Ftag of the Week – F690 Bowel/Bladder Incontinence, Catheter, UTI (Pt. 2)

Last week, in Part 1 of our CMSCG “Ftag of the Week” for F690, we reviewed some key terms used in the regulation and looked at some important items that need to happen on admission. In this post, we will continue our review of this regulation as it relates to catheter use – a high-risk area.

Catheter Use

As noted in Part 1, a resident who enters the facility without an indwelling catheter should not be catheterized unless the resident’s clinical condition demonstrates that this catheterization was necessary. If a resident enters the facility with an indwelling urinary catheter or subsequently has a catheter inserted, he/she is assessed for removal of the catheter as soon as possible unless the resident’s clinical condition demonstrates that catheterization is necessary.

If a resident arrives to your facility with a catheter in place, it needs to be determined if continued use of the catheter is medically necessary. Supportive documentation by a urologist is the best acknowledgement of need. Documentation in the resident’s record must reflect the attending practitioner’s valid clinical indication to support the use of an indwelling catheter. This is because indwelling catheter use can be associated with various complications – especially UTI, as well as:

  • Bacteremia
  • Sepsis, pyelonephritis or chronic renal inflammation due to urinary tract infections
  • Bladder stones
  • Febrile episodes
  • Fistula formulation
  • Epididymitis
  • Urethra erosion

Things to Think About

  • Many facilities discontinue foley catheters the morning after admission unless medical necessity is clearly documented in the record.
  • Monitoring of the resident post catheter removal should always be evident in the record.
  • The ongoing use of a catheter may increase the risk of urinary tract infections including sepsis and also may impact negatively on independence and dignity (don’t forget those privacy bags).
  • A catheter should never remain in place for the purpose of specimen collection. 

As far as documentation goes, the regulation spells out what needs to be included:

  • How and when the resident/representative was involved and informed of care and treatment including the potential use and indications for the need for a catheter, how long use is anticipated, and when and why a catheter must be removed.
  • Evidence that the resident/ representative were included in the development of the care plan, including the use of the catheter and associated interventions. Don’t forget – the resident/representative has the right to decline the treatment.
  • Education of the resident/representative on the identification of risks and benefits for the use of a catheter. Also remember – the resident/ representative may choose to continue a catheter even if there is no clinical indication for use. If this occurs, the counseling provided by the physician and staff must be documented and this education/counseling should be periodically done while the catheter is in place.
  • Physician’s valid clinical indication to support use of the catheter.

Recertification Survey Citation – F690 S/S: G (Actual Harm)

A resident was observed during survey to have an indwelling catheter draining dark urine. Review of the resident’s record found that the resident did not have a physician’s order, assessment or care plan for indwelling catheter use. The surveyor reviewed the resident’s TAR and identified there was a physician’s order on admission that if the patient has not voided during the shift, bladder scan and straight catheterize patient if retaining 300ml or more of urine. There were no notations on the TAR that a bladder scan or straight catheter use were done for the first ten days of admission however, there was a nursing progress note indicating that on the date of admission, the resident did not void so an indwelling catheter was inserted. There was no documentation that a bladder scan had been performed. Ten days later, the resident was transferred to the hospital after red blood was observed in the catheter bag and the resident stated he felt lightheaded and dizzy. There was no documentation indicating the date when the catheter had been inserted prior to the hospital transfer. The catheter remained in the resident after readmission for another two weeks, when it was observed by the surveyor. There are a number of issues here related to the facility’s practices related to catheter use, including the lack of evidence of nurse to physician communication.

Review Your Practices

  • Are your resident care policies and procedures up to date and include insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures?
  • Is it clear who is permitted to insert a catheter?
  • Do all staff members responsible for the procedure have a current competency on file?
  • Do you have a system in place to monitor follow-up visits for urology consults?
  • Do orders and care plans capture the correct rationale for use/size of the catheter?
  • Do MD progress notes include the reason for use and ongoing evaluation of use of the catheter? (It should be addressed in monthly/bimonthly comprehensive notes as well as on an interim basis.)
  • Is the use of catheter/any precautionary measures noted on the caregiver assignment?
  • Does nursing documentation reflect the resident’s response to the catheter?
  • Is catheter care noted on the CCP/documented?

In Part 3, we will review two key areas where a negative clinical outcome could occur – UTI and fecal impaction.

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