Ftag of the Week – F690 Bowel/Bladder Incontinence, Catheter, UTI (Pt. 3)

This week on the CMSCG Blog “Ftag of the Week” series, we will wrap up our review of F690 Bowel/Bladder Incontinence, Catheter, UTI.  First, we will look at the requirements related to Urinary Tract Infections (UTIs) and fecal incontinence.

Urinary Tract Infection (UTI)

Let’s discuss one of the biggest issues related to UTIs – antibiotic use. Just because an individual has non-specific symptoms that could be related to a UTI, such as cloudy or foul-smelling urine, change in mental status, change in function or bacteriuria, the rule of thumb should not be to treat with antibiotics. The resident’s physician is expected to thoroughly evaluate and assess the resident to ensure use of an antibiotic is indicated.

Per the Interpretive Guidance in Appendix PP:

• For a non-catheterized resident with symptoms associated with a UTI, the attending practitioner should order a urine culture prior to the initiation of antibiotic therapy to help guide treatment.
• If the resident has a long-term indwelling urethral catheter, a specimen should be obtained from a freshly placed indwelling catheter.
• Post-treatment urine culture is not always necessary, but may be helpful if the resident’s signs/symptoms of a UTI continue or do not respond to treatment with antibiotics.
• Continued bacteriuria without residual symptoms does not warrant repeat or continued antibiotic therapy.

The surveyor is expected to review the facility’s policy for obtaining urine cultures to ensure it is based on current standards of practice, since these may change over time.

It is important – including for Antibiotic Stewardship reasons – that UTIs are not treated unnecessarily with antibiotics. This can lead to the development of multi-drug resistant organisms and other complications which can pose a threat of infection to other residents or result in the resident potentially being hospitalized.

Recurrent UTIs

If an individual has two or more UTIs in a 6-month period, this is considered recurrent UTI. The guidance at F690 differs for individuals who are catheterized versus those who are not.

Non-catheterized individual

• When there is recurrent UTI, this may need to be evaluated further for issues such as a prolapsed bladder, tumors or enlarged prostate.

Catheterized individual

Recurrent UTIs should be reviewed to determine:

• If there is possible impairment of free urine flow through the catheter
• The need to reevaluate the techniques being used for catheter care and for perineal hygiene, including the proper technique to use for removal of fecal soiling
• The relative risks and benefits of continuing the use of an indwelling catheter

Please note — Changing catheters or urinary drainage bags at fixed intervals is not recommended.

Things to Think About

• Are your residents receiving sufficient fluids? The resident may need to be assessed for fluid needs and a fluid management program.
• Are your urine C&S results indicating contamination? Make sure staff are competent in specimen collection.  When was the last time catheterization competencies were completed?
• Staff also need to ensure that the resident is kept clean of feces to minimize the potential for bacterial migration into the urethra and bladder.  Are your staff completing checks of their assigned residents as per the plan of care and providing necessary brief changes accompanied with proper incontinence care?

Take a look at your catheters – literally.

• Are staff maintaining standard precautions? Don’t forget – the facility is expected to show that it employs appropriate infection prevention and control practices related to catheters.
• Are the bags in direct contact with the floor? This is routinely cited during a compliance survey – and something we see on most mock surveys. It’s a “gotcha” deficiency and is avoidable.
• Is the tubing looped?  Have the potentially negative outcomes such as reduced flow rate, looping being a contributing cause of bacteriuria and urinary tract infection been discussed with staff?
• When residents are being transferred, do staff maintain the catheter bag below the level of the bladder?  How often is the catheter drainage bag & excess tubing placed on the resident’s stomach by your staff so that the tubing doesn’t get pulled? When did you last do transfer competencies for a resident with a urinary catheter?

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

A facility was cited for Actual Harm when it did not ensure that a resident’s urinary catheter drain bag was kept from dragging on the floor and that the catheter bag was kept below the bladder. No physician orders on how to clean the area around the catheter site were found. The failure to ensure the resident’s catheter line did not drag on the floor and failure to cleanse the site contributed to a urinary tract infection, as evidenced by purulent drainage from the catheter exit site, which caused pain to the resident.

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Fecal Incontinence

Let’s start with a review of some definitions:

Passive incontinence —the involuntary discharge of fecal matter or flatus without any awareness. This suggests a loss of perception and/or impaired recto anal reflexes, either with or without sphincter dysfunction.

 Urge incontinence — the discharge of fecal matter or flatus in spite of active attempts to retain these contents. Here there is a predominant disruption of the sphincter function or the rectal capacity to retain stool.

Fecal seepage — the undesired leakage of stool, often after a bowel movement with otherwise normal continence and evacuation. This condition is mostly due to incomplete evacuation of stool and/or impaired rectal sensation. The sphincter function and pudendal nerve function are mostly intact.

Just as bladder incontinence needs to be assessed, fecal incontinence (FI) needs to be addressed as a part of the comprehensive resident assessment. There are many potential causes of fecal incontinence, including diarrhea, nerve damage, hemorrhoids or rectal prolapse. Since FI can create dignity concerns and loss of independence for a resident, it is important to attempt  for the resident’s quality of life that attempts to address this incontinence are attempted. The IG notes that increased fiber consumption, use of medications to develop more solid stools and even pelvic floor exercises can improve bowel control. Are you using nutritional interventions as well as educating the resident on how to do pelvic floor exercises?  Do you even think about incorporating these interventions into the resident’s plan of care?

The resident’s plan of care should focus on enhancing the resident’s dignity and reducing potential embarrassment related to FI. The IG lists both emotional and physical complications related to fecal incontinence, including:

• Loss of self-esteem
• Social isolation
• Skin irritation/excoriation
• Pain
• Itching

Lastly, the assessment and treatment plan for FI should also include infection control measures, including the appropriate use of personal protective equipment (PPE).