Resident care in the areas of bladder and bowel care require clinical and operational professionals to consider the impact of the minimum data set (MDS) 3.0 and its recent April 2012 changes, including updates to the resident assessment instrument (RAI) manual. These are very important treatment and regulatory areas, as they impact the treatment of nursing home residents for incontinence, urinary tract infections, toileting programs, and related skin issues.
The current MDS 3.0 collects a significant amount of data related to all of these areas of care.  Facility management needs to be very aware of the changes in the data collection processes, as well as the focus on outcomes of care that the data now represent, as they manage this very costly and complicated clinical issue.
The care and treatment of incontinence is a central part of clinical services to elders in skilled nursing facilities.
Even though incontinence is not a normal part of the aging process, many elders experience incontinence after hospitalization. Elders that experience debility or weakness due to complex medical problems also have a higher incidence of incontinence.
This can be a complex and costly issue for the facility and its clinical staff. The regulatory risks are higher, and as the data from assessments become more detailed and outcome-focused, attention to database content and tracking of the source of the data are much more important.

MDS Offers A Complete Picture

The new MDS 3.0 database is very rich with regard to toileting programs, continence, and changes in continence status, as well as the outcomes of planned programs and care. The data are complemented by specific numerical reporting of cognitive status, mood, and activities of daily living (ADL) functional status and ADL scores, which include toileting.
The current MDS database will report a much more complete picture of a resident’s status regarding the level of incontinence, progress being made with toileting or management programs, if strength or balance is improving, staff support for the toileting ADL, cognitive ability, and depression. Another important aspect of the MDS 3.0 database are overall skin issues, thanks to the new item in Section M 1040, Moisture Associated Skin Damage.
This is very integrated and specific coding that will create the data picture of the clinical situation and interventions that are being used.
Providers must be focused on this issue and discuss each component of the data, the definitions in the revised RAI Manual, and the data collection process in place in order to create the most accurate and complete picture of residents’ conditions and issues at the time of the Assessment Reference Period.
Complicating these is the Centers for Medicare & Medicaid Services’ (CMS’) focus on payment processes, medical necessity of rehabilitation therapy and other services, rehospitalizations, and outcomes-based reporting for accountable care organizations (ACOs) and other payment processes.

Given these facts, it is important to note that incontinence care is one of the highest cost centers and urinary tract infections are a very common reason for readmissions from home or institutional settings.

Processes And Data Collection

The first step to keeping up with incontinence care is to become familiar with the MDS and to look for the changes so that staff and management can be focused on the data being collected. Providers should review the facility process for completing the Brief Interview for Mental Status and Resident Mood interviews so that issues related to either of these areas that impact the assessment and care planning for incontinence are identified early in the stay.
ADL coding for transfers and toileting should be reviewed, and direct care staff must be very careful to accurately code the levels of functional decline the resident has at each assessment. The therapy plan for the resident must include building balance, strength, and skills for toileting. The test for balance in Section G of the MDS is very important, and the scores should be reviewed over time.

Clinical staff should discuss any previous incontinence issues with the resident and identify any interventions used prior to admission, as well as any interaction with specialty medical services related to the issue. Coding for the assessment needs to come from specific information in the record related to voiding, plans that include toileting programs, and outcomes data.

To correctly code Section H-200 of the MDS, the clinical team should review the definitions and intent information in chapter three of the RAI Manual, Section H, page H-3 to H-7. The steps for assessment are specific and must be addressed.

Current toileting programs do contribute to restorative program documentation, but these codes will also be used by the surveyors to identify residents in active programs during survey process. Therefore, coding must always be current and accurate. The related section (page H-3) of the RAI Manual states: “Research has shown one-quarter to one-third of residents will have a decrease or resolution of incontinence in response to toileting programs.”

Care Planning Steps Vital

The steps listed in this section related to planning for care are also very important and should be referenced as caregivers structure their approach, as follows: Determine the resident’s current continence status or risk, perform an accurate and thorough assessment, and take steps to implement appropriate individualized interventions.
The RAI Manual also references the information related to incontinence in the Care Area Resource #6 in Appendix C. Additional information about toileting programs or planning incontinence care programs can be found in the book, “Managing and Treating Urinary Incontinence,” by Diane Kaschak Newman and Alan Wein.

Coding for the level of urinary continence begins with the definitions of continence and incontinence, on page H-7 of the RAI Manual. Next, issues related to care planning, which include identification and treatment of underlying potentially reversible causes of the incontinence, must be addressed.

Be sure to look at the coding, as it is an excellent way to track outcomes of toileting programs. If the resident does not or cannot respond to the toileting program, then a plan to maintain skin dryness and minimize exposure to urine must be implemented.

To that end, a program of this type should focus not only on the times and types of incontinence, but the appropriate products and sizes needed to protect the skin while taking into consideration the resident’s dignity and comfort, as well as sleep hygiene.

Diagnostic documentation of the case is very important so the team can consider not only possible metabolic and functional issues, but also the impact of medications on the resident’s status of continence, and risk factors that will impact the total plan of care. This includes the history or risks of falls.

Incontinence and falls frequently are associated so this connects the ADL score, balance testing and coding, therapy programs, and goals, as well as the resident’s changes in cognition during the day.

Educate Staff About Skin Issues

Skin issues are always important, and facilities have been doing a good job of tracking the presence of pressure ulcers and their characteristics on the MDS 3.0, Section M. The April 1, 2012, changes to the MDS 3.0 include two new items that have impact on the status of continence. Section M of 1040 now includes G. Skin Tears and H. Moisture Associated Skin Damage (MASD) from incontinence-association dermatitis, perspiration, drainage.
The coding instructions in the RAI Manual for this section say: “Moisture-associated skin damage is a result of skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture, which can be caused, for example, by incontinence, wound exudate, and perspiration. MASD is also referred to as incontinence dermatitis.”
All staff must be educated about these new coding items and the risk they present to residents and the facility. All coded MASD should be investigated and acted on as soon as possible. Incontinence products should be evaluated for their efficiency to keep the skin dry, and the importance of proper sizing of product must be emphasized.
Coding of these items also needs to be communicated to the wound nurse and the clinical leadership of the unit.

Track Meds

Now that the MDS 3.0 dataset includes the frequency of medication use by residents, it is also important to track the use of diuretics and the frequency of administration, as it impacts the level of incontinence and related risk. A consultant pharmacist, as well as the therapy department, may be good sources for a discussion about the frequency and amount of incontinence at various times of the day that may be stimulated by medication use.

Another issue that the interdisciplinary team must focus on is the change to the Care Area Assessment (CAA) resources that are part of the care planning process and completion of Section V of the MDS. Many of the CAAs have an impact on the incontinence care plan. Therefore, members of the care planning team that are involved with the related CAAs should review the new CAA resources and look for the April 1 changes both in Chapter 4, where the CAAs are individually described, and in Appendix C, where the specific CAA resources are located.
There are many changes and significant information about toileting programs as well as related interventions.

The CAA notes need to be very specific about interventions and planning related to incontinence from many different CAA areas, such as cognition, ADL Functional Rehab, Urinary Incontinence, Psychosocial Well-Being, Dehydration and Fluid Maintenance, Pressure Ulcer, and Return to the Community.

The issues with the current MDS 3.0 and its database are very complex and have significant impact on reporting of clinical and behavioral data. The management of incontinence is very complex and requires much interdisciplinary support so the resident can reverse the condition, if possible, and have the best supportive care to protect their skin during the process.

For residents who cannot reverse the situation, there should be highly individualized plans and products to keep them out of risk and with as much dignity as possible. The changes in the assessment process and definitions and processes for care delivery will assist caregivers to establish the best policies and procedures to meet residents’ needs and keep them as functional as possible.
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