Continence care in nursing homes starts with an assessment. Each resident who is identified as incontinent should be evaluated and provided appropriate treatment so that normal bladder and bowel functioning improves as much as clinically possible. This means understanding the underlying conditions causing incontinence, then implementing interventions based on the assessment. In this week’s episode, we discuss how nursing homes can be liable for injuries arising from improper continence care.
Schenk: Hey out there. Welcome back to the podcast, an extra special podcast this week, not that there is a special guest but actually there’s a special host. Finally through COVID and through technology, I’ve been able to wrangle my co-host in this program, Will Smith. Will, what’s up, man?
Smith: Good to be back, man! It’s been a long time.
Schenk: Will is throwing up the power quotes, if you’re listening, because we’ve batched these way ahead of time and it just so happens Will has been unable due to court hearings and such and being a lawyer that he’s not been able to participate. And because he’s done that, the train left him. And so not much time – it’s kind of like those books Will used to read in high school, the science fiction books, the science and science fiction books where one twin gets on the spaceship and travels the speed of light and comes back to his twin who is now 80 years older. It doesn’t seem like much time has gone by for Will, but in terms of the audience, the audience hasn’t seen Will in about a year.
Smith: You know, I’ll always love the fact that we do batch these ahead of time because we have a lot of things to do, so we make these in advance. And no one could have predicted what was going to happen in 2020, the entire world falling apart and all these lockdowns. So I know it’s amusing for people who may see some of these previous ones and think, “Oh, they’re really not talking a lot about what’s going on.” We just didn’t predict knowing it.
Schenk: Right. We have abandoned the idea of this being some type of topical program. The content is evergreen.
Schenk: So speaking of that, good segue, now the point of today’s episode is to talk about continence care, incontinence care in nursing homes. And we get guidance from that from the federal regulations, the code of federal regulations, which say at 483.25, for all the nerds out there…
Smith: Or F-690.
Schenk: Yeah, or F-tag F-690 – a facility, a nursing home, must ensure that a resident who is continent of bladder and bowel on admission receive services and assistance to maintain continence care unless his or her clinical condition is or becomes such that continence is not possible to maintain, and that is both urinary continence as well as bowel continence.
And what essentially that is saying is that if you go into that nursing home with a level of continence, then it is expected under the federal regulations that you maintain or improve that level of continence unless you have some type of medical condition that would make that impossible or impracticable.
And Will, you can speak to this, but we’ve talked about this several times on the Nursing Home podcast, this podcast, I don’t know why I just said that, this podcast that a nursing home shouldn’t be able to come up to you and say, “Well your loved one, Ms. Johnson, is old, sick and dying. There’s nothing we can do about that.” I want to point out at the outset that clinical condition, as it is in this regulation, is not an excuse. The nursing home in its assessment needs to take into account whatever clinical condition there is while they’re doing the assessment and reflect that in the care plan. So they can’t say to you, “Well Ms. Johnson lost her ability to maintain continence because of medication or because of advanced age or because of the loss of cognitive capacity.” You say, “Well knowing that, what did you do? What interventions were put in place that maintained her continence care as per the regulations.”
Will, it’s been a year since you’ve been on here, so it’s been a year since you’ve been able to say you’ve worked over 10 years at a nursing home, so can you talk about that from a CNA perspective? What was your experience like with that?
Smith: So first of all, what Rob said was when you get to the facility, you should be maintaining your continence, or to the extent that you’re incontinent, trying to get you back to being continent. What I see as a practical matter, what I used to see a lot of times, is facilities that are understaffed just took it as a given that people would be incontinent, because a lot of times, there are residents who are incontinent perhaps because of spinal cord issues or other medical issues that are going on. Then there are residents who are not necessarily incontinent in that they don’t have control over their bowel or bladder muscles, but it takes them a while to get to the restroom, and if you don’t have enough staff, then you can’t wait the 20 minutes it takes someone to get there, and so all of a sudden, you’re voiding in your clothes. And what a lot of places will do is go, “Well Ms. Johnson’s incontinent. She couldn’t wait to go to the bathroom so we’re going to throw a brief on her.” And that’s not the case. If Ms. Johnson had adequate help so that every time she needed to go to the bathroom, somebody was there to take her, she could maintain her continence, her dignity, and not face a host of issues that come to incontinence as well.
Schenk: And at least one critical I guess ramification of that as you mentioned is not just dignity, the dignity issue, which is critical, but from a medical standpoint, the likelihood of negative outcomes, specifically UTIs if it’s a bladder incontinence issue, but also pressure injuries if it is a bowel or bladder issue is a possibility. And that’s why continence care in all of its forms is extremely important because it can lead to not just dignity but to real problems down the road.
And to Will’s point, that’s why the assessment is critical, and when we say assessment, it’s not a matter of being like, “Okay, can you go to the bathroom on your own or not?” An assessment is, “What medications are you on and do those medications fall into a category of making you have a type of incontinence?” Assessing when is it you go to the bathroom? What time of day? What type? That type of thing, if need be, and we can talk about this in a little bit but have a toileting program.
But the main area, and this is in my experience, where most nursing homes miss this completely, and it’s for various reasons I think, a lot has to do with the fact that it’s a CNA doing the assessment versus a registered nurse or in fact the interdisciplinary team, which is required under the law, but understanding the type of incontinence, the cause of the incontinence itself, there’s different categories, and I’m reading from – Will and I in our practice, we refer often to the regulations. We read some regulations at the top of the show. But in order to understand how the regulations are applied, we have a giant book – here, I’ll show it to you – this is the first appearance of this book on this program, but we call it the watermelon book, and this is the book that the surveyors, the people who go in and inspect the nursing homes, read to understand how the law is applied, how the regulations are applied. But anyways, I want to actually read from that really quickly because I’m talking about the importance of understanding the type of urinary incontinence.
It is standard operating procedure. It is a standard of practice to understand that, and this is the question, if you’re listening, that you need to ask the nurse, “Did you do this?” But the nature of the incontinence is a key aspect. So the first one is urge incontinence. That’s a type of incontinence. And urge incontinence is associated with detrusor muscle overactivity resulting in sudden strong urge to expel moderate to large amounts of urine before the bladder is full. It’s characterized by abrupt need to go. That’s urge incontinence.
Then there’s stress incontinence. Stress incontinence is associated with impaired urethral closure, which allows small amount of urine leakage when intra-abdominal pressure on the bladder is increased by sneezing, coughing, laughing, lifting or standing, so in other words, maybe or something physical happening to the person.
Smith: Well one very common trauma happens to females and that’s vaginal birth delivery.
Schenk: That’s exactly right. That’s a type of stress incontinence. And then we have mixed incontinence, which is a combination of different categories, overflow incontinence, which is associated with leakage of small amounts of urine when the bladder has reached its maximum capacity and has become distended from urine retention, which can be a major problem, and again, that’s one of the categories I say increases the likelihood of UTI.
Then there’s functional incontinence, which refers to loss of urine that occurs in a resident whose urine tract function is sufficiently intact that he or she should be maintain continence but cannot remain continent because of external factors other than inherently abnormal urinary tract function. Examples may include the failure of staff to respond to requests for assistance.
So the reason why I drone on about the types of urinary continence is because that is going to dictate the interventions that you use with the resident. So Will, you can speak to this, if there’s like the one that I just ended on, the functional incontinence, which is not responding to the call light, that has an implication on what the interventions are going to be. So I mean like we have UTI cases in which they don’t respond to the call light in time, and it goes, as you mentioned, it goes to staffing.
Smith: And it’s not just staffing but also, and we keep mentioning it, call lights. It’s very important – you’ll see in a lot of nursing notes that they always put in there, “Call light placed within reach.” A lot of times that’s not actually the case. They don’t give the person who’s actually bed-bound the call light. The call light may be on the ground, the call light doesn’t work, and of course with staffing issues, people just aren’t responding to call lights.
Schenk: You mentioned earlier too that it’s sometimes the go-to for the nursing home is some type of absorbent product, like a brief.
Schenk: Yeah, adult brief. And so typically the regulations say that should not be a long-term solution for incontinent care, that in fact some other intervention, whether it’s a toileting program, whether it’s responding to the call, like whatever the case may be, the adult diaper should not be something that’s utilized for an extended amount of time.
Smith: And that is just – I mean that’s what being a CNA in a nursing home is – 90 percent of your job is changing diapers, because I remember the first time that I ever – I got put on a med surg unit, which is just your typical hospital unit for somebody that has gotten out of surgery or is there in the short term. And these are functional adults. They’re not residents with incontinence. And I was amazed at the difference in the job because I was like, “Man, this is a cake walk being a CNA in a hospital,” because changing briefs on the elderly is very difficult. I mean you’re not only short-staffed, but a lot of the elderly are larger. Americans tend to be larger human beings, and so it’s a very difficult and physically demanding job, and we don’t have enough staff. There’s no way mathematically that you’re going to be able to change everybody’s briefs in time.
Schenk: Yeah. And that’s the thing is like there are so many other options for continence care. You can do medicine reviews to make sure the medicine is not causing it. There’s so many things to do. But I want to draw us back where we had an episode – this is going back maybe a couple years ago – about catheter care and UTIs, catheter-associated UTIs, and that was one thing I remember being an issue is that you might not need to mess with that catheter but once a month, like it should be changed once a month. That didn’t use to be the way it was. I remember not realizing that, that the changing of the catheter only occurs once every 30 days depending on the catheter.
Smith: Yeah, and it makes sense because it’s an intrusion into the body, right? And it comes from if you’ve ever watched a nurse place a catheter in, it’s ideally sterile. So the entire area is sterilized, the nurse’s hand is sterilized. She has the appropriate PPE on, which everyone knows what PPE is at this point, personal protective equipment, that also protects the resident. And she opens the sterile container and inserts the catheter and it’s a very intrusive process. So the more times that you do it, the more you open up somebody to the possibility of a UTI or a CUTI. For example, individuals who are paralyzed at least from the waist down, they have to use catheters to void themselves, and they have to do this on a daily basis, so they’re more prone to getting these UTIs. So if you’ve got an in-dwelling catheter, a Foley catheter, you don’t want to take it out all the time and put it back in. It’s just opening you up to an infection.
Schenk: That’s right. And so and in fact, the same with the adult briefs, in-dwelling catheters should not be in the care plan as a long-term intervention.
Smith: Sometimes they have to be. And none of this is to say these things, there’s no circumstance in which these are long-term solutions. It’s just that a lot of these nursing homes as a default say, “Well they have to have a catheter,” or “They’re going to have to have briefs,” without attempting to avoid that.
Schenk: Right. So the idea here at the end of the day, to circle back, is that continence care plays an important part in the overall care of residents in nursing homes. And the reason is because without proper continent care, infection can occur and infection can lead to sepsis and septic shock, and that can lead to organ function and failure. Aside from that, there’s the issues of quality of life and dignity. That’s why our Congress, the United States Congress, decided to make this a regulation and make it an important regulation that continence care should be assessed and interventions reviewed periodically to make sure that this individual maintains both dignity and health, so it’s an important component.
And that is to say that it’s important during the care plan process that you ask these questions. “My loved one is incontinent. What are you guys doing? What are the interventions you’re putting in place that are going to allow the resident to achieve continence as soon as possible?”
Smith: Yeah. Talk with the care plan team, the director of nursing. Talk with them about your loved one’s continence issue, both urinary and fecal. So ask them, “What are their bowel movements like? Have they had impaction? How often have they had impaction?” These are very important issues because impactions, not to get off on something else, which is also related to fecal incontinence, are very dangerous and can possibly kill somebody.
Schenk: Right. We’ve had several cases where fecal impaction over the course of days and a week has caused sepsis and organ failure.
Schenk: So along those lines, asking the interdisciplinary team about the care plan, if there’s a toileting program, what are the physician’s orders with regard to catheter care, if it’s an in-dwelling catheter, how long are they going to be that – don’t be afraid to ask questions. There are no stupid questions. Yeah, there are no dumb questions, only dumb answers. What is that? Is that from the Bible or something? Where am I getting that from?
Smith: I don’t think that’s from the Bible.
Schenk: Something from the Bible? Okay. But anyways, don’t be afraid to ask questions.
Smith: Don’t be afraid to look at the chart, like, “This is my loved one. I’m part of the interdisciplinary team as a family representative. What is her voiding scheduled? How often is she voided? How often has she had a bowel movement or a BM?”
Schenk: That’s right. And one of the important things from that is once you have an understanding in the care plan of what they’re doing with regard to what they’re doing with continence care or incontinence care, if your loved one is susceptible or at a high risk for developing a UTI because of incontinence of the bladder or incontinence of the bowel, then you need to make sure that your loved one is getting their vitals checked regularly and that the signs and symptoms of infection are being monitored. That’s a lot of our cases involving UTI and unfortunately sepsis death due to UTI. It’s not necessarily the inability or the negligence of the nursing home to prevent the UTI. It’s failure to observe the signs and symptoms of the infection after it was developed. So understand, know the signs and symptoms of UTI I guess is what I’m trying to say.
I think that we – this is kind of a broad topic, so I feel like we kind of hit everything. Is there anything else? Like what else do we got?
Smith: No, I mean I would just say in general, know the medications and the results, the side effects of certain medications. A lot of the elderly, because of edema or other issues, are on blood thinners like Coumadin, and those diuretics can make the necessity to void a lot more frequent. So it just goes in line with knowing everything you can about your loved one and talking with the interdisciplinary team about it.
Schenk: That’s right. And so I guess to round out the episode, can you sue a nursing home for poor continence care or for poor incontinence care? The answer is you can sue a nursing home for whatever you want to. The real issue is, as we’ve explained on this podcast many, many times, is the infection, and we’ll say in this instance, the UTI, is the UTI the result of a breach of the standard of care at that nursing home? When we say breach of standard of care, we mean those three things that we’re always talking about. Did the nursing home conduct an accurate assessment? Did the nursing home create a care plan based on that assessment? And did the nursing home monitor and observe the effectiveness of that care plan? If the answer is no to any of those three and as a result your loved one developed a UTI or maybe worse, they passed away from sepsis from the UTI, then yes, there is a possibility that you can sue that nursing home for poor continence care.
Well Will, this has been pretty crazy having you back, so to speak. I mean your name was at the beginning of the episode. I think people were beginning to wonder if I had killed you.
Smith: Right. I definitely – I can tell I need to figure out the lighting issue because you look really good and presentable and I can tell I look like I’m about to enter the gates of heaven or something with the light.
Schenk: You do look like you have an interrogation light over you, but you are in our library, so that’s the thing. We’re in different locations. You’re where we typically would have been taping the show.
Smith: That’s right. That’s correct.
Schenk: The Dungeon. Okay. Well I think that’s going to do it for this episode. If you are enjoying the content of the Nursing Home Abuse Podcast, be sure to like and subscribe wherever you get your podcasts from. And while you’re doing that, go over to our YouTube channel, the Nursing Home Abuse Podcast YouTube channel, and like and subscribe, hit the notification bell. New episodes every other week, that is twice a month, on Mondays. Be sure to check us out. Maybe Will will be back. We don’t know. Who knows? Definitely Will doesn’t know. But great, that will do it for this episode, and with that, folks, we’ll see you next time.
Smith: See you next time.