What s new? INVESTIGATIVE PROTOCOL FOR URINARY INCONTINENCE & CATHETERS. The Revised Guidance Includes: Interpretive Guidelines

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1 INVESTIGATIVE PROTOCOL FOR URINARY INCONTINENCE & CATHETERS The Revised Guidance Includes: Interpretive Guidelines Investigative Protocols Compliance & Severity Guidance What s new? The new guidance for incontinence and catheters collapses the current F315 & F316 Tags The new Tag will be F315 - Incontinence & Catheters

2 In Addition: Guidelines and Protocols are expanded and more detailed Increased focus on observations and interviews, especially of the resident, family and health care practitioners Detailed guidelines for care planning and revisions Regulation - F (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 (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 Effective Dates: CMS Appendix PP issuance for F315 was June 27 th, 2005 MDH Effective Date will be 11/7/05

3 What is the Investigative Protocol? An Objective Tool for Surveyors to Use When Investigating: Residents at risk for urinary incontinence Residents with incontinence & indwelling catheters Objective of the Protocol Determine adequacy of intervention to prevent, improve and/or manage urinary incontinence Determine whether initial insertion or continued use of an indwelling catheter is based upon clinical indication for use of a urinary catheter Determine whether appropriate treatment and services have been provided to prevent and/or treat UTI s

4 When is the Investigative Protocol used? During the survey For each resident in the sample with either urinary incontinence or at risk of developing urinary incontinence For each resident in the sample with an indwelling catheter Basic Investigative Steps: Observations Interviews Record Review Initial Steps in Investigation Brief review of assessment, care plan and orders to identify: - residents who require special assistance for their individual program - noted facility interventions *This process guides the observations

5 Observe, Note & Follow up: Whether staff consistently implements individualized and planned interventions Different times of day & across various shifts Deviations from care plan or current standards of practice Potential negative outcomes Whether staff provide assistance to prevent incontinent episodes Whether staff make appropriate accommodations consistent with the individualized assessment Questions to ponder? For residents on a program to restore continence Observations include: How frequent are the incontinent episodes? How do the staff respond to the incontinence episodes? Are staff using appropriate Infection Control procedures with respect to the resident s dignity? How frequently is the resident encouraged to take fluids to meet their hydration needs?

6 For residents who are unable to participate in a program to restore continence scheduled toileting Observations include: Is the resident on a scheduled check and change program based on the individualized assessment? Does staff check and change the resident in a timely fashion? For resident who has experienced an incontinent episode Observations include: What is the condition of pad/sheets/clothing? What is the resident s physical condition? What are the resident s psychosocial outcomes? Are staff using appropriate hygiene measures? What is the staff response to incontinence episodes, and are they consistent with standards of practice, infection control & resident s dignity? For resident with an indwelling catheter Observations include: Does staff use appropriate infection control practices regarding hand washing, catheter care, tubing, and collection bag? Does staff recognize and assess potential evidence of a symptomatic UTI or changes in the urine? How does staff manage and assess urinary leakage from insertion to bag, if present? If catheter-related pain is present, how does staff assess and manage pain? What interventions are used to prevent dislodging the catheter?

7 Observation includes noting whether residents appear to be in pain or expresses pain related to urination or with the catheter and/or treatment 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 Identifying the nature of the incontinence is a key aspect of the assessment and helps identify the appropriate program/interventions to address incontinence.

8 Surveyors will attempt to validate their observations by interview and record review Interviews Resident, Family and/or Responsible Party Staff on various shifts Health care practitioners and other professionals, as necessary Resident/Family Interviews Is there involvement in care plan, goals, choices and preferred interventions? Are they aware of interventions in place? Is timely assistance provided for toileting needs, hydration and personal hygiene? Does the resident comprehend, apply information &/or instructions to help restore and maintain continence? Is there presence of urinary tract-related pain, including cause and management? Were consequences and alternatives offered if interventions were refused? Are they aware of current UTI, hx of UTI s, or perineal skin problems?

9 Staff Interviews Nursing Assistant Interview Are staff aware of, and understand, the interventions specific to this resident - toileting pattern/schedule? Have staff been trained to handle catheters, tubing and drainage bags? Do staff know what, when, and whom to report changes in status regarding bowel and bladder function, hydration status, urine characteristics, and complaints of urinary-related symptoms? Record Review Assessment Care Plan Reassessment and revisions to care plan Assessment Reviews RAI, hx & physical, physician orders, interdisciplinary notes, progress notes, and nurse s notes Includes observation of resident and overall condition Considers risk factors identified upon admission and that residents at risk are identified promptly Looks for preventive interventions identified and environmental factors related to incontinence Notes residents responses to catheter/continence services

10 Assessment of resident admitted with incontinence or indwelling catheter requires: Admission documentation describing resident s continence status Type of incontinence and contributing factors Patterns of voiding-individualized assessments Nutritional/hydration/skin condition History of incontinence or UTI s Risk factors Medication review The assessments must be consistent with the documentation within the record and comprehensively reflect the status of the resident Document:! Admission information! Patterns! Risks or conditions that affect urinary incontinence! Use of medications! Type of incontinence and frequency of assistance needed! Environmental factors! Resident refusal of interventions and facility actions to address concerns and offer alternatives! Clinical rationale for use of an indwelling catheter! Alternatives to extended use of indwelling catheters! Evaluation of factors possibly contributing to chronically recurring or persistent UTI s

11 Care Plan for Person at Risk for Incontinence or Indwelling Catheter Individualized care plan addressing prevention strategies and treatment Care Plan for Person with Incontinence or Indwelling Catheter Individualized care plan addressing prevention strategies and treatment Specific interventions to guide services Measurable objectives and time frames Care plan availability to direct care staff Interventions may be included in other components of care plan Resident Choices and Refusals Care plan should address: Resident refusal Any specific alternatives acceptable to resident Promotion and maintenance of resident dignity Potential psychosocial complications Review of risks and benefits Sufficient fluid intake Intervention to prevent skin breakdown

12 Care Plan - Residents Special Needs For residents on a scheduled toileting or restorative program: Identifies type of urinary incontinence Considers resident s medical/health condition, cognition and functional ability Contains specific individualized approaches for improving or maintaining continence Care Plan - Residents Special Needs For resident with a catheter: Includes indications for catheter and defines care of catheter and bag including P & P for changing the catheter, tubing, and bag Establishes interventions to minimize catheterrelated injury, pain, encrustation, urethral tension, accidental removal or obstruction of urine flow Provides for assessment and removal of catheter when no longer needed Reassessment and Care Plan Revision Are current approaches effective? Has the facility evaluated interventions? Was it revised to reflect modifications? Is there evidence of ongoing monitoring and evaluation of preventive and/or treatment strategies? Was there input by the resident and/or the responsible person? Does it include an evaluation of the resident s level of participation in, and response to, the continence program?

13 Interview: Health Care Practitioners & Professionals Determine: The decision making process identifying the chosen interventions as appropriate Why a specific risk factor is not addressed How staff has been taught to respond if the resident resists toileting How often intervention effectiveness is evaluated How staff monitors approaches to continence programs Whether the resident has any physical or cognitive limitations that influence potential improvement of his/her continence The need to interview dietitian, physical therapist, attending physician or medical director, as appropriate Interview: Health Care Practitioners & Professionals For residents with urinary catheters, whether the nursing staff: Can provide appropriate justification for the use of the catheter Can identify previous attempts made to remove a catheter Can identify a hx of UTI s and interventions aimed to prevent recurrence Interview: Health Care Practitioners & Professionals For resident on a program of toileting, to determine whether staff can identify the program applicable to resident: Does staff know the type of incontinence & interventions addressing each specific type? Can they identify changes in condition that may justify additional or different interventions; or how they validated the effectiveness of current interventions? How do they monitor the approaches for effectiveness of continence programs?

14 Investigative Protocol Completed! Gathered lots of information during investigation! Next: Review what information means Determine compliance Thank you!