A week before Christmas I dropped by to see my father and give him the weekly update on family.  He seemed mildly interested but a little distant.  I asked him if he would like anything for Christmas like pajamas, cologne, or a certain dessert and he just said…”No…. Nothing I want.”  I told him I was excited to be bringing him some food from our Christmas spread this year.  We had decided to change it up and do a Louisiana style seafood boil. He again said, “No…. Don’t worry about bringing me anything”. He even turned down pecan pie, which is a FIRST for him.

Ever since his heart attack back in October I have felt my father pulling away from me.  In November he went in for a few days with a mild case of pneumonia too. Sometimes I feel that he is pulling away since he is not sure how much longer he will be around….. Either way it’s not easy.  My attempts at joking around with him and taking him on walks outside have even been met with little feedback. I even bought him a nicer coccyx seat cushion a few weeks ago but that just has prevented him from complaining about being in a wheelchair as much during the day.

So what do you do when your elderly parent seems to have lost their hope and joy in the small things in life? I must tell you…. I do not even know.  I have read a few articles that clearly state it is common at this stage of life but their must be more I can do.   It takes me about 30 minutes to drive out to see him and when you start feeling like your visit is unwanted it makes it harder to get in the car once a week and visit anyway.  I know I will continue to see him because it’s the right thing to do.  I will do my best to be positive and bring him good news about his grandchildren.


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In this second part regarding how Nursing Home and Hospital Surveyors look at pain management in the nursing home we are going to look at some of the definitions they use for common concepts. If you remember, the State Operations Manual (SOM) provides much guidance to Nursing Home and Hospital surveyors on how to investigate and survey facilities. In regards to pain managment, the guidance provides the following definitions at F309 in Appendix PP:

“Addiction” – a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addiction 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” refers to any medication with a primary indication other than pain management but with analgesic properties in some painful conditions.

“Adverse Consequence” – an unpleasant symptom or event that is due to or associated with a medication.  Examples would include impairment or decline in a resident’s mental or physical condition or functional or psychosocial status and various types of adverse drug reactions and interactions.

“Adverse drug reaction” (ADR) is a form of adverse consequence that 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 guidance goes on to explain to nursing home and hospital surveyors that the term “side effect” is often used interchangeably with ADR; however, side effects are actually one of five ADR categories. The other categories of ADRs are 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) –  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” are approaches to care that do not involve medications, generally directed towards stabilizing or improving a resident’s mental, physical or psychosocial well-being.

“Pain” – an unpleasant sensory and emotional experience that can be acute, recurrent or persistent. The guidance then breaks this down further and provides the following descriptions of several different types of pain:

“Acute Pain” – 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” – an episodic increase in (flare-up) pain in someone whose pain is generally being managed by his/her current medication regimen;

“Incident Pain” – typically predictable pain that is related to a precipitating event such as movement or certain actions; and

“Persistent Pain” or “Chronic Pain” – 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 neuro-adaptation 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.

So with those definitions Nursing Home and Hospital Surveyors are more prepared to evaluate the pain management program in a Long Term Care Facility. The knowledge they gain from these guidelines also serve them well as they look at pain management in other facility types. It is, though, more common to find inadequate pain management in a long term facility. We will continue with the discussion of pain management the n ext time. Meanwhile, keep yourself informed as to what is required of facilities, whether nursing home, clinic, hospital, hospice, dialysis or whatever. You are then more empowered to watch for, comment on, and report problems you see.

Remember, Be your own advocate!


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It wasn’t too many years ago that pain was often misunderstood or ignored in the Long Term Care Facility geriatric population and especially in those residents with cognitive impairment who could not verbally express the level of pain they were in. Unrelieved pain often causes residents to have behavioral changes such as resisting care, pacing, depression, negative verbalizations, facial expressions, and self-harm. It has significant consequences in the areas of function as pain causes a decrease in ability to perform activities of daily living. It leads to sleep deprivation, which can decrease pain thresholds, limit the amount of daytime energy and increase the incidence and severity of depression and mood or behavioral disturbances. Pain can cause changes in walking, skin color, vital signs, and appetite.

Now though pain management is under intense scrutiny in the CMS survey process in Long Term Care Facilities. F-tag 309 provides extensive pain management guidance and investigative protocols for Nursing Home Surveyors to follow.

Facilities must recognize and manage pain in residents in order to help each resident attain or maintain the highest practicable level of well-being for that resident. In order to accomplish that each facility must, to the extent possible, recognize when the resident is experiencing pain and identify circumstances when pain can be anticipated; evaluate the existing pain and the cause(s), and manage or prevent pain, consistent with the comprehensive assessment and plan of care developed for that resident, current clinical standards of practice, and the resident’s goals and preferences.

The guidance basically states that nursing facilities must assess and address pain in all residents, including the cognitively impaired. The guidance gives surveyors new direction to cite facilities that do not adequately manage pain with deficiencies. The guidance to surveyors at F309 helps the Nursing Home and Hospital Surveyor to determine if the facility is fulfilling these requirements in regards to pain management in the residents of that healthcare facility.

We will continue more about pain in the next installment of Pain Management in the Nursing Home. Meanwhile – Keep safe and be your own advocate in the healthcare world!


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My father is 78 and has been in 5 different nursing homes over the last 4 years. He has 4 children but I am the only one that has chosen to stay in the area to help take care of him OR even communicate with him. The current nursing home he has been in for almost 2 years and by far is the best of all the previous nursing homes. Let me tell you a quick story of what life can be like for the only child in the family that is the contact point for this man.

Monday night at 11pm I received a phone call from the nursing home stating that my father had coughed so much that he had thrown up a little and aspirated into his lungs. He was breathing OK now but his color was off and they didn’t want him to get pneumonia so they recommend him be taken by ambulance to the closest hospital for further review and treatment. I was relieved to know his blood sugar, he has a history of diabetic problems, had not spiked over 600 sadly. I agreed to the ambulance and thought this didn’t sound like to big of a deal and would get an update from the hospital the next day.

As usual life got crazy and I didn’t think of it. I knew I would be going to the nursing home on Thursday to see my dad and I would get an update on everything then. When I arrived the nursing home had me fill out his readmission papers since he had been readmitted on Wednesday and now Medicare would be covering him the first 20 days, then his summplemental policy would kick in again. Typical paperwork that I am very familiar with at this point. I was in a for a big surprise just a few minutes later.

I walked into visit my father who was fast asleep and snoring. I assumed after his hospital stay he had probably gotten little sleep and was now catching up on it. I chatted with his roomate and went down to the nurses station for an update. I let them know I had heard nothing else since their phone call and was wondering how everything went at the hospital…….. They looked at each other in schock and looked at me……. with a short silence then said…….. “The hospital never called you?”. I said….”No, were they supposed too?”. Then things got interesting. I will tell you more in my next installment of.

“Taking care of my dad, when the other siblings have abandoned him”.



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