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rinary incontinence (UI) has a major impact in long-term care facilities. It is the second-leading reason for placement of older adults into institutionalized care,¹ and it is the primary reason why many elderly persons are not accepted into assisted living facilities.^2,3 In long-term care facilities, it has been estimated that about 50% of the residents are urinary incontinent and that many who are continent at admission tend to become incontinent over time.⁴ In 1 study of 430 newly admitted nursing home residents, 22% of women who were continent at admission were incontinent after 1 year.⁵ The conversion rate in men was even higher (56%). The reasons for this increase involve cognitive and mobility impairment and adjustment to the nursing home environment.
       In addition to staff, many nursing home residents believe UI is inevitable. Residents will utilize self-management strategies for urine leakage in order to protect social and psychological integrity, privacy, and dignity.⁶ Not only does UI have a substantial social effect on residents, it also has associated morbidities, including urinary tract infections (UTI), pressure ulcers, and falls with subsequent injury.^2,7 In addition, caring for residents with UI adds considerably to the burden of nursing staff and can result in morale problems and increased staff turnover.⁸ Because of these negative influences, the prevalence of UI is considered an indicator of the quality of care within long-term care facilities,⁹ and several clinical practice guidelines have been developed by regulatory agencies and caregiver associations in an effort to improve the recognition, treatment, and outcomes of UI.^{10, 11}
       In addition to UI, other bladder-related disorders like UTI are common in nursing home residents. The use of catheters to manage bladder disorders, such as UI and urinary retention, is a major problem in this setting. Historically, indwelling catheters have been used in the chronic, medically compromised elderly patient, and the prevalence of long-term catheter usage is the greatest in residents with UI residing in skilled nursing facilities (SNF). These devices increase mortality and morbidity in both men and women.^12,13 Urinary tract infections are very common in elderly persons, especially those living in nursing homes. At least 40% of all infections seen in nursing homes are in the urinary tract system; of these infections, 80% are due to urinary tract catheterization and instrumentation. UTI is of major importance because of its effect on outcomes and treatment costs. While many approaches have been used to minimize catheter-induced UTI, elimination of catheter usage remains the best method.

Federal Tag 315

       The Centers for Medicare and Medicaid Services (CMS) plans to issue new surveyor guidance for incontinence and urinary catheters. This new guidance collapses current Federal Tags 315 and 316 into 1 Tag, which will be Federal Tag 315 (Tag F315). The new guidance contains interpretive guidelines, a new investigative protocol, and compliance and severity guidance.

Table 1

The intent of this requirement is to ensure that:
•  Each resident who is incontinent of urine is identified, assessed, and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible
•  An indwelling catheter is not used unless there is valid medical justification and, if not medically justified, it is discontinued as soon as clinically warranted
• Services are provided to restore or improve normal bladder function to the extent possible after the removal of the catheter
•  A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible.
       Assessment of incontinence is the key component of this new guidance, and emphasis is placed on identifying the transient and persistent causes of UI (see Tables 1 and 2)

Table 2

Criteria for Compliance

       The guidance provides information for compliance to this regulation. Whether the resident is incontinent of urine on admission or develops incontinence after admission, the steps of assessment, monitoring, reviewing, and revising approaches to care (as needed) are essential to managing UI and restoring as much normal bladder function as possible.
       For a resident with UI, the facility is in compliance with this requirement if it 1) recognized and assessed factors affecting the risk of symptomatic UTIs and impaired urinary function; 2) defined and implemented interventions to address correctable underlying causes of UI (see Table 1) and to try to minimize the occurrence of symptomatic UTIs; 3) monitored and evaluated the resident’s response to preventive efforts and treatment interventions; and 4) revised the approaches as appropriate.
       For a resident with an indwelling urinary catheter, the facility is in compliance if it has 1) recognized and assessed factors affecting the resident’s urinary function and identified the medical justification for the use of an indwelling urinary catheter; 2) defined and implemented pertinent interventions to try to minimize complications from an indwelling urinary catheter and to remove it if clinically indicated; 3) monitored and evaluated the resident’s response to interventions; and 4) revised the approaches as appropriate.
       For a resident who has or has had a symptomatic UTI, the facility is in compliance with this requirement if it has 1) recognized and assessed factors affecting the risk of symptomatic UTIs and impaired urinary function; 2) defined and implemented interventions to try to minimize the occurrence of symptomatic UTIs and to address correctable underlying causes; 3) monitored and evaluated the resident’s responses to preventive efforts and treatment interventions; and 4) revised the approaches as appropriate.

Surveyor Steps

       The guidance outlines areas that will be of importance during the survey process. The assessment, care plan, and orders identifying facility interventions will be scrutinized and corroborated through observations by interview and record review. The surveyor will determine if staff consistently implemented care plan interventions across various shifts and will note and/or follow up on deviations from the care plan or from current standards of practice as well as potential negative outcomes. Surveyors will determine if staff made appropriate resident accommodations for residents whose assessments indicate that a toileting program is most appropriate (eg, placing the call bell within reach, responding to the call bell, and maintaining a clear pathway and ready access to toilet facilities). Toileting programs will be scrutinized to determine if assistance (eg, prompting, transfer, stand-by assist to ambulate) is required for toileting and/or the resident is on a program to restore continence or a scheduled toileting program. Also, surveyors will check to see whether the patient is generally continent and observe whether assistance has been provided to try to prevent incontinence episodes. Many residents will not be candidates for toileting programs, and in those cases the facility will need to document its clinical assessment that notes the inability of the resident to participate in a program to restore continence or a scheduled toileting program as well as who requires care due to incontinence of urine. If the resident is on a scheduled check-and-change program, compliance will be met if the staff checks and changes the resident in a timely fashion. The care of the resident who has experienced an incontinent episode will be observed as part of the survey process. Areas of interest will include:
• Condition of the pads/sheets/clothing (eg, brown rings/circles, saturated linens/clothing, odors, etc.)
• The resident’s physical condition (eg, skin integrity, maceration, erythema, erosion)
• Whether staff implemented appropriate hygiene measures (eg, cleansing, rinsing, drying, and applying protective moisture barriers or barrier films as indicated) to try to prevent skin breakdown from prolonged exposure of the skin to urine.
       The guidance for Tag F315 also reviews care of the resident with an indwelling urinary catheter. The survey process will include use of appropriate infection control practices with regard to hand washing, care of the catheter tubing, and the collection bag. Of importance will be whether staff recognizes and assesses potential signs and symptoms of symptomatic UTI or other changes in urine condition (such as onset of bloody urine, cloudiness, oliguria, or deepening/concentrating urine color). The management and assessment of urinary leakage or bypassing of the catheter will be evaluated.
       The guidance also provides nursing staff with “best practices” for catheter care to include anchoring the catheter. The avoidance of tugging on the catheter during transfer and care delivery is best to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. The guidance also reviews the different types of absorbent incontinence pads and notes that product selection should be based on the resident assessment.

Urinary Incontinence Treatment

Table 3

       The treatment for UI depends on the type of incontinence, its causes, and the capabilities and motivation of the resident. Options for managing UI in nursing home residents include primarily behavioral programs (see Table 3) and medication therapy. Other measures and supportive devices used in the management of UI and/or urinary retention may include intermittent catheterization, pelvic organ support devices (ie, pessaries), incontinence products, garments and an external collection system, and environmental accommodation and/or modification.

Deficiency Categorization

       The key elements for severity determination for Tag F315 are as follows:
• Presence of harm/negative outcome(s) or potential for negative outcomes because of lack of appropriate treatment and care
• Actual or potential harm/negative outcome for Tag F315 may include the development, recurrence, persistence, or increasing frequency of UI, which is not the result of underlying clinical conditions; complications, such as urosepsis or urethral injury, related to the presence of an indwelling urinary catheter that is not clinically justified; significant changes in psychosocial functioning, such as isolation, withdrawal, or embarrassment, related to the presence of un-assessed or unmanaged UI and/or a decline in continence, and/or the use of a urinary catheter without a clinically valid medical justification
• Complications like skin breakdown that are related to the failure to manage UI.
       The guidance also notes that surveyors will be instructed to determine the degree of harm (actual or potential) related to the noncompliance. The survey team must evaluate the harm or potential for harm based upon levels of severity for Tag F315. These levels are detailed in the guidance.

Conclusion

       The success of an incontinence care program hinges on nursing staff. The CMS guidance values “restoration of bladder function and continence” as a high quality-of-life goal for most nursing home residents. This guidance has a wealth of information about how to assess and manage residents with UI and provides resources for staff. Nursing staff will need to embrace this goal, as CMS will be watching.