Ftag of the Week – F690 Bowel/Bladder Incontinence, Catheter, UTI (Pt. 1)

Next up on the CMSCG Blog series, “Ftag of the Week,” we will be reviewing one of the regulations in the Quality of Care regulatory group, F690 Bowel/Bladder Incontinence, Catheter, UTI. CMSCG Clinical Consultant Mary Quinn is providing clinical insight for this Ftag series.

F690 – The Regulation

In a nutshell, here is the regulation for F690:

• Providers are responsible for ensuring that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence, unless his/her clinical condition is/becomes such that it is no longer possible to maintain continence.

For residents with urinary incontinence:

If a resident has urinary incontinence, the facility must provide services based on the resident’s comprehensive assessment which ensure that:

• A resident who is admitted with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible, unless the resident’s clinical condition necessitates continued catheterization.
• A resident who is incontinent of bladder receives appropriate care and services to prevent urinary tract infections (UTIs) and, to the extent possible, restore continence.

Related to indwelling catheters, the regulatory intent is to ensure that an indwelling catheter is not used unless there is a valid medical justification for catheterization and that use is discontinued as soon as it is clinically warranted.

For residents with fecal incontinence:

• Providers are responsible for ensuring a resident with fecal incontinence receives appropriate treatment and services to restore as much normal bowel function as possible, based on the resident’s comprehensive assessment.

Regarding fecal incontinence under F690, it is worth noting that the scope of this regulation is related to treatment and services to restore bowel function, unless it is not clinically possible – but concerns related to bowel management should be reviewed under F684 Quality of Care.

Definitions

Let’s review some definitions of key terms from the regulation:

“Bacteremia” is the presence of bacteria in the bloodstream.

“Bacteriuria” is defined as the presence of bacteria in the urine.

 “Continence” refers to any void that occurs voluntarily, or as the result of prompted, assisted, or scheduled use of the bathroom

 “Sepsis” is the body’s overwhelming and life-threatening response to an infection which can lead to tissue damage, organ failure, and death.

“Urinary Incontinence” is the involuntary loss or leakage of urine. 

Types of Urinary Incontinence

Here are some more specific definitions related to types of urinary incontinence. Understanding the nature of incontinence helps with assessment and identification of appropriate interventions. Per the Interpretive Guidance in Appendix PP, here are some common types of urinary incontinence:

• Urge Incontinence is the most common cause of urinary incontinence in older adults. It is associated with detrusor muscle over activity (excessive contraction of the smooth muscle in the wall of the urinary bladder) resulting in a sudden, strong urge (also known as urgency) to expel moderate to large amounts of urine before the bladder is full). The resident can feel the need to void, but is unable to inhibit voiding long enough to reach and sit on the commode.
• Stress Incontinence is the second most common type of urinary incontinence in older women. It is associated with impaired urethral closure (malfunction of the urethral sphincter), which allows small amounts of urine leakage when pressure on the bladder is increased. This can  occur when laughing, standing from a sitting position, sneezing or laughing.
• Mixed Incontinence is a combination of the above types of incontinence. Many older adults, especially women, may experience both stress and urge incontinence symptoms.
• Overflow Incontinence may mimic urge or stress incontinence, but is less common than either of those types of incontinence. It is associated with leakage of small amounts of urine when the bladder has reached its maximum capacity and has become distended due to urinary retention. Symptoms may include weak stream, hesitancy, intermittency, nocturia, incomplete voiding, constant dribbling or dysuria. There are multiple factors that can contribute to this form of incontinence.
• Transient Incontinence is related to a potentially improvable or reversible cause. It is temporary or occasional incontinence that could be due to many causes, including infection, delirium, atrophic urethritis or vaginitis, restricted mobility, increased urine production or some medications.
• Functional Incontinence occurs when an individual whose urinary tract function is sufficiently intact that he/she should be able to maintain continence, but loss of urine occurs due to external factors. This may be due to staff response to a request for toileting assistance or the resident’s inability to utilize the toilet in time. Other possible contributing factors include poor physical weakness or poor mobility/dexterity, cognitive problems, medications or environmental impediments.

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Recertification Survey Citation – F690 S/S: D

An alert and oriented resident who required staff assistance for ADL care did not receive morning care during the 7-3 shift until 12:15 because no CNA had been assigned to provide care to the resident. The surveyor observed the resident in bed, visibly upset and loudly saying that no one took care of them that morning. There was a strong urine odor in the room.

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Let’s look at what should happen on admission/readmission.

Admission/Readmission

As part of the comprehensive assessment, the resident’s continence status needs to be addressed on admission and whenever there is a change in status.

Many facilities utilize an assessment tool that is completed along with other risk assessments on a quarterly basis or on a specific defined basis unless incontinence is determined to be irreversible i.e., spinal cord disease, bladder tumors.

So . . . the resident is continent- are you done? No. You need to determine if and how much assistance is needed to get to the toilet – this is an area that can get you into trouble.

Surveyors are directed to observe for actual or potential harm as well as to observe for visual cues of psychosocial harm and distress:

• A resident who is continent but due to temporary functional limitations (i.e., recent TKR) needs assistance to the bathroom. The resident soils him/herself because staff do not respond to their call bell on a timely basis.
• A male resident uses a urinal. Staff leave it in the bathroom after emptying and the resident soils himself.
• A resident who is continent of urine asks to be assisted to the bathroom, but staff instead encourage them to “just go in the diaper.”
• Although many residents have used absorbent products prior to admission to the nursing home and the use of absorbent products may be appropriate, absorbent products should not be used as the primary long-term approach to continence management until the resident has been appropriately evaluated and other alternative approaches have been considered.  

Any changes in status should be addressed when they occur and not wait for a routinely scheduled assessment i.e., resident previously continent is noted with episodes of incontinence, foley catheter removal.

Many tools do not capture all areas that should be considered in addressing urinary continence:

• The resident’s prior history of bladder functioning – i.e., were they continent prior to hospitalization?
• Pertinent diagnosis – DM, CHF, CVA
• Voiding patterns – i.e., frequency, nocturnal voiding
• Medication use – i.e., diuretics, narcotics
• Patterns of fluid intake i.e., consider limiting fluids after a certain hour
• Use of stimulants/irritants – caffeine
• Physical exam – enlarged prostate, prolapsed uterus
• Functional and cognitive needs – manual dexterity, need for task segmentation, pain 
• Environmental factors – lighting, distance to the bathroom, use of bedside commodes
• Potential/actual skin breakdown

Interventions

Interventions need to be residents-specific, so an accurate and comprehensive assessment is needed to ensure all elements are addressed. Make sure there is monitoring of the interventions put in place – Are we following the plan of care? Some things to thing about:

• Behavioral programs such as bladder rehab/bladder retraining, pelvic floor muscle rehab require the resident’s cooperation and motivation.
• Prompted voiding and scheduled voiding are more staff-directed programs rather than dependent on resident function. Scheduled voiding is not considered to be a bladder retraining /rehab program.
• Proper sizing of products may impact on potential for skin breakdown i.e., blister formation.
• It is important that residents using absorbent products be checked (and changed as needed) on a schedule based upon the resident’s voiding pattern, professional standards of practice, and the manufacturer’s recommendations. Products may contain urine but check and changes are still needed due to an increased risk of MASD.
• Intermittent catheterization may be an appropriate intervention for some residents. If the resident self-performs the task, make sure there is documentation to support ongoing ability and use of acceptable infection control practices.

In next week’s post, we will review some information about catheter use.