INVESTIGATIVE PROTOCOL
FOR URINARY
INCONTINENCE &
CATHETERS
The Revised Guidance Includes:
• Interpretive Guidelines
• Investigative Protocols
• Compliance & Severity Guidance
What’s new?
• The new guidance for incontinence
and catheters collapses the current
F315 & F316 Tags
• The new Tag will be F315 Incontinence & Catheters
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In Addition:
• Guidelines and Protocols are expanded
and more detailed
• Increased focus on observations and
interviews, especially of the resident,
family and health care practitioners
• Detailed guidelines for care planning
and revisions
Regulation - F315
• 483.25(d)(1) A resident who enters the facility
without an indwelling catheter is not catheterized
unless the resident’s clinical condition
demonstrates that catheterization was necessary
• 483.25(d)(2) A resident who is incontinent of
bladder receives appropriate treatment and
services to prevent urinary tract infections and to
restore as much normal bladder function as
possible
Effective Dates:
• CMS Appendix PP issuance for
F315 was June 27th, 2005
• MDH – Effective Date will be
11/7/05
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What is the Investigative
Protocol?
An Objective Tool for Surveyors
to Use When Investigating:
• Residents at risk for urinary
incontinence
• Residents with incontinence &
indwelling catheters
Objective of the Protocol
• Determine adequacy of intervention to prevent,
improve and/or manage urinary incontinence
• Determine whether initial insertion or continued use
of an indwelling catheter is based upon clinical
indication for use of a urinary catheter
• Determine whether appropriate treatment and
services have been provided to prevent and/or treat
UTI’s
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When is the Investigative
Protocol used?
During the survey
• For each resident in the sample with
either urinary incontinence or at risk
of developing urinary incontinence
• For each resident in the sample with
an indwelling catheter
Basic Investigative Steps:
• Observations
• Interviews
• Record Review
Initial Steps in Investigation
• Brief review of assessment, care plan and
orders to identify:
- residents who require special
assistance for their individual program
- noted facility interventions
*This process guides the observations
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Observe, Note & Follow up:
• Whether staff consistently implements
individualized and planned interventions
• Different times of day & across various shifts
• Deviations from care plan or current standards of
practice
• Potential negative outcomes
• Whether staff provide assistance to prevent
incontinent episodes
• Whether staff make appropriate
accommodations consistent with the
individualized assessment
Questions to ponder?
For residents on a program
to restore continence
Observations include:
• How frequent are the incontinent episodes?
• How do the staff respond to the incontinence
episodes?
• Are staff using appropriate Infection Control
procedures with respect to the resident’s
dignity?
• How frequently is the resident encouraged to
take fluids to meet their hydration needs?
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For residents who are unable to
participate in a program to restore
continence – scheduled toileting
Observations include:
• Is the resident on a scheduled check and
change program based on the individualized
assessment?
• Does staff check and change the resident in a
timely fashion?
For resident who has experienced
an incontinent episode
Observations include:
• What is the condition of pad/sheets/clothing?
• What is the resident’s physical condition?
• What are the resident’s psychosocial
outcomes?
• Are staff using appropriate hygiene
measures?
• What is the staff response to incontinence
episodes, and are they consistent with
standards of practice, infection control &
resident’s dignity?
For resident with an indwelling
catheter
Observations include:
• Does staff use appropriate infection control practices
regarding hand washing, catheter care, tubing, and
collection bag?
• Does staff recognize and assess potential evidence
of a symptomatic UTI or changes in the urine?
• How does staff manage and assess urinary leakage
from insertion to bag, if present?
• If catheter-related pain is present, how does staff
assess and manage pain?
• What interventions are used to prevent dislodging the
catheter?
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Observation includes noting
whether residents appear to
be in pain or expresses pain
related to urination or with the
catheter and/or treatment
Staff are expected to:
• Assess and provide appropriate
care from the day of admission,
for residents with urinary
incontinence or a condition that
may contribute to incontinence or
the presence of an indwelling
urinary catheter
Identifying the nature of the
incontinence is a key aspect of
the assessment and helps
identify the appropriate
program/interventions to
address incontinence.
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Surveyors will attempt to
validate their
observations by interview
and record review
Interviews
• Resident, Family and/or Responsible Party
• Staff on various shifts
• Health care practitioners and other
professionals, as necessary
Resident/Family Interviews
• Is there involvement in care plan, goals, choices and
preferred interventions?
• Are they aware of interventions in place?
• Is timely assistance provided for toileting needs, hydration
and personal hygiene?
• Does the resident comprehend, apply information &/or
instructions to help restore and maintain continence?
• Is there presence of urinary tract-related pain, including
cause and management?
• Were consequences and alternatives offered if interventions
were refused?
• Are they aware of current UTI, hx of UTI’s, or perineal skin
problems?
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Staff Interviews
Nursing Assistant Interview
• Are staff aware of, and understand, the interventions
specific to this resident - toileting pattern/schedule?
• Have staff been trained to handle catheters, tubing
and drainage bags?
• Do staff know what, when, and whom to report
changes in status regarding bowel and bladder
function, hydration status, urine characteristics, and
complaints of urinary-related symptoms?
Record Review
• Assessment
• Care Plan
• Reassessment and
revisions to care plan
Assessment
• Reviews RAI, hx & physical, physician orders,
interdisciplinary notes, progress notes, and nurse’s
notes
• Includes observation of resident and overall
condition
• Considers risk factors identified upon admission
and that residents at risk are identified promptly
• Looks for preventive interventions identified and
environmental factors related to incontinence
• Notes residents’ responses to catheter/continence
services
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Assessment of resident admitted with
incontinence or indwelling catheter
requires:
• Admission documentation describing resident’s
continence status
• Type of incontinence and contributing factors
• Patterns of voiding-individualized assessments
• Nutritional/hydration/skin condition
• History of incontinence or UTI’s
• Risk factors
• Medication review
The assessments must be
consistent with the
documentation within the
record and comprehensively
reflect the status of the
resident
Document:
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Admission information
Patterns
Risks or conditions that affect urinary incontinence
Use of medications
Type of incontinence and frequency of assistance
needed
Environmental factors
Resident refusal of interventions and facility actions
to address concerns and offer alternatives
Clinical rationale for use of an indwelling catheter
Alternatives to extended use of indwelling catheters
Evaluation of factors possibly contributing to
chronically recurring or persistent UTI’s
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Care Plan for Person at Risk for
Incontinence or Indwelling Catheter
• Individualized care plan addressing
prevention strategies and
treatment
Care Plan for Person with
Incontinence or Indwelling Catheter
• Individualized care plan addressing prevention strategies
and treatment
• Specific interventions to guide services
• Measurable objectives and time frames
• Care plan availability to direct care staff
• Interventions may be included in other components of
care plan
Resident Choices and Refusals
Care plan should address:
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Resident refusal
Any specific alternatives acceptable to resident
Promotion and maintenance of resident dignity
Potential psychosocial complications
Review of risks and benefits
Sufficient fluid intake
Intervention to prevent skin breakdown
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Care Plan - Residents Special Needs
For residents on a scheduled toileting or
restorative program:
• Identifies type of urinary incontinence
• Considers resident’s medical/health condition,
cognition and functional ability
• Contains specific individualized approaches for
improving or maintaining continence
Care Plan - Residents Special Needs
For resident with a catheter:
• Includes indications for catheter and defines care of
catheter and bag including P & P for changing the
catheter, tubing, and bag
• Establishes interventions to minimize catheterrelated injury, pain, encrustation, urethral tension,
accidental removal or obstruction of urine flow
• Provides for assessment and removal of catheter
when no longer needed
Reassessment and Care Plan Revision
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Are current approaches effective?
Has the facility evaluated interventions?
Was it revised to reflect modifications?
Is there evidence of ongoing monitoring and
evaluation of preventive and/or treatment
strategies?
• Was there input by the resident and/or the
responsible person?
• Does it include an evaluation of the resident’s
level of participation in, and response to, the
continence program?
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Interview: Health Care
Practitioners & Professionals
Determine:
• The decision making process identifying the chosen
interventions as appropriate
• Why a specific risk factor is not addressed
• How staff has been taught to respond if the resident resists
toileting
• How often intervention effectiveness is evaluated
• How staff monitors approaches to continence programs
• Whether the resident has any physical or cognitive limitations
that influence potential improvement of his/her continence
• The need to interview dietitian, physical therapist, attending
physician or medical director, as appropriate
Interview: Health Care
Practitioners & Professionals
For residents with urinary catheters,
whether the nursing staff:
• Can provide appropriate justification for the use of
the catheter
• Can identify previous attempts made to remove a
catheter
• Can identify a hx of UTI’s and interventions aimed
to prevent recurrence
Interview: Health Care
Practitioners & Professionals
For resident on a program of toileting, to
determine whether staff can identify the
program applicable to resident:
• Does staff know the type of incontinence & interventions
addressing each specific type?
• Can they identify changes in condition that may justify
additional or different interventions; or how they validated
the effectiveness of current interventions?
• How do they monitor the approaches for effectiveness of
continence programs?
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Investigative Protocol Completed
! Gathered lots of information during
investigation
! Next:
– Review what information means
– Determine compliance
Thank you!
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