INDEX Bowel and Bladder Management program Sample forms

INDEX
TAB ONE
Bowel and Bladder Management program
TAB TWO
Sample forms
- Assessments
- Voiding Patterns and Re-training tools
- QA Tools
TAB THREE
F-tag 315 Guidance to Surveyors and
Investigative protocol.
Manual includes:
Program CD –Bowel and Bladder Management --includes entire program, protocol, and forms.
PROCEDURES
How to use this manual:
All systems and processes have key steps or components that are needed to achieve the desired
outcome. For a clinical program, the desired outcomes include:
1. Compliance with regulations and best practices.
2. Provides for individualized assessment and care planning.
3. Monitors effectiveness of processes in achieving desired resident outcomes.
The QA Committee should review all outlined key components in this manual, then
perform a gap analysis comparing current systems to recommended best practices
recommended.
SA
M
PL
E
Steps:
1. Evaluate current systems to key components outlined in this manual.
2. Define standards and key components for the health center.
3. Review F-tag 315 guidelines and protocols. Access clinical resources listed in guidance
as a resource for developing procedures.
4. Use text from the manual provided on CD to develop center specific procedures.
5. Finalize forms.
6. Provide education and training to staff.
7. Implement systems.
8. Develop ongoing QA to monitor effectiveness.
BLADDER CONTINENCE ASSESSMENT
RESIDENT:
ROOM:
MEDICAL HISTORY *
(over)
MEDICATION
HISTORY ** (over)
MOBILITY
1
SLIGHTLY
IMPAIRED
Occasional
confusion; some
difficulty in new
situations only
1
2
MODERATERLY
IMPAIRED Frequently
confused and
disoriented; decisions
poor; requires cues and
supervision
2
3
SEVERELY
IMPAIRED Continual
confusion; decisions
never or rarely made/
also includes
comatose resident
3 or more
≤1 Group I
No Group II, III
2 Group I; and/or 1
Group II; No Group
III
3 Group I; and/or 2
Group II; and/or 1 Group
III
>3 Group I; and/or
≤ 3 Group II; and/or
≤ 2 Group III
INDEPENDENT
Fully ambulatory;
self-sufficiency
once in W/C; able
to transfer to and
from toilet
LIMITED
ASSISTANCE
Ambulates with
limited assistance
(i.e. walker, cane)
able to transfer to
and from toilet with
minimal assistance
USUALLY /
OCCASIONAL
Incontinent ≤ 1 per
week; and/or ≤ 2 per
week, but not daily
FAIR
1000 – 2000 cc
daily
EXTENSIVE
ASSISTANCE
Ambulates and transfers
to and from toilet with
moderate assistance
DEPENDENT Non
weight bearing; unable
to transfer without full
staff assistance
FREQUENTLY Daily
incontinence, but some
control present
INCONTINENT
Inadequate control,
multiple daily
episodes
No
LIMITATIONS
Alert, oriented x3
decisions
consistent and
reasonable
None
FLUID INTAKE
GOOD
≤ 2000 cc daily
SA
BLADDER CONTROL
STATUS
CONTINENT
Aware of need to
void; includes
foley
POOR
500 – 1000 cc daily
SIGNATURE
EXTREMELY POOR
< 500 cc daily
TOTAL
0 – 3 = High restorative potential (retraining)
4 – 9 = Moderate restorative potential (habit/prompted)
10 – 14 =Low restorative potential (habit/prompted)
15 - 18 = Minimal restorative potential (Check Change)
INTL
SCORE
E
COGNITIVE STATUS
0
M
PL
CRITERIA
DATE
INITIAL
INTL
SIGNATURE
INTL
SIGNATURE
SEE INSTRUCTION ON BACK
Polaris Group (800) 275-6252
Page 1 of 2
COMPLETION OF THE BLADDER CONTINENCE ASSESSMENT
1.
2.
3.
4.
The licensed nurse will evaluate each resident for each of the six criteria, determine the description that most
closely approximates the condition of the resident, and record the numerical score in the scoring column at the
far right.
Add the scores from the criteria and enter the total in the spaces provided to determine the nursing interventions
for each resident.
The assessing nurse signs and dates the Bladder Continence Assessment.
Using the total score, implement the nursing interventions according to the scale listed.
0–3=
4–9=
5.
High restorative potential (retraining)
Moderate restorative potential (habit/prompted)
10 – 14 =Low restorative potential (habit/prompted)
15 - 18 = Minimal restorative potential (CheckChange)
The Bladder Continence Assessment form should be placed in the medical record upon completion.
* MEDICAL HISTORY: Refers to medical conditions that affect the restorative potential of the resident.
Examples below are not all inclusive:
j. Other -
SA
d. Pulmonary e. Sensor/Perceptual f. Cognitive g. Psychiatric h. Endocrine i. Genitourinary -
E
c. Musculoskeletal -
ASHD, CHF, Cardiac Dysrhythmia, HTN, PVD, CAD, Hypotension, Pacemaker
CVA, MS, CP, Huntington’s Chorea, Parkinson’s Disease, Peripheral Neuropathy,
Hemiplegia, Paraplegia, Quadriplegia, Hemiparesis, Seizure Disorder, Transient Ischemic
Attach (TIA), Comatose, Aphasia
Previous Fractures, Arthritis, Scoliosis, Pain, Skeletal Deformities, Kyphosis, Amputation
(i.e. missing limb)
Asthma, DOPD, Emphysema
Balance Abnormality, Dizziness, vertigo, Glaucoma, Cataracts, Blindness, Hearing Loss
Alzheimer’s Disease, Dementia other than Alzheimer’s Disease
Depression, Anxiety Disorder, Manic Depressive (bipolar dx.) Psychosis, Neurosis
Hypo/Hyperglycemia, Diabetes Mellitus, Hypo/Hyperthyroidism
Vitamin B12 Deficiency, High BUN or Creatinine, Atrophic Vaginitis, Rule Out UTI, Rule
Out Fecal Impaction, Rule Out Laxative Dependence, Cancer (i.e. Prostate), Hemorrhoids,
Fissures/Fistulas, Rectal Bleeding
Cancer (i.e. Brain), Explicit Terminal Prognosis
M
PL
a. Cardiovascular b. Neurological -
** MEDICATION HISTORY: refers to medications that affect the restorative potential of the resident. Review 24
hour regularly administered (scheduled & prn) medications. Examples below are not all
inclusive:
GroupI
a. Cardiac Lanoxin, Inderal, Procardia, Calan, Nitrobid, Transderm-Nitro, Lopressor
b. Antihypertensive/Diuretic - Lasix, capoten, Dyazide, HCTZ, Diuril, Catapres, Tenorectic
c. Sedative/HypnoticsSedative - Restoril, Halcion, Dalmane, Benadryl
Group II
a. Antidepressants/Antianxiety –Valium, Librium, Sinequan, Elavil, Ativan, Desyrel, Xanax, Ludiomil,
Vistaril, Buspar
Antivert, Dramamine, Compazine
b. Anticholingerics Group III
a. Antipsychotic/Neuroleptics - Mellaril, Haldol, Stelazine, Thorazine, Prolixin, Trilaforn, Navane
b. Anticonvulsants/Neuromuscular – Phenobarbital, Artane, Dilantin, Moban, Tegretol, Depakene, Klonopin
c. Anti-Parkinson Levodopa, Sinemet, Eldepryl, Permax, Parlodel, Cogentin
Polaris Group (800) 275-6252
Page 2 of 2
PRELIMINARY NURSING ASSESSMENT
Admit Date _____________ Admit time ______________ From _______________ Via __________________
Diagnosis __________________________________________ Allergies: ______________________________
T: ___________ P: ___________ R: ___________ BP: __________ HT: __________ WT: ______________
1.
COGNITIVE (CIRCLE)
ALERT / ORIENTED TO: PERSON – PLACE – TIME MEMORY PROBLEMS / ACUTE CONFUSION /
LETHARGIC / SEMI COMATOSE / COMATOSE: DESCRIBE __________________________________________
CARE PLAN Y OR N
2.
MOOD AND BEHAVIOR (CIRCLE)
ELOPEMENT POTENTIAL: Y or N __________________________ If yes, complete full Elopement Assessment tool
E
(Circle One) WITHDRAWN / PACING / VERBALLY ABUSIVE / CRYING / WEEPING / ANGRY / RESISTS CARE /
M
PL
REPETITIVE BEHAVIORS / AGITATION/ OTHER: ____________________________________________________
CONDITION/DIAGNOSIS:_____________________________________________________CARE PLAN: Y OR N
RECEIVING: HYPNOTIC / ANTIPSYCHOTIC / ANTIANXIETY / ANTIDEPRESSANT:
LIST MEDS: _______________________________________________________________________________________
If applies:
BEHAVIOR MONITOR INITIATED: _____ REFERRED TO PHARMACY: _____
3.
SA
CONSENT SIGNED:_______SIDE EFFECT MON. STARTED:______ AIMS:__________
COMMUNICATION (CIRCLE)
HOH / DEAF L R B
HEARING AIDE L R B / OTHER:
COMMUNICATES: SPEECH / GESTURES / WRITES / OTHER APHASIC
CAN BE UNDERSTOOD Y OR N UNDERSTANDS Y OR N
CARE PLAN: Y OR N
4.
REFER TO THERAPY: Y OR N
VISION (CIRCLE)
ADEQUATE Y OR N GLASSES Y OR N
BLIND Y OR N – L R B
LENS IMPLANTS L R B
PROSTHESIS L R B GLAUCOMA / CATARACTS / FIELD CUT L R B
5.
CARE PLAN: Y OR N
PAIN (CIRCLE) VERBAL OR NONVERBAL EXPRESSION OF PAIN: PAIN: Yes No CARE PLAN Y OR N
COMPLETE PAIN SCREEN ON ALL RESIDENTS: IF SCORE IS GREATER THAN 3, COMPLETE FULL
ASSESSMENT FORM.: Pain Screen Score: _______ Pain Scale: 1-10:_______
RESIDENT:__________________________________ RM:_______MR#________
Page 1 of 4
ELIMINATION ASSESSMENT SUMMARY
Summary of risk factors, environmental. Functional/adaptive device needs, & voiding pattern data: Bladder Risk Score: ___
Type of Incontinence: Urge___ Stress___ Mix___ Overflow___ Functional___ Other___ Unknown___
† Implement Bladder or Bowel retraining program:
Remove † Continue with Foley Catheter Justification:
Infection Control in place:
Fluid needs:
Care Plan Completed
M
PL
†
†
†
†
E
† Implement Intermittent Catheterization:
† Implement [] Prompted [] Habit [] Scheduled toileting training program as the individualization scheduled toileting plan for:
† Bladder
† Bowel
OR
† Prior failed attempts at toileting schedules, implement Check and Change
Describe toileting plan:
Assessment completed by: _________________________________________
Date_______________
ELIMINATION ASSESSMENT SUMMARY
SA
Summary of risk factors, environmental. Functional/adaptive device needs, & voiding pattern data: Bladder Risk Score:___
Type of Incontinence: Urge___ Stress___ Mix___ Overflow___ Functional___ Other___ Unknown___
† Implement Bladder or Bowel retraining program:
† Implement Intermittent Catheterization:
† Implement [] Prompted [] Habit [] Scheduled toileting training program as the individualization scheduled toileting plan for:
† Bladder
† Bowel
OR
† Prior failed attempts at toileting schedules, implement Check and Change
Describe toileting plan:
†
†
†
†
Remove † Continue with Foley Catheter - Justification:
Infection Control in place:
Fluid needs:
Care Plan Completed
Assessment completed by: _________________________________________
Date_______________
Resident_______________________ Med Rec_______ Physician_______________ Rm_____________
Polaris Group (813) 886-6500
Page 1 of 1
1. INTIAL/QUARTERLY ELIMINATION ASSESSMENT SUMMARY
Summary of risk factors, environmental. Functional/adaptive device needs, & voiding pattern data: Bladder Risk
Score: ___
Type of Incontinence: Urge___ Stress___ Mix___ Overflow___ Functional___ Other___ Unknown___
† Implement Bladder or Bowel retraining program:
† Remove † Continue with Foley Catheter Diagnosis:
† Infection Control precautions in place:
† Special Fluid needs:
† Care Plan revised/updated/current
E
† Implement Intermittent Catheterization:
Implement: [] Prompted [ ] Habit [] Scheduled toileting plan: † Bladder † Bowel † Both
Prior failed attempts at toileting schedules, † implement Check and Change
Describe plan:
M
PL
Assessment completed by: _______________________________________
Date_______________
2. QUARTERLY ELIMINATION ASSESSMENT SUMMARY
Summary of risk factors, environmental. Functional/adaptive device needs, & voiding pattern data: Bladder Risk
Score: ___
SA
Type of Incontinence: Urge___ Stress___ Mix___ Overflow___ Functional___ Other___ Unknown___
† Implement Bladder or Bowel retraining program:
† Implement Intermittent Catheterization:
Implement: [] Prompted [ ] Habit [] Scheduled toileting plan: † Bladder † Bowel † Both
Prior failed attempts at toileting schedules, † implement Check and Change
Describe plan:
† Remove † Continue with Foley Catheter Diagnosis:
† Infection Control precautions in place:
† Special Fluid needs:
† Care Plan revised/updated/current
Assessment completed by: _______________________________________
Resident: _____________________________________
MR#:_________
Date_______________
Rm #: ______ Page 2 of 3
Page 1 of 2
CONTINENCE & CATHETER ASSESSMENT & RAP
FACTORS POTENTIALLY related to CONTINENCE STATUS
Bowel and Bladder Risk Score: _______________________________________
(Complete as part of RAI process and after Voiding Pattern Data Collection has occurred)
Current DIAGNOSES
Indicate MEDICATIONS currently taking:
† Antibiotics
† Disopyramide
† Diuretics
† Calcium channel blockers
† Antipsychotics
† Antianxiety
† Antispasmodics
† Antidepressants
† Antihistamines
† Hypnotics
† Narcotics
† Parkinsonism
† Antacids
† Drugs that stimulate or
† Stool softeners/laxatives
block sympathetic nervous
† Antidiarrheals
system
Admit date:
History of:
† Urinary disorders
† Prostate Problems
† Other (describe)
† Bladder disorders
† Neurological problems
† Pain
† Kidney disease
† U.T.I.
† Abnormal labs
† Edema
† No impairments impacting ability to toilet
† Impaired cognitive ability to use:
Due to decline in:
† Impaired sensory ability to use:
Due to decline in:
† Environmental factors:
† commode
† ROM
† transferability
† Fx
† cast
† need for adaptive device
† toilet
† commode
† bedpan/urinal
† call light
† ambulation
† bed mobility
† lighting
† balance
† use of restraints
† difficulty
removing clothes
E
Due to decline in:
† toilet
† bedpan/urinal
† call light
† impaired memory † comatose
† resistive to care
† refusal of care
† inability to remember toileting tasks
M
PL
† Impaired physical ability to use:
† toilet
† commode
† bedpan/urinal
† call light
† vision
† blind
† decline in communication skills
† hearing
† aphasic
† location of toilet
† location of commode
† lighting
† See RD Assessment regarding diet, fiber, fluid needs._______________________________________________________________________________
BOWEL ASSESSMENT
SA
(Complete at end of 3-day observation period)
CONTINENT of STOOL:
† Yes
† No
If incontinent: How long has resident been incontinent?
_______________ † Days † Months † Years
Reason identified, if known:
___________________________________________________
Frequency of incontinence:
† Less than weekly † Once a week † 2-3 times a week
† All (or almost all) the time
USUAL ELIMINATION PATTERN:
Frequency: _______________________________________________
Time(s) of Day:
† Upon rising
† After meal(s): † Bkfst † Lunch † Dinner
† No apparent pattern
† Other (describe):
__________________________________________________
Amount: † Small † Med. † Large † Other: _________________
Perception of need to evacuate: † Present † Diminished † Absent
Prompting method:
________________________________________________________
History of impactions: † No † Yes, freq: ___________________
________________________________________________________
Results of 3-day Observation: ________ % Continent
Pattern: _________________________________________________
________________________________________________________
________________________________________________________
Resident Name
ID#
USUAL CONSISTENCY:
Consistency: † Hard † Formed † Soft † Liquid † Other: ____________
Color:† Tarry † Light/Medium † Dark Brown † Clay † Other: _________
Flatulence:
If known, caused by: ____________________________________________
Other (describe): _________________________________________________
Comments:
_______________________________________________________________
ADDITIONAL PHYSICAL SYMPTOMS/PROBLEMS:
† Bowel Sounds: ________________________________________________
Comments: _____________________________________________________
ELIMINATION ASSISTS:
† None used
† Stool softeners, name, dose, freq: _________________________________
† Laxatives, name, dose, freq: _____________________________________
† Enemas, type, amount, freq: _____________________________________
† Suppositories, type, amount, freq: ________________________________
† Juice/Fiber, type, freq:__________________________________________
Comments:
______________________________________________________________
EXERCISE PATTERNS:
Describe usual daily activities: _____________________________________
Is resident capable of increasing? † Yes † No, describe:
______________________________________________________________
Comments:
______________________________________________________________
______________________________________________________________
Room #
Physician
FOLEY CATHETER ASSESSMENT AND MANAGEMENT
Y
(Yes)
N
(No)
M
PL
E
A resident is not to be catheterized unless his/her clinical condition demonstrated
that catheterization was necessary. An indwelling catheter should only be used
when there is a valid medical justification. In order to assess the need for
catheterization the following questions need to be answered:
Does the resident have a valid medical justification (supporting diagnosis) for use of the
indwelling catheter?
List:___________________________________________________
Does the resident have documented urinary retention that cannot be treated or corrected
medically or surgically, for which alternative therapy is not feasible characterized by:
[ ] Documented post void residual (PVR) volumes in a range over 200ml.
[ ] Inability to manage the retention/incontinence with intermittent catherization;
and
[ ] Persistent overflow incontinence, symptomatic infections, and/or renal
dysfunction
Does the resident have supporting diagnostic testing or unsuccessful catheter-free trials
documented?
Does the resident have contamination of Stage 3 or 4 pressure ulcer with urine which has
impeded healing, despite appropriate personal care for the incontinence?
Does the resident have a terminal illness or severe impairment, which makes positioning
or clothing changes uncomfortable or which is associated with intractable pain?
If any of the above questions in this section are answered “yes”, then indwelling catheterization may
be medically necessary if benefits outweigh risks. Re-evaluation should occur at least quarterly or
at time of a symptomatic UTI.
Catheter size: _____
SA
Check the following practices:
Y
(Yes)
N
(No)
Is the staff following the facility’s protocol and/or written procedures for catheterization?
Do all personnel wash their hands before and after caring for the
catheter/tubing/collecting bag ?
Is staff securing catheter to minimize injury and positioning bag to decrease risk of
infection?
Is staff cleaning the catheter and providing bowel care per protocol?
Fluid Needs addressed and met?
SUMMARY: [ ] Remove catheter and initiate bladder program
[ ] Continue indwelling catheter
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
RESIDENT: ______________________________________________________
ROOM: _______________
SIGNATURE: _____________________________________________________
DATE: _______________
Polaris Group (813) 886-6500
Page 1 of 1
Page 1 of 2
RESTORATIVE BOWEL AND/OR BLADDER RETRAINING PROGRAM
RESIDENT:
ROOM:
MONTH:
[ ] RETRAINING PROGRAM [ ] SCHEDULED TOILETING PROGRAM PROMPTED VOIDING PROGRAM
[ ] BOWEL PROGRAM [ ] CATHETER REMOVAL/RETRAINING
(PLACE A CHECKMARK IN THE BOX FOR THE APPROPRIATE PROGRAM)
2
3
4
5
6
7
8
9
10 11 12 1
2
3
4
5
DATE
7
8
9
10 11 12 1
p
p
p
p
p
p
p
p
p
p M A A A A A
A A A A A N p
1
YEAR:
INITIAL
(SIGN ON REVERSE)
6
A
11-7
7-3
3-11
E
2
3
6
7
8
9
10
11
12
SA
5
M
PL
4
13
14
BLADDER PLAN: 1ST – 2ND Week: Check resident q2 hours, record code in boxes. Nurse circle hours that have established patterns. Toilet resident within one hour prior to circled times.
3rd–4th week: The length of time the resident has successfully delayed voiding will become the new established voiding pattern. Continue working with this patter until the resident is continent; usually 1-2 weeks.
BOWEL PLAN: Determine individual bowel pattern; obtain physician order for reflex bowel training program. On 1st morning, examine rectum and remove any impaction. Completely evacuate rectum by
suppository, enema or both. According to individual bowel patter, insert a suppository as ordered by physician 30 minutes prior to determined time of evacuation. After 15-30 minutes, or when resident has urge to
defecate, place resident on toilet. If defection doesn’t occur, return resident to bed to check rectally. Progress is shown by repeated periods of continence; bowel reflex usually resumes by 3 weeks.
CODES: S = TOILETED c SUCCESS
L= LAXATIVE
UI = URINARY INCONTINENCE BI = BOWEL INCONTINENCE W = TOILETED s SUCCESS
UC = URINARY CONTINENCE BC = BOWEL CONTINENCE
R = RESIDENT REFUSED
SP = SUPPOSITORY
E = ENEMA
LG = LARGE
M = MEDIUM
SM= SMALL
RESIDENT VOIDING PATTERN & HABIT/SCHEDULED TOILETING PLAN
Goal: Circle One: Continent 100% of the time
.Continent during waking hours
.Occasionally incontinent (<3x in 24 hrs)
IU= INCONTINENT URINE (Wet) (IB=Inc. Bowel)
CU= CONTINENT URINE (CB=Cont. Bowel)
CODE FOR EACH HOUR TO MEASURE SUCCESS OF PLAN
12
M
1
am
2
am
3
am
4
am
5
am
6
am
7
am
8
am
9
am
10
am
11
am
12
Noon
1
pm
2
pm
3
pm
4
pm
5
pm
6
pm
7
pm
8
pm
9
pm
10
pm
11
pm
SA
M
PL
E
Date
D=Dry
Instructions: Resident is to be toileted =
Upon Arising
Before Meals
After Meals
At Bedtime
______ Toileting every two hours while awake ______ Toileting every one hour while awake
Other (specify times)
During the night at
Intervals
______________
Devises Used (D-Day, E-Eve. N-Night): ____Commode at bedside___urinal___bedpan___toilet___Other______________________________
Other directions: _____________________________________________________________________________________________________
Fluid Needs:_________________________________________________________________________________________________________
RESIDENT NAME:
Polaris Group (813) 886-6500
DOCTOR:
ROOM#:
Page 1 of 1
.
BLADDER RETRAINING FLOWSHEET
Residents Name:
Room#:
WEEK ONE: Record date. Initial in the appropriate box for each shift. Enter the code from the bottom in the box for the applicable
MR#:
time which best applies.
Comments/Progress:
7-3
3-11
11-7
7
am
8
am
9
am
10
am
11
am
12
pm
1
pm
2
pm
3
pm
4
pm
5
pm
6
pm
7
pm
8
pm
9
pm
10
pm
11
pm
12
am
1
am
2
am
3 am
4
am
5 am
6 am
3
am
4
am
5
am
6
am
M
PL
E
Date
/ Init
WEEK Two: Record date. Initial in the appropriate box for each shift. Enter the code from the bottom in the box for the applicable time which best applies.
Comments/Progress:
7-3
3-11
11-7
7
am
8
am
9
am
10
am
11
am
12
pm
1
pm
2
pm
3
pm
4
pm
5
pm
6
pm
7
pm
8
pm
9
pm
10
pm
11
pm
12
am
1
am
2
am
SA
Date
/Init
CODES:
U
C
B
T
Episode of urinary incontinence
Resident found to be clean/dry
Episode of bowel incontinence
Toileted self/continent
Polaris Group (813) 886-6500
A
N
W
O
Assisted to toilet with result
Resident not cooperative
Assisted to toilet without result
Assisted to toilet with incontinent episodes
Page 1 of 2
QA SCREEN
Prevalence of Indwelling Catheter
Threshold = 90% or greater
Directions: Audit 100% of residents with Prevalence of Indwelling Catheter if flagged at the 90th % or greater.
Y or X = Met
NA = Not Applicable
Medical Record/Room Number
Criteria/Questions
2.
3.
4.
5.
6.
MDS items that trigger QI and risk status are accurate
for observation period
Bowel and Bladder Assessment (RAP) upon admission,
quarterly, and at time of change
Bladder and bowel patterns collected for three days
upon admission and at time of decline in continence
Toileting plan documented: 1) Bladder/Bowel
Retraining, 2) Scheduled Toileting,
3) Attends/diapers only, 4) Indwelling Catheter
Care plan addresses fluid needs and bowel routine as
indicated
Care Plan addresses catheter care per facility policy
E
1.
Comments
Observe provision of catheter care; infection control
practices followed during care
8. Positioning of catheter in bed or chair maintains
infection control best practices
9. Catheter and bag are covered to protect privacy per
facility policy
Indwelling Catheter: Documentation supports continued use
of Indwelling catheter
An indwelling catheter must be justified per regulations
F315:
1. Urinary Retention that a) is causing persistent overflow
incontinence, symptomatic infections, and/or renal
dysfunction, b) Cannot be corrected surgically, c)
Cannot be managed practically with intermittent
catheter use.
2. Skin wounds, pressure sores or irritations that are being
contaminated by urine
3. Terminal illness or severe impairment, which
makes bed and clothing changes uncomfortable or
disruptive.
SYSTEM: QIs printed out monthly; review and investigate
if flagged at the 90th % or greater
SA
M
PL
7.
Percentage of Compliance =
# of Yes responses x100
Total #of blocks: )the # of
audits x’s the # of questionsexclude System and NA
questions)
Assessor:
Threshold Reached:
Yes
No
Percentage of Compliance (# yes divided by # blocks = % compliance)
Completed By:
Polaris Group (813) 886-6500
Title:
Date:
Page 1 of 1