W

ith the recent survey focus on urinary incontinence and the release of the Federal Tag 315 (Tag F315) survey protocol, additional focus should be given to fecal incontinence as well. It has been reported that some surveyors are asking additional questions about bowel elimination and continency. It is important for clinical managers to be prepared to answer questions related to bowel continence as well as urinary incontinence. Active bowel retraining or a scheduled toileting plan for fecal elimination must be considered as part of the comprehensive plan.
       The Minimum Data Set (MDS) manual states, “Determination of whether or not to code incontinence is not a matter of volume. It is a matter of skin wetness and irritation and the associated risk for skin breakdown.” Urinary incontinence is a major risk factor for pressure ulcer development. Excessive moisture (from stool and/or urofecal incontinence) can cause the skin to become macerated with less pressure needed to develop a stage 2 pressure ulcer. Coding incontinence is a matter of acknowledging and recording a resident’s incontinence problem on the assessment and ensuring that the care plan derived from the assessment addresses the problem. Any episode of incontinence requires intervention, not just in terms of immediate incontinence care but also in terms of dealing with the underlying problem whenever possible and instituting a retraining, toileting, or incontinence care plan. And since incontinence is a problem that many residents are sensitive about, intervention involves maintaining dignity and lifestyle.
       The coding of the resident’s continency status has a special tracking for bowel incontinence, and the MDS codes for these events must be validated in the record. Fecal incontinence is caused by either a deficiency in the contracture of the external sphincter of the anus or a change in the consistency of the fecal material, causing accidental or spontaneous release. The anal musculature is unique in telling the difference between solid, liquid, and gas. In the elderly, this sensation can be impaired around the anus. Liquid or semi-solid stool can be released, soiling underwear or clothing.
       The most common cause of incontinence in the nursing home is constipation and fecal wedging (impaction). Some elderly persons experience lower anal sensation and sphincter pressure, and their rectal angle is often straighter. Incontinent persons are often mentally impaired and/or less mobile. Another cause of incontinence is global brain disease in which the reflexes are ignored and the body takes over and flushes itself automatically. A third group is associated with local colon or rectal disease, such as diarrhea, cancer, diabetes, diverticula (multiple outpouchings), inflammatory bowel disease, or overuse of laxatives. Also, when the anal muscles are weak (ie, an open, expanded anus), a stool in the rectum is not held up for convenient evacuation—it escapes.

Constipation

       Constipation is a symptom, not a disease. It is frequently caused by a disturbance of how the colon works. The normal functions of the colon are to:
• Remove water from the waste material that passes from the small intestine into the colon
• Serve as a storage area for waste material
• Help move and expel stool from the body.
Constipation may occur because:
• Too much water is removed by the colon, causing dry or hard stools
• Stool moves too slowly through the colon
• The patient is unable to expel stools.
       Normal bowel habits among healthy persons vary greatly, from 3 times a day to 3 times a week. The MDS assessment also has a focus on bowel elimination patterns in section H2. This causes many care-planning and assessment problems. The first issue is the general knowledge base of the nurses doing the documentation so that determination of fecal continence is consistent in the record. The quality of the assessment and planning process is based on the quality of the documentation as well as the interventions and observations. Careful intake and output records need to be kept during the assessment reference period, and changes to the resident’s condition and/or incontinence occurrences must be tracked.
       The MDS process does give us basic definitions and guidance for coding section H2. I suggest for a facility to begin with these definitions, which are clinically sound and straightforward. There are 4 assessment codes:
• Bowel Elimination Pattern Regular: The resident has at least one movement every 3 days
• Constipation: The resident passes 2 or fewer bowel movements per week or strains more than 25% of the time when having a bowel movement
• Diarrhea: Frequent elimination of watery stools from any etiology (eg, diet and viral or bacterial infection)
• Fecal Impaction: The presence of hard stool upon digital rectal exam; fecal impaction may also be present if stool is seen on an abdominal X-ray in the sigmoid colon or higher, even with a negative digital exam or documentation in the clinical of daily bowel movement.
       All staff must be speaking the same language for the assessment-planning and delivery process to work well. The manual also provides additional information about the distinction between constipation and fecal impaction. The first issue is a proper assessment of the resident’s bowel elimination pattern or habit. Frequently, the change in eating habits and lack of mobilization with the frail elderly in the hospital or skilled facility does not permit a normal elimination habit. Any fecal incontinence or release of fecal material is a problem for the skin. So all incontinence must be recorded and addressed.
       Many caregivers only consider it fecal incontinence if there is a large amount of fecal material. Consequently, many residents with more minor sphincter-control problems are not identified. They are at risk for skin breakdown because the feces are on their underwear and skin, which can cause irritation, burning, excoriation, and/or breakdown. Caregivers must be very specific about reporting even small episodes of fecal incontinence or presence of feces on the skin or clothing. Not all of these situations can be changed with scheduled toileting plans or retraining programs, however; if the resident cannot control the release of feces, improved cleansing and/ or the use of barrier cream is advised to diminish the risk of skin breakdown.
       Clinical managers must be specific with the care delivery team as they assess the resident and then manage risks with careful interventions. Some residents would apply barrier creams to themselves if they were aware of its importance. Especially dependent residents require additional attention to perineal care and specific treatment to diminish the risk of skin breakdown. Some fecal incontinence can be controlled with toileting or retraining programs. Nurses must be aware of the resident’s bowel habits and changes immediately so that the loss of control due to an infection or reaction to foods can be identified.

Conclusion

       The most serious problem facing most long-term care facility residents related to bowel elimination is fecal impaction. This is a sentinel health event in the eyes of the regulatory agencies. When a fecal impaction is suspected, the physician must be notified and aggressive assessment and treatment instituted. The MDS manual has a clarification statement for cleanliness that describes the relativity of constipation and impaction. Frequently, a person with an impaction will have watery stools and incontinence. Careful cleansing and documentation of these episodes must be done to assist in the diagnosis and treatment of fecal impaction.
       Fecal incontinence is not as frequent as urinary incontinence but brings the same risks for caregiving outcomes and regulatory review. All members of the team should be using the same terminology and definitions in their assessment and treatment documentation. All episodes of incontinence should be documented and interventions implemented to protect the resident and properly cleanse after any episodes. Interventions are necessary for all residents with incontinence, and all staff should be prepared for questions about incontinence from surveyors.