In June 2005, the Centers for Medicare & Medicaid Services (CMS) issued new surveyor guidance—F-tag 315—for urinary incontinence (UI) and indwelling urinary catheter use in SNF residents.1 While the federal regulation did not change, the guidance to state and federal agencies did, as SNFs must address the following:

If these criteria are not met, SNFs can receive financial penalties up to $10,000 a day. Understanding the new guidance is therefore important, but many challenges exist. The following comments offer specific guidance; further information on specific techniques/products/methods mentioned can be found in the reference list at the end of the article.

Causes

Surveyor guidance for UI and urinary catheters expects SNFs to provide an evaluation of residents at the time of admission and when there is a change in cognition, physical function, or urinary tract function.1 Emphasis is placed on identifying the transient causes—especially in a resident with new onset UI—and persistent causes of UI. The mnemonic “PRAISED” addresses transient causes:

• Pharmaceuticals, psychological

• Restricted mobility, retention

• Atrophic urethritis or vaginitis

• Infection (urinary)

• Stool impaction

• Endocrine disorders

• Delirium, dehydration

Persistent causes of UI include:

• urge or overactive bladder

• stress

• a combination of urge/overactive bladder and stress, called mixed UI

• overflow

• functional problems, such as physical, cognitive, medication, or environmental issues

Assessment

Assessment should include signs and symptoms, UI onset, duration, history, and previous treatment.3 Completion of a three-day Bladder and Bowel Record is essential for determining urinary and bowel habits and is required by F315. Staff must comply with post-void residual (PVR) testing to determine the presence of incomplete bladder emptying. F315 recommends PVR testing in residents at risk for incomplete bladder emptying (e.g., those with diabetes; prostate disorders; neurologic conditions such as post-acute stroke, multiple sclerosis, and spinal cord injury; history of urinary retention; and elevated PVR). There are two methods for PVR testing: (1) bladder ultrasound or bladder scan and (2) catheterization.4 As catheterization of the bladder can increase the likelihood of UTIs, SNFs should use noninvasive technology that ensures quality and evidence-based clinical practice while preventing associated medical problems in vulnerable residents.5

Care Plan

Once the resident is assessed, a resident-centered plan of care should be developed to optimize bladder function and to prevent UTI and the inappropriate use of an indwelling catheter.3 SNF staff will need to determine the most appropriate treatment program, which in certain residents will include toileting programs or drug therapy. Toileting programs include:

• scheduled or timed toileting

• habit training

• prompted voiding

• bladder training/retraining

Drug therapy includes anticholinergic agents, quaternary ammonium compounds, and selective M3-receptor antagonists. If drug therapy is instituted, staff should check for side effects over a one- to two-month period; assess frequency of and resident/family satisfaction with treatment; administer the maximum tolerated dose, and if there is no response discontinue or switch to another agent; and use the MDS to evaluate treatment.3

Containment Devices

Assessment will identify those residents whose urine leakage should be managed by containment devices such as absorbent incontinence products, external condom catheters, or toileting devices such as a urinal.6 An appropriate incontinence absorbent product is one that keeps the urine away from the skin. Staff should choose products based on absorbing properties, the ability to minimize or prevent exposure to urine and feces, and the quantity of the resident’s urine leakage.2 A skin-friendly product provides a surface area against the resident’s perineum, and collects and transmits the urine to a super-absorbent polymer (SAP) inner core, which holds more urine than fluff pulp. These products have two layers: an upper layer that distributes the urine more efficiently and maintains a drier layer next to the skin, and an outer later that provides the absorption capacity. “Breathable” backings reduce skin occlusion. This inner core promotes urine distribution throughout the entire pad, facilitating absorption capacity while preventing urine leakage and odor. Staff may need to reevaluate old practices such as having a resident “open to air” at night, lying on an absorbent or reusable product while asleep. This should be avoided.2

Conclusion

CMS F-tag 315 reflects the standard of care for all persons with UI despite age or place of care. Recommendations within the guidance present real challenges to SNFs attempting to provide the best quality nursing care to residents who are older and frailer. Staff need to remember that the core of F315 is assessment, and only once this is completed can care be determined.

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