F690 – Incontinence & Urinary Catheters

While recently reviewing LeadingAge Illinois/Iowa performance in quality measures, two areas stood out as areas that members can use performance improvement. Urinary tract infections and indwelling catheter use. While these measures are separate in quality performance, regulatory requirements fall into one, F690.

First, this regulation requires that the nursing home ensures that residents who are continent of bladder and/or bowel upon admission receive necessary care and service to maintain their continence, unless it is possible to maintain. The interpretative guidance related to this requirement includes the following:

Assessment:

• Upon admission, the resident’s continent status is assessed.
• Ongoing assessments of continence status are assessed and if incontinence is noted, attempts are made to understand the reason along with whether the condition is reversible or irreversible.
• Additionally, staff should assess the residents:
  • prior bladder functioning
  • voiding patterns
  • medication review (particularly those that may affect continence)
  • patterns of fluid intake
  • use of urinary tract stimulants or irritants (such as caffeine intake)
  • practitioners completing a pelvic and/or rectal examination to identify possible medical causes such as prolapsed bladder or prostate enlargement
  • functional or cognitive capabilities that could enhance urinary continence or limit such as dementia, impaired mobility, etc.
  • type and frequency of physical assistance necessary to assist to the toilet or commode
  • pertinent diagnoses that can affect urinary tract or function such as congestive heart failure, stroke, diabetes, etc.
  • identification of possible complications such as skin breakdown
  • tests or studies completed that identify the types of urinary incontinence, post-void residual, urinary retention, etc.
  • environmental factors and assistive devices that may restrict or facilitate a resident’s ability to access the toilet

When incontinence is identified, staff should identify interventions to aid the resident in achieving and/or maintaining their highest functional level including but not limited to:

• Managing pain and/or providing adaptive equipment to improve function.
• Removing or improving environmental impediments such as improved lighting or use of a bedside commode
• Treating underlying conditions
• Adjusting medications that may affect continence status
• Implementing fluid and/or bowel management programs.

Secondly for residents with urinary incontinence, the nursing home must ensure that:

• Residents who are admitted without an indwelling catheter is not catheterized unless there is a clinical condition that demonstrates this was necessary. A resident who is admitted with an indwelling urinary catheter that is not medically necessary, has it removed as soon as possible. The documented assessment should include consideration of the risks and benefits of an indwelling catheter, the potential for removal of the catheter, and consideration of complications resulting from the use of an indwelling catheter.

Indwelling catheter use for residents must be in collaboration with the medical director, director of nursing, and based upon professional standards of practice. This includes developing policies and procedures that address catheter care and services including but are not limited to:

• Involvement of the resident and/or representative in the discussion of risks and benefits, removal criteria, and the right to decline the use of a catheter
• Timely and appropriate assessments for indication of use.
• Identification and documentation of appropriate clinical indications for the use.
• Insertion, care, and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures.
• Response of the resident to the use of a catheter.
• Ongoing monitoring for changes in condition related to possible urinary tract infections, recognizing, reporting, and addressing such changes.

Examples of appropriate indications for the use of indwelling catheter use based on previous Centers for Disease Control & Prevention guidance:

• Urinary retention
• Bladder Outlet Obstruction
• Need for accurate urinary output measurements
• Assist in healing of open sacral or perineal wounds in incontinent residents
• Prolonged immobilization in the presence of potentially unstable spinal injuries or multiple traumatic injuries
• Comfort for end-of-life care

Examples of inappropriate use include substitute care for incontinent residents and urine specimen collection in residents who can normally voluntarily void.

• Residents with bladder incontinence receive appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible.

Nursing homes should ensure that they are collecting specimens based on evidence-based practice and only treating with antibiotics when diagnostic criteria such as McGeer or Loebs are met as unnecessary antibiotic use may lead to the development of multi-drug-resistant organisms and additional complications.

Lastly, the regulation requires that residents with bowel incontinence receive appropriate treatment and services to restore as much normal bowel function as possible.

• Similar to urinary incontinence, providers should complete assessments to identify possible causes of fecal incontinence and treat them as necessary and appropriate.
• The care plan must reflect the results of the assessment and any resident specific interventions for possible reversible causes or if irreversible, appropriate interventions for managing bowel incontinence.

Examples of non-compliance based on review of survey findings frequently include concerns identified during perineal or incontinence care such as staff not completing hand hygiene or glove changes appropriately while performing care, not cleansing the entire area that an incontinent brief or product touched such as the residents hips or buttocks, not completing incontinent or perineal care based on infection prevention and control standards such as wiping from the back to front, not changing the side of the cloth or changing the cloth between swipes, and not following the resident’s care plan related to toileting plans.

Note that appropriate indications for an indwelling catheter in the regulation differ from those diagnoses listed in the Centers for Medicare & Medicaid Five-Star Technical User’s Guide. While the diagnosis may be appropriate to prevent a regulatory deficiency, it may not exclude the residents from being included in the quality measure.