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linical problems are common in nursing homes, with urinary incontinence (UI) identified as a severe problem. In 2000, more than one third of nursing home residents experienced bladder (urinary) incontinence all or most of the time. The Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration) has singled out UI in its regulations, mandating that long-term care facilities appropriately assess and treat this disorder. The CMS requires comprehensive assessment as the basis for developing a plan of care that will help the resident to attain and maintain the best possible physical, mental, and psychosocial functioning.
       This comprehensive assessment is performed using the Resident Assessment Instrument (RAI). The RAI provides a comprehensive, accurate, standardized, reproducible assessment of each long-term care facility resident's functional capabilities and identified medical problems through the use of the Minimum Data Set (MDS) and Resident Assessment Protocol (RAP). The MDS is a primary screening and assessment form for urinary incontinence. The MDS provides state and federal regulators with immediate and current information, so they can make decisions on an on-going basis concerning the need for on-site assessment of care and resident outcomes. The RAP is considered to reflect the critical components of problem solving, care plan development, and treatment decisions in the provision of comprehensive care and the improvement of residents' quality of life.
       As part of the annual state certification survey to which nursing homes that receive federal and state funding must submit, surveyors look for a completed MDS, appropriate RAP, and updated care plans to address urinary incontinence. A facility must ensure that a resident:
- Who is incontinent of bladder receives the appropriate treatment and services to restore normal bladder functioning
- Is not catheterized unless it is necessary
- Who has an indwelling catheter in place receives appropriate treatment to prevent infections.
       CMS is currently working on a narrative guidance project for state surveyors to provide more structured guidance for determining severity and scope of deficient practices in nursing homes and to increase the consistency with which states apply federal standards for determining severity and scope of facility deficiency practices. This project is a multi-year effort that has involved a variety of participants (representatives include professional experts, state surveyors, and Medicare regional and federal staff). The goal is to identify issues surrounding the use of indwelling catheters and urinary incontinence and critical observations that belong to four severity levels using the following scale:
- Level 4: Immediate jeopardy to resident health or safety
- Level 3: Actual harm that is not immediate jeopardy
- Level 2: No actual harm with potential for more than minimal harm
- Level 1: No actual harm with potential for no more than minimal harm.
       The intent of the narrative guidance and the federal regulation is to ensure that facilities:
1. Provide services and care that ensure that an indwelling urinary catheter is only used when there is a valid medical justification
2. Provide appropriate treatment and services related to catheter care for a resident admitted with or having continued catheter use; remove the catheter as soon as clinically warranted; and provide necessary services and treatment to restore or improve bladder function as much as possible and to prevent infection
3. Identify each resident who is incontinent of urine and assess the potential for restoring normal function or improving function; provide appropriate treatment and services to assist the resident to restore as much function as possible; and provide appropriate care and services to prevent and address urinary tract infections (UTIs).
       The areas that the guidance will address include:
- Use of indwelling catheters with no medical necessity
- Poor personal hygiene, primarily perineal care
- Poor indwelling (Foley) catheter care
- Repeated UTIs
- Lack of toileting programs
- No rehabilitation program (e.g., bladder retraining)
- Overuse of absorbent products.
       Clinical nursing practice in the management of UI must change in nursing homes. CMS's narrative guidance may be the catalyst for this change. Nursing administration will need to adopt recommended guidelines to implement procedures for assessment and treatment/management of incontinence. Each resident's continence status is to be assessed at admission and quarterly. If the resident is found to be incontinent, a basic diagnostic evaluation should be performed and focused on reversible factors. Consulting with an advanced practice nurse/incontinence expert to assist with UI evaluation may be helpful. To insure that staff members are knowledgeable about UI, nursing homes will need to provide education and in-service programs on assessment and management of UI. Staff should ensure interdisciplinary decision about residents' potential and expand on options for management (e.g., devices, products, etc.). Finally, nursing home staff need to develop toileting programs patterned on evidence-based research, which has been preformed on prompted voiding and bladder retraining.