be looking to see that the care plan is not the same for most residents in the facility. An example of this would be “Toilet the resident before and after meals and at bedtime”. When I see this as a surveyor it starts ringing bells. Again, as mentioned before in this series of posts, everyone has their own pattern of needing to use the bathroom. Residents don’t fit into a cookie cutter. The plan should be based upon the goals, needs, and strengths specific to the resident and it should reflect the comprehensive assessment. It should identify objectives, timeframes, potential complications, and even environmental obstacles that affect the resident. Every care plan, whether for this issue or another, should identify specific approaches and interventions and should include input by the resident and/or the responsible person.

The information I have provided in the posts on this topic are just the “tip of the iceburg”. You will find much more information in the SOM and I encourage you to take some time to read and review it, especially if you are in a nursing home or have a loved one in a nursing home.

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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