Pain assessments

Here is the interpretive guidance under F309 for pain. I am sure you have read this and it is probably redundant to you, but it is the guidance we follow. It may be too much unnecessary information, but gives an idea of the scope of the pain issue under the Quality of Care tag.

Once a day is NOT sufficient, in my opinion. When you read the guidance it does not specify how frequently it should be assessed, but missing a complaint of pain resulting in the pain going untreated for 24 hours (especially in a demented resident if you are only doing it once a day) could result in harm for the resident depending on the severity of the pain. It is important that residents who are having therapy or wound care be treated prior to therapy or wound care, or asked if they are having pain. Certainly your corporate person isn't referring to those folks (?), probably just to those with "less specific" pain issues. As a general rule, and which I am sure you are used to, the Nursing staff usually assess the pain at each med pass, which would be at least every shift. When they are in the rooms to give meds, it is one of the 5 vital signs to ask about pain.

Stand your ground!

Interpretive Guidance:

Review of a Resident Who has Pain Symptoms, is being Treated for Pain, or Who has the Potential for Pain Symptoms Related to Conditions or Treatments.

Recognition and Management of Pain - In order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, the facility, to the extent possible:

Recognizes when the resident is experiencing pain and identifies circumstances when pain can be anticipated;

Evaluates the existing pain and the cause(s), and

Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current clinical standards of practice, and the resident's goals and preferences.

Definitions Related to Recognition and Management of Pain

"Addiction" is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by an overwhelming craving for medication or behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

"Adjuvant Analgesics" describes any medication with a primary indication other than pain management but with analgesic properties in some painful conditions.

"Adverse Consequence" is an unpleasant symptom or event that is due to or associated with a medication, such as impairment or decline in a resident ' s mental or physical condition or functional or psychosocial status. It may include various types of adverse drug reactions and interactions (e.g., medication-medication, medication-food, and medication-disease).

NOTE: Adverse drug reaction (ADR) is a form of adverse consequences. It may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic effect of the medication or any response to a medication that is noxious and unintended and occurs in doses for prophylaxis, diagnosis, or treatment. The term "side effect" is often used interchangeably with ADR; however, side effects are but one of five ADR categories, the others being hypersensitivity, idiosyncratic response, toxic reactions, and adverse medication interactions. A side effect is an expected, well-known reaction that occurs with a predictable frequency and may or may not constitute an adverse consequence.

" Complementary and Alternative Medicine" (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine.

"Non-pharmacological interventions" refers to approaches to care that do not involve medications, generally directed towards stabilizing or improving a resident ' s mental, physical or psychosocial well-being.

"Pain" is an unpleasant sensory and emotional experience that can be acute, recurrent or persistent.4 Following are descriptions of several different types of pain:

-"Acute Pain" is generally pain of abrupt onset and limited duration, often associated with an adverse chemical, thermal or mechanical stimulus such as surgery, trauma and acute illness;

-"Breakthrough Pain" refers to an episodic increase in (flare-up) pain in someone whose pain is generally being managed by his/her current medication regimen;

-"Incident Pain" refers to pain that is typically predictable and is related to a precipitating event such as movement (e.g., walking, transferring, or dressing) or certain actions (e.g., disimpaction or wound care); and

-"Persistent Pain" or "Chronic Pain" refers to a pain state that continues for a prolonged period of time or recurs more than intermittently for months or years.

"Physical Dependence" is a physiologic state of neuroadaptation that is characterized by a withdrawal syndrome if a medication or drug is stopped or decreased abruptly, or if an antagonist is administered.

"Standards of Practice" refers to approaches to care, procedures, techniques, treatments, etc., that are based on research and/or expert consensus and that are contained in current manuals, textbooks, or publications, or that are accepted, adopted or promulgated by recognized professional organizations or national accrediting bodies.

"Tolerance" is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce the same effect or a reduced effect is observed with a constant dose.

Overview of Pain Recognition and Management

Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain. Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. The onset of acute pain may indicate a new injury or a potentially life-threatening

condition or illness. It is important, therefore, that a resident's reports of pain, or nonverbal signs suggesting pain, be evaluated.

The resident's needs and goals as well as the etiology, type, and severity of pain are relevant to developing a plan for pain management. It should be noted that while analgesics can reduce pain and enhance the quality of life, they do not necessarily address the underlying cause of pain. It is important to consider treating the underlying cause, where possible. Addressing underlying causes may permit pain management with fewer analgesics, lower doses, or medications with a lower risk of serious adverse consequences.

Certain factors may affect the recognition, assessment, and management of pain. For example, residents, staff, or practitioners may misunderstand the indications for, and benefits and risks of, opioids and other analgesics; or they may mistakenly believe that older individuals have a higher tolerance for pain than younger individuals, or that pain is an inevitable part of aging, a sign of weakness, or a way just to get attention. Other challenges to successfully evaluating and managing pain may include communication difficulties due to illness or language and cultural barriers, stoicism about pain, and cognitive impairment.

It is a challenge to assess and manage pain in individuals who have cognitive impairment or communications difficulties. Some individuals with advanced cognitive impairment can accurately report pain and/or respond to questions regarding pain. One study noted that 83 percent of nursing home residents could respond to questions about pain intensity.

Those who cannot report pain may present with nonspecific signs such as grimacing, increases in confusion or restlessness or other distressed behavior. Effective pain management may decrease distressed behaviors that are related to pain. However, these nonspecific signs and symptoms may reflect other clinically significant conditions (e.g., delirium, depression, or medication-related adverse consequences) instead of, or in addition to, pain. To distinguish these various causes of similar signs and symptoms, and in order to manage pain effectively, it is important to evaluate (e.g., touch, look at, move) the resident in detail, to confirm that the signs and symptoms are due to pain.

Resources Related to Pain Management

Examples of clinical resources available for guidance regarding the assessment and management of pain include:

American Geriatrics Society Clinical Practice Guideline at: http://www.americangeriatrics.org/education/cp_index.shtml;

American Medical Directors Association (AMDA) Clinical Practice Guideline

"Pain Management in the Long-Term Care Setting" (2003) at: http://www.amda.com/tools/guidelines.cfm;

American Academy of Hospice and Palliative Medicine at http://www.aahpm.org;

American Academy of Pain Medicine at http://www.painmed.org;

American Pain Society at http://www.ampainsoc.org;

Brown University's Pain and Physical Symptoms Toolkit at http://www.chcr.brown.edu/pcoc/physical.htm;

Hospice and Palliative Nurses Association at http://www.hpna.org;

John A Hartford Institute for Geriatric Nursing "Try This" series at http://www.hartfordign.org/Resources/Try_This_Series;

National Initiative on Pain Control at http://www.painedu.org;

Partners Against Pain® at http://www.partnersagainstpain.com;

Quality Improvement Organizations at http://www.medqic.org; and

Resource Center for Pain Medicine and Palliative Care at Beth Israel Medical Center (2000) at http://www.stoppain.org/education_research/index.html.

NOTE References to non-U.S. Department of Health and Human Services (HHS) sources or sites on the Internet are provided as a service and do not constitute or imply endorsement of these organizations or their programs by CMS or HHS. CMS is not responsible for the content of pages found at these sites. URL addresses were current as of the date of this publication.

Care Process for Pain Management

Processes for the prevention and management of pain include:

o Assessing the potential for pain, recognizing the onset or presence of pain, and assessing the pain;

o Addressing/treating the underlying causes of the pain, to the extent possible;

o Developing and implementing interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both;

o Identifying and using specific strategies for different levels or sources of pain or

pain-related symptoms, including:

- Identifying interventions to address the pain based on the resident-specific assessment, a pertinent clinical rationale, and the resident' s goals;

- Trying to prevent or minimize anticipated pain;

- Considering non-pharmacological and CAM interventions;

- Using pain medications judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences;

- Monitoring appropriately for effectiveness and/or adverse consequences (e.g., constipation, sedation) including defining how and when to monitor the resident ' s symptoms and degree of pain relief; and

- Modifying the approaches, as necessary.

Pain Recognition

Because pain can significantly affect a person's well-being, it is important that the facility recognize and address pain promptly. The facility's evaluation of the resident at admission and during ongoing assessments helps identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment. In addition, it is important that a resident be monitored for the presence of pain and be evaluated when there is a change in condition and whenever new pain or an exacerbation of pain is suspected. As with many symptoms, pain in a resident with moderate to severe cognitive impairment may be more difficult to recognize and assess.

Expressions of pain may be verbal or nonverbal. A resident may avoid the use of the term "pain." Other words used to report or describe pain may differ by culture, language and/or region of the country. Examples of descriptions may include heaviness or pressure, stabbing, throbbing, hurting, aching, gnawing, cramping, burning, numbness, tingling, shooting or radiating, spasms, soreness, tenderness, discomfort, pins and needles, feeling "rough," tearing or ripping. Verbal descriptions of pain can help a practitioner identify the source, nature, and other characteristics of the pain. Nonverbal indicators which may represent pain need to be viewed in the entire clinical context with consideration given to pain as well as other clinically pertinent explanations. Examples of possible indicators of pain include, but are not limited to the following:

Negative verbalizations and vocalizations (e.g., groaning, crying/whimpering, or screaming);

Facial expressions (e.g., grimacing, frowning, fright, or clenching of the jaw);

Changes in gait (e.g., limping), skin color, vital signs (e.g., increased heart rate, respirations and/or blood pressure), perspiration;

Behavior such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities;

Loss of function or inability to perform Activities of Daily Living (ADLs), rubbing a specific location of the body, or guarding a limb or other body parts;

Difficulty eating or loss of appetite; and

Difficulty sleeping (insomnia).

In addition to the pain item sections of the Minimum Data Set (MDS), many sections such as sleep cycle, change in mood, decline in function, instability of condition, weight loss, and skin conditions can be potential indicators of pain. Any of these findings may indicate the need for additional and more thorough evaluation.

Many residents have more than one active medical condition and may experience pain from several different causes simultaneously. Many medical conditions may be painful such as pressure ulcers, diabetes with neuropathic pain, immobility, amputation, post- CVA, venous and arterial ulcers, multiple sclerosis, oral health conditions, and infections. In addition, common procedures, such as moving a resident or performing physical or occupational therapies or changing a wound dressing may be painful. Understanding the underlying causes of pain is an important step in determining optimal approaches to prevent, minimize, or manage pain.

Observations at rest and during movement, particularly during activities that may increase pain (such as dressing changes, exercises, turning and positioning, bathing, rising from a chair, walking) can help to identify whether the resident is having pain. Observations during eating or during the provision of oral hygiene may also indicate dental, mouth and/or facial pain.

Recognizing the presence of pain and identifying those situations where pain may be anticipated involves the participation of health care professionals and direct care and ancillary staff who have contact with the resident. Information may be obtained by talking with the resident, directly examining the resident, and observing the resident ' s behavior. Staffing consistency and the nursing staff 's level of familiarity with the residents was reported in one study to have a significant effect on the staff member's ability to identify and differentiate pain-related behavior from other behavior of cognitively impaired residents.

Nursing assistants may be the first to notice a resident's symptoms; therefore, it is important that they are able to recognize a change in the resident and the resident's functioning and to report the changes to a nurse for follow-up. Family members or friends may also recognize and report when the resident experiences pain and may provide information about the resident's pain symptoms, pain history and previously attempted interventions. Other staff, e.g., dietary, activities, therapy, housekeeping, who have direct contact with the resident may also report changes in resident behavior or resident complaints of pain.

Assessment

Observing the resident during care, activities, and treatments helps not only to detect whether pain is present, but also to potentially identify its location and the limitations it places on the resident. The facility must complete the Resident Assessment Instrument (RAI) (See 42 CFR 483.20 F272). According to the CMS Revised Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 2.0, Manual Chapter 1.14 CMS Clarification Regarding Documentation Requirements, "Completion of the MDS does not remove the facility's responsibility to document a more detailed assessment of particular issues of relevance for the resident....Clinical documentation that contributes to identification and communication of residents' problems, needs and strengths, that monitors their condition on an on-going basis, and that records treatment and response to treatment is a matter of good clinical practice and is an expectation of trained and licensed health care professionals. " An assessment or an evaluation of pain based on clinical standards of practice may necessitate gathering the following information, as applicable to the resident:

o History of pain and its treatment (including non-pharmacological and pharmacological treatment);

o Characteristics of pain, such as:

-Intensity of pain (e.g., as measured on a standardized pain scale);

-Descriptors of pain (e.g., burning, stabbing, tingling, aching);

-Pattern of pain (e.g., constant or intermittent);

-Location and radiation of pain;

-Frequency, timing and duration of pain;

o Impact of pain on quality of life (e.g., sleeping, functioning, appetite, and mood);

o Factors such as activities, care, or treatment that precipitate or exacerbate pain;

o Strategies and factors that reduce pain;

o Additional symptoms associated with pain (e.g., nausea, anxiety);

o Physical examination (may include the pain site, the nervous system, mobility and function, and physical, psychological and cognitive status);

o Current medical conditions and medications; or

o The resident's goals for pain management and his or her satisfaction with the current level of pain control.

Management of Pain

Based on the evaluation, the facility, in collaboration with the attending physician/prescriber, other health care professionals, and the resident and/or his/her representative, develops, implements, monitors and revises as necessary interventions to prevent or manage each individual resident's pain, beginning at admission. These interventions may be integrated into components of the comprehensive care plan, addressing conditions or situations that may be associated with pain, or may be included as a specific pain management need or goal.

The interdisciplinary team and the resident collaborate to arrive at pertinent, realistic and measurable goals for treatment, such as reducing pain sufficiently to allow the resident to ambulate comfortably to the dining room for each meal or to participate in 30 minutes of physical therapy. Depending on the situation and the resident ' s wishes, the target may be to reduce the pain level, but not necessarily to become pain-free. To the extent possible, the interdisciplinary team educates the resident and/or representative about the need to report pain when it occurs and about the various approaches to pain management and the need to monitor the effectiveness of the interventions used.

The basis for effective interventions includes several considerations, such as the resident's needs and goals; the source(s), type and severity of pain (recognizing that the resident may experience pain from one or more sources either simultaneously or at different times) and awareness of the available treatment options. Often, sequential trials of various treatment options are needed to develop the most effective approach.

It is important for pain management approaches to follow pertinent clinical standards of practice and to identify who is to be involved in managing the pain and implementing the care or supplying the services (e.g., facility staff, such as RN, LPN, CNA; attending physician or other practitioner; certified hospice; or other contractors such as therapists). Pertinent current standards of practice may provide recommended approaches to pain management even when the cause cannot be or has not been determined.

If a resident or the resident's representative elects the Medicare hospice benefit for end-of-life care, the facility remains the resident's primary care giver and the SNF/NF requirements for participation in Medicare or Medicaid still apply for that resident. According to the Medicare Hospice Conditions of Participation at 42 CFR 418.112(b) Standard: Professional Management, "The hospice must assume responsibility for professional management of the resident's hospice services provided, in accordance with the hospice plan of care and the hospice conditions of participation, and make nay arrangements necessary for hospice-related inpatient care in a participating Medicare/Medicaid facility according to 418.100 and 418.112(b)." The care of the resident, including pain management, must be appropriately coordinated among all providers.

In order to provide effective pain management, it is important that staff be educated and guided regarding the proper evaluation and management of pain as reflected in or consistent with the protocols, policies, and procedures employed by the facility.

Non-pharmacological interventions

Non-pharmacologic interventions may help manage pain effectively when used either independently or in conjunction with pharmacologic agents.22 Examples of non-pharmacologic approaches may include, but are not limited to:

Altering the environment for comfort (such as adjusting room temperature, tightening and smoothing linens, using pressure redistributing mattress and positioning, comfortable seating, and assistive devices);

Physical modalities, such as ice packs or cold compresses (to reduce swelling and lessen sensation), mild heat (to decrease joint stiffness and increase blood flow to an area), neutral body alignment and repositioning, baths, transcutaneous electrical nerve stimulation (TENS), massage, acupuncture/acupressure, chiropractic, or rehabilitation therapy;

Exercises to address stiffness and prevent contractures; and

Cognitive/Behavioral interventions (e.g., relaxation techniques, reminiscing, diversions, activities, music therapy, coping techniques and education about pain).

The list of Complementary and Alternative Medicine (CAM) options is evolving, as those therapies that are proven safe and effective are used more widely.

NOTE: Information on CAM may be found on the following sites:

National Center for Complementary and Alternative Medicine at http://www.nccam.nih.gov; and

Food and Drug Administration (FDA) at http://www.fda.gov.

Because CAM can include herbal supplements, some of which potentially can interact with prescribed medications, it is important that any such agents are recorded in the resident's chart for evaluation by the physician and consultant pharmacist.

Pharmacological interventions

The interdisciplinary team (nurses, practitioner, pharmacists, etc.) is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain, such as during a treatment. The regimen considers factors such as the causes, location, and severity of the pain, the potential benefits, risks and adverse consequences of medications; and the resident's desired level of relief and tolerance for adverse consequences. The resident may accept partial pain relief in order to experience fewer significant adverse consequences (e.g., desire to stay alert instead of experiencing drowsiness/confusion). The interdisciplinary team works with the resident to identify the most effective and acceptable route for the administration of analgesics, such as orally, topically, by injection, by infusion pump, and/or transdermally.

It is important to follow a systematic approach for selecting medications and doses to treat pain. Developing an effective pain management regimen may require repeated attempts to identify the right interventions. General guidelines for choosing appropriate categories of medications in various situations are widely available.

Factors influencing the selection and doses of medications include the resident's medical condition, current medication regimen, nature, severity, and cause of the pain and the course of the illness. Analgesics may help manage pain; however, they often do not address the underlying cause of pain. Examples of different approaches may include, but are not limited to: administering lower doses of medication initially and titrating the dose slowly upward, administering medications "around the clock" rather than "on demand" (PRN); or combining longer acting medications with PRN medications for breakthrough pain. Recurrent use of or repeated requests for PRN medications may indicate the need to reevaluate the situation, including the current medication regimen. Some clinical conditions or situations may require using several analgesics and/or adjuvant medications (e.g., antidepressants or anticonvulsants) together. Documentation helps to clarify the rationale for a treatment regimen and to acknowledge associated risks.

Opioids or other potent analgesics have been used for residents who are actively dying, those with complex pain syndromes, and those with more severe acute or chronic pain that has not responded to non-opioid analgesics or other measures. Opioids should be selected and dosed in accordance with current standards of practice and manufacturers' guidelines in order to optimize their effectiveness and minimize their adverse consequences. Adverse consequences may be especially problematic when the resident is receiving other medications with significant effects on the cardiovascular and central nervous systems. Therefore, careful titration of dosages based on monitoring/evaluating the effectiveness of the medication and the occurrence of adverse consequences is necessary. The clinical record should reflect the ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications.

Other interventions have been used for some residents with more advanced, complex, or poorly controlled pain. Examples include, but are not limited to: radiation therapy, neurostimulation, spinal delivery of analgesics (implanted catheters and pump systems), and neurolytic procedures (chemical or surgical) that are administered under the close supervision of expert practitioners.

Monitoring, Reassessment, and Care Plan Revision

Monitoring the resident over time helps identify the extent to which pain is controlled, relative to the individual's goals and the availability of effective treatment. The ongoing evaluation of the status (presence, increase or reduction) of a resident's pain is vital, including the status of underlying causes, the response to interventions to prevent or manage pain, and the possible presence of adverse consequences of treatment. Adverse consequences related to analgesics can often be anticipated and to some extent prevented or reduced. For example, opioids routinely cause constipation, which may be minimized by an appropriate bowel regimen.

Identifying target signs and symptoms (including verbal reports and non-verbal indicators from the resident) and using standardized assessment tools can help the interdisciplinary team evaluate the resident's pain and responses to interventions and determine whether the care plan should be revised, for example:

o If pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated; or

o If pain has resolved or there is no longer an indication or need for pain medication, the facility works with the practitioner to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics.

Investigative Protocol for Pain Management

Quality of Care Related to the Recognition and Management of Pain

Objective

The objective of this protocol is to determine whether the facility has provided and the resident has received care and services to address and manage the resident ' s pain in order to support his or her highest practicable level of physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Use

Use this protocol for a resident who has pain symptoms or who has the potential for pain symptoms related to conditions or treatments. This includes a resident:

Who states he/she has pain or discomfort;

Who displays possible indicators of pain that cannot be readily attributed to another cause;

Who has a disease or condition or who receives treatments that cause or can reasonably be anticipated to cause pain;

Whose assessment indicates that he/she experiences pain;

Who receives or has orders for treatment for pain; and/or

Who has elected a hospice benefit for pain management.

Procedures

Briefly review the care plan and orders to identify any current pain management interventions and to focus observations. Corroborate observations by interview and record review.

NOTE: Determine who is involved in the pain management process (for example, the staff and practitioner, and/or another entity such as a licensed/certified hospice).

1. Observation

Observe the resident during various activities, shifts, and interactions with staff. Use the observations to determine:

o If the resident exhibits signs or symptoms of pain, verbalizes the presence of pain, or requests interventions for pain, or whether the pain appears to affect the resident's function or ability to participate in routine care or activities;

o If there is evidence of pain, whether staff have assessed the situation, identified, and implemented interventions to try to prevent or address the pain and have evaluated the status of the resident's pain after interventions;

o If care and services are being provided that reasonably could be anticipated to cause pain, whether staff have identified and addressed these issues, to the extent possible;

o Staff response, if there is a report from the resident, family, or staff that the resident is experiencing pain;

o If there are pain management interventions for the resident, whether the staff implements them. Follow up on:

- Deviations from the care plan;

- Whether pain management interventions have a documented rationale and if it is consistent with current standards of practice; and

- Potential adverse consequence(s) associated with treatment for pain (e.g., medications); and

o How staff responded, if the interventions implemented did not reduce the pain consistent with the goals for pain management.

2. Resident/Representative Interviews

Interview the resident, or representative to the degree possible in order to determine the resident's/representative's involvement in the development of the care plan, defining the approaches and goals, and if interventions reflect choices and preferences, and how they are involved in developing and revising pain management strategies; revisions to the care plan, if the interventions do not work. If the resident is presently or periodically experiencing pain, determine:

Characteristics of the pain, including the intensity, type (e.g., burning, stabbing, tingling, aching), pattern of pain (e.g., constant or intermittent), location and radiation of pain and frequency, timing and duration of pain;

Factors that may precipitate or alleviate the pain;

How the resident typically has expressed pain and responded to various interventions in the past;

Who the resident and/or representative has told about the pain/discomfort, and how the staff responded;

What treatment options (e.g., pharmacological and/or non-pharmacological) were discussed;

How effective the interventions have been; and

If interventions have been refused, whether there was a discussion of the potential impact on the resident, and whether alternatives or other approaches were offered.

3. Nurse Aide(s) Interview. Interview staff who provide direct care on various shifts to determine:

If they are aware of a resident's pain complaints or of signs and symptoms that could indicate the presence of pain;

To whom they report the resident's complaints and signs, or symptoms; and

If they are aware of, and implement, interventions for pain/discomfort management for the resident consistent with the resident's plan of care, (for example, allowing a period of time for a pain medication to take effect before bathing and/or dressing).

4. Record review

Assessment. Review information such as orders, medication administration records, multidisciplinary progress notes, The RAI/MDS, and any specific assessments regarding pain that may have been completed. Determine if the information accurately and comprehensively reflects the resident's condition, such as:

Identifies the pain indicators and the characteristics, causes, and contributing factors related to pain;

Identifies a history of pain and related interventions, including the effectiveness and any adverse consequences of such interventions;

Identifies the impact of pain on the resident's function and quality of life; and

Identifies the resident's response to interventions including efficacy and adverse consequences, and any modification of interventions as indicated.

NOTE Although Federal requirements dictate the completion of RAI assessments according to certain time frames, standards of good clinical practice dictate that the assessment process is more fluid and should be ongoing. (Federal Register, Vol. 62, No. 246, 12/23/97, Page 67193)

Care Plan. Review the care plan. Determine if pain management interventions include as appropriate:

Measurable pain management goals, reflecting resident needs and preferences;

Pertinent non-pharmacological and/or pharmacological interventions;

Time frames and approaches for monitoring the status of the resident's pain, including the effectiveness of the interventions; and

Identification of clinically significant medication-related adverse consequences such as falling, constipation, anorexia, or drowsiness, and a plan to try to minimize those adverse consequences.

If the care plan refers to a specific facility pain management protocol, determine whether interventions are consistent with that protocol. If a resident's care plan deviates from the protocol, determine through staff interview or record review the reason for the deviation.

If the resident has elected a hospice benefit, all providers must coordinate their care of the resident. This care includes aspects of pain management, such as choice of palliative interventions, responsibility for assessing pain and providing interventions, and responsibility for monitoring symptoms and adverse consequences of interventions and for modifying interventions as needed.

NOTE If a resident is receiving services from a Medicare certified hospice and the hospice was advised of concerns by the facility and failed to address and/or resolve issues related to coordination of care or implementation of appropriate services, file a complaint with the State Agency responsible for oversight of this hospice, identifying the specific resident(s) involved and the concerns identified.

Care Plan Revisions

Determine whether the pain has been reassessed and the care plan has been revised as necessary (with input from the resident or representative, to the extent possible). For example, if the current interventions are not effective, if the pain has resolved, or the resident has experienced a change of condition or status.

5. Interviews with health care practitioners and professionals:

Nurse Interview. Interview a nurse who is knowledgeable about the needs and care of the resident to determine:

How and when staff try to identify whether a resident is experiencing pain and/or circumstances in which pain can be anticipated;

How the resident is assessed for pain;

How the interventions for pain management have been developed and the basis for selecting them;

If the resident receives pain medication (including PRN and adjuvant medications), how, when, and by whom the results of medications are evaluated (including the dose, frequency of PRN use, schedule of routine medications, and effectiveness);

How staff monitor for the emergence or presence of adverse consequences of interventions;

What is done if pain persists or recurs despite treatment, and the basis for decisions to maintain or modify approaches;

How staff communicate with the prescriber/practitioner about the resident's pain status, current measures to manage pain, and the possible need to modify the current pain management interventions; and

For a resident who is receiving care under a hospice benefit, how the hospice and the facility coordinate their approaches and communicate about the resident's needs and monitor the outcomes (both effectiveness and adverse consequences).

Interviews with Other Health Care Professionals. If the interventions or care provided do not appear to be consistent with current standards of practice and/or the resident's pain appears to persist or recur, interview one or more health care professionals as necessary (e.g., attending physician, medical director, consultant pharmacist, director of nursing or hospice nurse) who, by virtue of training and knowledge of the resident, should be able to provide information about the evaluation and management of the resident's pain/symptoms. Depending on the issue, ask about:

How chosen interventions were determined to be appropriate;

How they guide and oversee the selection of pain management interventions;

The rationale for not intervening, if pain was identified and no intervention was selected and implemented;

Changes in pain characteristics that may warrant review or revision of interventions; or

When and with whom the professional discussed the effectiveness, ineffectiveness and possible adverse consequences of pain management interventions.

If during the course of this review, the surveyor needs to contact the attending physician regarding questions related to the treatment regimen, it is recommended that the facility's staff have the opportunity to provide the necessary information about the resident and the concerns to the physician for his/her review prior to responding to the surveyor's inquiries. If the attending physician is unavailable, interview the medical director as appropriate.

DETERMINATION OF COMPLIANCE WITH F309 FOR PAIN MANAGEMENT

See SOm, Appendix PP for the continuation of this task)

wow, i was just going to say that under J0800 indicators of pain in the RAI manual under staff assessment (for those resident's who could not be understood) it says to interview staff on each shift.

I too am a patient advocate especially when it comes to pain. I worked in oncology at one time and have had experience with unfortunatly many friends and family members with cancer. when i worked the floor, whether 7-3 or 3-11 i would frequently assess for pain. i always felt what if this were my mother, etc. in this day and age, no one should have to suffer. finding the correct medication and dose for the specific situation should be of the utmost importance. truely a quality of life issue.

Our standard orders are QShift. I can't imagine doing it once a day.... Of course I don't like the BP orders that say "Hold if BP

At my last building, the doc wrote orders for blood glucose testing on Monday, Wednesday, and Friday with a sliding scale for coverage. Apparently they weren't concerned about the blood sugars the other days.

If any nurse goes into a room and DOESN'T notice indications of pain, (or none) hmmm.....But documentation of the negative goes against efficiency. And I will be dammed if i will wake a patient to ask, and we know that sleeping doesn't mean no pain. I can be in only one place at one time, if I assess at 2 am and there doesn't appear to be a pain issue, that is it for the shift unless there is reason to recheck/be in the room for some other reason/patient has specific pain issues. Rechecking as many as 40 patients in a shift "ain't" gonna happen!

how are you noting your pain assessments? Do you have a form for q shift assessments?

We rate pain pre and post prn or standing pain meds, but don't really have a form to mark off q shift assessments?

I think that most nurses are assessing for pain, just not documenting it. I know that if I have a resident that has pain or a dx with potential pain, I will start off my shift at my med pass and ask...do you have any pain, etc but we have no place to document it until we give a med for it.

how are you noting your pain assessments? Do you have a form for q shift assessments?

We rate pain pre and post prn or standing pain meds, but don't really have a form to mark off q shift assessments?

I think that most nurses are assessing for pain, just not documenting it. I know that if I have a resident that has pain or a dx with potential pain, I will start off my shift at my med pass and ask...do you have any pain, etc but we have no place to document it until we give a med for it.

We write it in the MAR: Assess for pain and document Qshift. If they have pain any time during the shift, it gets documented there. then we have a PRN flow sheet for giving PRN pain meds for the pain, and any time after that.

We write it in the MAR: Assess for pain and document Qshift. If they have pain any time during the shift, it gets documented there. then we have a PRN flow sheet for giving PRN pain meds for the pain, and any time after that.

In my facility we (meaning DSD,DON, MDS nurse) put pain assessment on the MAR q shift for anybody on a "pain management program" (meaning everybody on routine pain medicine). If the resident does not receive routine pain medicine, pain is only specifically addressed when a full set of vital signs is taken (pain is 5th vital in CA).

I am almost afraid to ask my nurses exactly how they asses this pain every shift. I suspect I might get this response, "The resident didn't ask for a pain pill so I marked a '0'." I guess I should ask the nurses because it would be better for me to ask than a surveyor.

Of course, anyone asking for a pain pill get a pre and post pain assessment.