This week’s “Ftag of the Week” on the CMSCG Blog is F691 Colostomy, Urostomy, or Ileostomy Care, which is part of the Quality of Care regulatory group. The regulation requires nursing home providers to ensure that resident who require colostomy, urostomy or ileostomy services receive care that is consistent with the resident’s goals/preferences, the resident’s comprehensive care plan and professional standards of practice.
On Survey
The CMS 802 Matrix for Providers item #12 is for residents who have indwelling urinary catheters. On survey, the surveyors are directed to use the Urinary Catheter or Urinary Tract Infection Critical Element Pathway for residents who have an indwelling urinary catheter, but are not prompted to cite F691. Surveyors also have the Bladder or Bowel Incontinence Critical Element Pathway to use for concerns related to incontinence, but are also not prompted to cite F691 for an identified concern. So, how will surveyors identify concerns related to colostomy, urostomy or ileostomy care?
Surveyors are directed to review the appropriate sections of the MDS to identify if the resident triggers any of these Care Area Assessments (CAAs):
- Urinary incontinence
- Nutritional status
- Pressure injuries/skin care
The surveyors will review the resident record to see if the resident has been provided with self-care instructions, if appropriate. The surveyor will also make observations about whether staff observe and respond to any signs that the resident is having discomfort with the ostomy or its care. If necessary, through visual observation, the surveyor will look to see if the skin surrounding the ostomy is free of any excoriation, such as tissue breakdown or abrasion, and if there is excoriation present, if the resident record documents the date of onset and the treatment plan for the skin issue.
Let’s look at a couple of actual survey citations to see how F691 is cited during survey:
Standard Survey – F691 S/S: D
A resident was observed by a surveyor to have an ostomy bag that was leaking onto the bed and there was a towel placed under the bag. The resident stated to the surveyor that the staff change the bag every three to five days, but they try to stretch it out because of the high cost for the supplies. The resident told the surveyor that she would get stool on her skin and it would irritate the stoma site, and the barrier creams being used varied depending on the staff member performing the treatment, some of which made her skin feel like it was burning.
Complaint Survey – F691 S/S: D
The facility did not ensure a resident who required ostomy care received services consistent with professional standards of practice when it was identified that the resident’s ostomy tube leaked, and there was no documentation to show that the facility had implemented timely intervention to prevent leakage. The resident’s abdomen became irritated and the skin had several open areas, which were not assessed or monitored by a qualified staff member when the areas were identified. The resident’s physician was not notified of the open areas, and the facility did not implement a recommendation for evaluation at an ostomy clinic.
We need to remember that the essence of this tag is about care and treatment. Residents with any type of ostomy are usually very conscious of having an ostomy and are usually not hesitant about sharing information as to when “things” did not go well with the care of their ostomy. So, the IDCP team, including the physician, needs to ensure that the plan of care is comprehensive and individualized.
We need to remember that the essence of this tag is about care and treatment.
Develop your plan of care so that it considers the resident’s lifestyle, preference for when ostomy care is provided, the resident’s mental and emotional acceptance of the ostomy, refusals or resistance to care, etc. Wafer size for a colostomy is very important to the resident! Above all, make sure that the staff who are responsible for the care of any type of ostomy has been educated on how to perform the necessary care and has demonstrated competency in providing that care.
