Harmony Healthcare Blog

Five Steps to Understanding Low Risk Bowel and Bladder Incontinence

Posted by Melissa Fox on Tue, Nov 29, 2016

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

maninwheelchair.jpgHarmony Healthcare International (HHI) has noted an increase in facilities who wish to improve their measure of this quality indicator on their facility Quality Measure (QM) report. It is important to remember that high ratings may not be an indicator of substandard patient care. Substandard care is not the presence of incontinent residents in your facility. Substandard care is the lack of competent assessment, inappropriate treatment or management of incontinence, and lack of adjustments to clinical care that preserve the dignity of residents who are incontinent. 

  1. Root Cause Analysis
    The Quality Measures addressing loss of bowel or bladder control reflect the percent of low-risk long stay residents who often lose control of their bowels or bladder.
    • Loss of bowel or bladder control is defined as frequently incontinent or fully incontinent on the most recent MDS in an episode of care greater than or equal to 101 days.
    • Low-risk residents include those who do not have a severe cognitive impairment (BIMS less than or equal to 7) or total dependence in bed mobility, transfer or locomotion on unit. Patients with a catheter or ostomy are also excluded from this measure. 
  1. Understanding the Defined Criterion
    Loss of bowel or bladder control is not an ordinary part of the normal aging process, and treatable causes should be investigated. Incontinence can lead to poor quality of life, including personality changes for the resident, and is a risk factor for impaired skin condition, pressure ulcers, and urinary tract infections. Causes of incontinence may include the following:
    • Medication changes
    • Physical problems such as constipation, muscle weakness or bladder infection
    • Medical conditions such as diabetes, depression, dementia, and neurological disease
    • Limited ability to walk or move around
    • Inadequate diet and fluid intake
    • Reaction to medication
    • Toileting routine
    • Physical Assistance for toileting as needed
  1. Interventions
    The incontinence may be improved or resolved by the following:
    • Referral to rehabilitation services
    • Placing a urinal or bedside commode in a resident's room
    • Helping resident get to the toilet, including a scheduled toileting program
    • Ensure adequate staffing
    • Nutritional assessment by a dietician
    • Medication review, decreasing the use of unnecessary medications
    • Eliminating restraints
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  1. Prevention
    To prevent incontinence in low-risk residents, protocols that embrace primary prevention strategies should be implemented. These protocols include assisting residents to maintain mobility and transfer abilities, thus reducing incidences of incontinence. Bladder control is a social skill developed during the first five years of life.  Facilitating cognitive functioning by creating triggers (such as prompting the resident to void and helping the resident to sit on the toilet) may also help preserve continence.

    Questions to ask if your facility is high in this measure:
    • How does the facility determine the cause of loss of bowel or bladder control?
    • How many residents are restrained and what's the procedure for their use?
    • How often does staff help mobility impaired residents use the bathroom?
    • How does the facility help the resident restore bowel or bladder control?
    • How does the facility avoid complications such as pressure ulcers in these residents? 
  1. How to Improve the Facility Measure
    • First, ensure your staff is all educated on ADL coding, specifically in regards to requiring dependent level of assistance for care and toileting. Provide education on incontinence, including its definition and coding. This education should include nursing assistants, nursing staff, MDS Coordinators and Management.
    • Second, initiate bowel and bladder assessments and diaries on every resident at admission. Analyze results and initiate interventions, be proactive and attempt to eliminate incontinence.
    • Third, determine the population sample for your facility. Review the MDS associated with the Quality Measure report and validate the coding as an Interdisciplinary team. Make modifications to the MDS as required and document in the medical record the reason for modification, update the care plan and complete an incontinence assessment.
    • Fourth, initiate a QAPI plan to demonstrate the facilities actions.

      An example of a QAPI worksheet:
Resident Name Dx Bladder Assmnt Date Possible Reason for Inc. Referral to Rehab BIMs PHQ-9 Referral to Specialist Skin Areas UTI <30 Days Mode of Transfer Mode of Toilet Med Review New Plan

The facility should develop a team to address the question of how we can improve our incontinence outcomes:

  • Involve nursing assistants from each shift, they work the closest with the residents.
  • PIP team meetings to identify potential root case.
  • Develops action plan/interventions.
  • Monitor and report back to team.
  • Maintain a log and documentation of all team efforts to improve this outcome. 

Finding the cause and treating the problem of bowel or bladder control is important for many reasons. Physically, it can help prevent infections and pressure sores. Mentally, treatment can help the well-being of the resident by restoring dignity and social interaction. Fewer residents with bowel and bladder control problems can give the nursing home staff more time to provide optimal care. It is important to remember that high ratings may not be an indicator of substandard patient care. Facilities that are proactive to determine the root cause, provide comprehensive assessment, search for appropriate treatments and adjust plans of care are those who will succeed in impacting their Quality Measure report in this area.

Please contact Harmony Healthcare International (HHI) if you need help with your Quality Measures. You can contact harmony by clicking here or calling 800.530.4413.

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Tags: Quality Measures, Bowel, Bladder

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