According to the Centers for Medicare & Medicaid Services (CMS), the minimum data set (MDS) version 3.0 is designed to improve the reliability, accuracy, and usefulness of the instrument to include the resident in the assessment process and to apply standard protocols that are used in other settings.

These improvements, CMS has said, will have “profound implications for nursing home and swing bed care and public policy.”

Improvements notwithstanding, the MDS 3.0 contains numerous and substantial changes that represent a radical shift from the MDS 2.0. Some of the changes, however, can be turned into opportunities for incontinence management, especially when it comes to assessment and documentation.

The new MDS 3.0, which will be implemented on Oct. 1, 2010, is reconfigured and supported by new material, definitions, and assessment processes. The Bladder and Bowel portion of the MDS—also known as Section H—now covers the following topics:
  • Appliances;
  • Urinary toileting programs;
  • Urinary continence;
  • Bowel continence; and
  • Bowel patterns. 

Review, Review, Review

Nursing facilities would be wise to have the entire clinical staff and the MDS nurse review the form in order to begin making sense of these changes. Comparing the MDS 2.0 to the 3.0 form and becoming familiar with the items, terminology, and coding requirements is a good place to start.
Section H places an emphasis on the accurate assessment of urinary and bowel continence and the interventions used to manage incontinence. It is important to note that this section also centers on outcomes—the resident’s response to the trial toileting program.
According to the CMS “Resident Assessment Instrument 3.0 Manual,” “each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment and services  to achieve or maintain as normal elimination function as possible.”
Facilities must review chapter three of the manual, pages H-1 to H-13. This section provides details on each item in Section H of the MDS instrument, including the following topics: Item Rationale, Planning for Care, Steps for Assessment, Coding Instructions, and Coding Tips and Special Populations. Also included in this section of the manual are definitions for each appliance listed in Section H, such as an indwelling catheter, suprapubic catheter, and nephrostomy tube.
Caregivers and assessment nurses should pay close attention to these definitions. Coding instructions are also listed for each appliance on pages H-1 and H-2, with specific directions for coding appliances used in the last seven days. These definitions are very specific and should be easy to comprehend.

Get To Know MDS 3.0

Next on the new MDS form is Urinary Toileting Program. According to the MDS 3.0 manual, this section of the instrument centers on “an individualized, resident-centered toileting program [that] may decrease or prevent urinary incontinence, minimizing or avoiding the negative consequences of incontinence.”
This terminology is very sound and represents current clinical thought as well as good clinical practice and quality of life for the elderly.
In order to comply with the intent of this terminology, nursing facilities should begin with a comprehensive plan to address residents’ needs, including an accurate assessment of the patient’s level of incontinence, then move to a toileting program or a retraining program. In addition, residents should be monitored to determine if the incontinence can be decreased or resolved.
And, if the resident does not respond to the interventions, a program of supportive management should be instituted with the proper use of high-quality incontinence products and preventative skin care.
The new MDS 3.0 utilizes three codes for this section of the MDS. The first code refers to documentation that the trial of a toileting program has been attempted on admission, reentry, or since the onset of the incontinence.
The MDS manual describes all toileting programs, and the definitions are very specific. The new items are Habit Training/Scheduled Voiding and Check and Change programs.
 This is very positive. Not all residents are incontinent, and the definition in the manual for urinary incontinence is “the involuntary loss of urine,” which makes it very clear that residents with stress or postural incontinence will be coded as incontinent.
The steps for assessment, as outlined on pages H-4 and H-5 of the manual, emphasize that individualized programs need to be established, communicated to the staff and the resident, and monitored through documentation and evaluations. The goal of these steps is to diminish the number of incontinent episodes and also to maintain the resident’s dignity, quality of life, and functional status.

Combined Programs Work

Combined use of toileting programs and appropriate product use can and do work, so flexibility and individualization are the keys to success. The facility should work with vendors and suppliers that provide superior products, providing education and resources to staff, and tracking the outcomes of the toileting or retraining programs.
The resident needs to be involved in the program, and it is imperative to document any and all successes in decreasing incontinent episodes and their impact on the resident’s quality of life. 
The manual has very specific coding instructions, as well as excellent examples, and should be used as part of a facility training program.
What’s more, the manual’s definitions of the four urinary toileting programs should be consistent with facility policy and documentation standards.
Page H-4 of the manual, Response To Trial Toileting Program, and page H-5, Current Toileting Program, are very specific outcome- and implementation-reporting items that were not part of the MDS 2.0 process. It is important to note that the data gleaned from these sections will enable regulators to monitor the use and outcome, or lack thereof, of toileting programs.
On the other hand, facilities will also have the abilityto track these statistics for internal quality assurance

Importance Of Documentation

The Urinary Continence section of the MDS 3.0 manual, page H-7, asks the facility to document the level of urinary continence during the assessment period. It also outlines the devastating impact that incontinence can have on the resident, so the assessment must look at the level of incontinence over all shifts and throughout all documentation.
All clinical staff members, including physicians and other members of the interdisciplinary team, such as the activities director and therapy employees, must understand the importance of documenting for all the shifts. The coding for this section must represent the resident’s experience over the entire assessment period.
If the resident’s incontinence cannot be improved, then the staff must have a clear plan to protect the skin and the resident from unnecessary negative outcomes related to overall quality of care and quality of life.
Properly sized products that have appropriate absorbency and wicking for the level of incontinence being treated is important.
Many toileting plans and interventions need to be flexible and combine the use of treatment, interventions, and products to achieve the goal for the resident to improve quality of life, decrease the incontinent episodes, and decrease clinical risk.
This is a big assignment since such a high percentage of residents have some level of incontinence when they enter the facility.
More treatment options are available today, such as exercise, surgical interventions, behavioral programs, and combined nursing and therapy interventions. Product variety and sizing have also improved and give clinical staff the ability to establish truly individualized plans that work. 

Daunting But Worthwhile

In preparing to implement the MDS 3.0, the MDS nurse should review the facility’s current documentation process and compare it to the MDS 3.0 manual’s current practice and documentation. Educating and training staff is important, as is a complete assessment of all residents’ levels of continence, current interventions, and individualization of programs and plans. Once the plans are established, documentation must show that they have been delivered and evaluated for efficacy and outcomes.
The MDS 3.0 manual contains numerous resources for training and preparation. Appendix C, Care Area Assessment (CAA) Resources, section six on Urinary Incontinence and Indwelling Catheter(s), contains a review of the causes of incontinence, the types of incontinence, and the factors that impact the level of incontinence. This reference should assist the facility’s care team in establishing the resident’s unique plan and documenting its outcomes.
It may seem a daunting task, but preparation will pay off if clinical staff have learned more about the causes of incontinence and its successful treatment, as well as the variety of products that are available for residents to use during the retraining process.
With a clear plan that includes targeted staff education and support products, staff can work together to successfully navigate the MDS 3.0. 
With consistent efforts, the MDS 3.0 also offers the facility a new opportunity to document and achieve success in this very important area of care and support the care planning process when urinary toileting programs do not solve the problem.
Leah Klusch, RN, BSN, FACHCA, is a nurse educator, consultant, speaker, and executive director of the Alliance Training Center, an educational foundation that focuses on issues related to the care of the frail elderly. She can be reached at: