Continence: A Review of F Tag 315

Introduction

In June of 2005, the Centers for Medicare and Medicaid Services (CMS) combined F-Tags 315 and 316 into one by deleting F-Tag 316. The updated F-Tag 315 issued new surveyor guidance for the different types of urinary incontinence (UI) and indwelling urinary catheters for long-term care facilities. The purpose of the updated F-Tage 315 is to improve the management of UI and follow evidenced based practice. The expectation for facilities is an evaluation of the residents upon admission and change of cognition, physical ability, or new onset of UI. Any recent onset changes could indicate a functional or transient cause of UI. Facilities are to have in place timely assessments and appropriate interventions. Nursing should assess indwelling urinary catheter use for medical necessity. If the catheter is not justified, the nurse will remove it. This blog provides several revised features of F-Tag 315 and strategies to improve UI care in long-term care facilities.

Long-Term Indwelling Catheters

Catheters placed for longer than two weeks should be limited to certain situations. Long-term use of a catheter is one month or longer. For example, residents with chronic urinary retention will be on an intermittent catheterization program. The candidates for this program should be able to tolerate the procedure. Those that cannot tolerate the procedure, such as difficult catheterization, would be better managed with the long-term use of an indwelling catheter.

Admission Assessment

Assessment is a crucial component of the F-Tag 315 and focuses on continence restoration rather than containment. Nurses will screen all admitted residents for UI. Identifying transient causes with new-onset and persistent causes of UI.

Critical components of assessment should include:

History: A structured interview with the resident, family, and caregiver to determine:

  • The onset, duration, associated symptoms, and past treatment of UI.
  • Voiding patterns: frequency, volume, daytime or nighttime, and stream quality.
  • Ability to recognize or delay signals to void
  • A history of urinary tract infections (UTI) or kidney stones.
  • Comorbid conditions associated with UI or incomplete bladder emptying. (diabetes, CHF, morbid obesity, neurological disorders, prostate disorders)
  • Dietary assessment and fluid intake.
  • Identification of types of incontinence.
  • Medications: review those that might affect continence. (anticholinergic, sedative, diuretics, narcotics, alpha-adrenergic agonists, or antagonists, and calcium channel blockers).

Physical Examination

The admitting physician or nurse practitioner should perform a focused physical examination. The exam should include:

  • Functional and cognitive assessment
  • Pelvic and rectal examination

Laboratory Testing

  • Urinalysis for signs and symptoms of UTI
  1. New onset of fever or chills.
  2. New or increased dysuria, flank, or suprapubic pain.
  3. Increased frequency and urgency.
  4. Changes in urine (foul odor, increased sediment, hematuria).
  5. Deterioration of mental status.
  • PRV testing for residents at risk for incomplete bladder emptying.

Voiding Trial

Nurses will initiate a voiding trial with any resident with leaking problems.

  • Complete a two to three-day bladder and bowel record.
  • Residents with good cognitive function and fully mobile can record the information.
  • For residents with good cognitive function and impaired mobility, staff should assist the resident to the restroom—the staff and the resident complete the form.
  • For residents with some cognitive impairment and compromised mobility, the staff prompts voiding, takes the resident to the restroom every two hours, and completes the form.

Interventions

After the assessment, the registered nurse will develop a resident-centered care plan. The goal is to optimize bladder function, prevent inappropriate use of an indwelling urinary catheter, and prevent urinary tract infection. All interventions require monitoring and modification of the care plan.

Behavioral Therapy Programs

These programs include non-medication strategies to improve bladder control. The programs have shown to be effective when used appropriately.

  • Habit training: Prompted, timed, or scheduled toileting for ambulatory residents with assistance who can respond to verbal cues and void at least 60% of the time. Residents may use a pull-up brief or pad and preventative skin care.
  • Bladder training/bladder rehabilitation: Residents who are cognitively intact with overactive bladder, urgency, and frequency. Residents are taught urge suppression techniques and ideally coordinated with a continence nurse specialist.
  • Pelvic Floor Muscle Rehabilitation: Residents with stress, urge, and mixed UI. It consists of biofeedback and Kegel exercises. It starts with daily training of 10 repetitions and gradually increases to 25 to 35 repetitions.

Medication Therapy:

  • Monitor for side effects over a one or two-month period.
  • Administer the maximum amount of tolerated dose.
  • Assess and document resident/family satisfaction with treatment.
  • If there is no response to medication, either discontinue or change to another medication.

Containment Devices:

  • Devices include absorbent incontinence products, external catheters, and toileting devices.
  • Pull-up briefs and pads in pants are only used when necessary in conjunction with routine toileting.
  • External catheters are appropriate for residents without urinary retention and are not candidates for the toileting program.

Check and Change program:

  • Residents who are not a candidate for a toileting program don’t respond to a toileting program or medication therapy.
  • Devices include absorbent incontinence products, external catheters, and toileting devices.
  • Use containment devices and Super-absorbent polymer inner core absorptive products with a breathable backing.
  • Skin care products include skin cleansers and skin barrier products.

Conclusion

The F-Tag 315 reflects the standard of care for all residents with UI. The core is assessment, monitoring, and modification of interventions. In addition, it addresses the restoration of continence care and the appropriate use of an indwelling catheter. A step-by-step approach helps establish an individualized bladder management program to fulfill the F-Tag 315 requirements.

References

Centers for Medicare & Medicaid Services. CMS Manual System, Pub. 100-07, State Operations Provider Certification, Transmittal 8. June 28, 2005. https://www.cms.hhs.gov/transmittals/downloads/R8SOM.pdf.

Doughty, Dorothy; Kisanga, Joseph. Regulatory Guidelines for Bladder Management in Long‐term Care: Are You in Compliance With F‐Tag 315?. Journal of Wound, Ostomy and Continence Nursing: July/August 2010 – Volume 37 – Issue 4 – p 399-411 doi: 10.1097/WON.0b013e3181e3a32c

Johnson TM 2nd, Ouslander JG. The newly revised F-Tag 315 and surveyor guidance for urinary incontinence in long-term care. J Am Med Dir Assoc. 2006 Nov;7(9):594-600. doi: 10.1016/j.jamda.2006.08.007. PMID: 17095426.

Kahl, Ann CWOCN. IMPLEMENTATION OF F TAG 315: 2340. Journal of Wound, Ostomy and Continence Nursing: May 2008 – Volume 35 – Issue 3 – p S42 doi: 10.1097/01.WON.0000347655.56851.04

Newman DK. Urinary incontinence, catheters, and urinary tract infections: an overview of CMS tag F 315. Ostomy Wound Manage. 2006 Dec;52(12):34-6, 38, 40-4. PMID: 17204825. https://www.in.gov/health/files/overview_F315.pdf

Parker, Diana; Callan, Laurie; Harwood, Judith; Thompson, Donna L.; Wilde, Mary; Gray, Mikel. Nursing Interventions to Reduce the Risk of Catheter-Associated Urinary Tract Infection: Part 1: Catheter Selection. Journal of Wound, Ostomy and Continence Nursing: January 2009 – Volume 36 – Issue 1 – p 23-34 doi: 10.1097/01.WON.0000345173.05376.3e

Willson, Margaret; Wilde, Mary; Webb, Marilyn-Lu; Thompson, Donna; Parker, Diana; Harwood, Judith; Callan, Laurie; Gray, Mikel. Nursing Interventions to Reduce the Risk of Catheter-Associated Urinary Tract Infection: Part 2. Journal of Wound, Ostomy and Continence Nursing: March 2009 – Volume 36 – Issue 2 – p 137-154 doi: 10.1097/01.WON.0000319369.53397.b0

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