A Guest Post by Alan Brady

Elder abuse is a serious topic that many don’t know about. Child or familial abuse – These topics we are warned about when we are too young to understand the implications. Elder abuse though – There is a wall of silence created by the fact that it does not affect the majority of American citizens. It’s not until you begin researching nursing homes that you even learn that abuse does occur. And when any form of abuse occurs—physical or verbal—there is anger, guilt, and the need to remedy the situation. And with that arises the question: why?

Does Asking Why Matter?

For your family, why the abuse occurred may not matter. After all, the damage has already occurred. Instead of dwelling on the abuse, you may feel the urge to hire a nursing home abuse attorney, sue the perpetrator, and find a different facility that will keep your relative safe. By all means do that, if that is what you need to do but while you are working on achieving justice for your family member, you should try to determine why the abuse occurred because doing so will help ensure the safety of all the seniors who live at the nursing home.


When it is your relative that was harmed, you don’t want to hear that the torn skin or fall was accidental. But the reality is that being a nursing home employee requires you to engage in back breaking work that must be accomplished delicately. Any wrong moves can easily result in a skin tears or bruises on the elderly who have fragile skin. Does the fact that the pain was accidental change anything?

I believe it does in this case. Incompetence can be fixed. Maliciousness cannot. If it is the first or second offence, the employee might need to be trained on properly performing processes and procedures. If, though, the “accident” is a continual pattern of incompetence that causes painful injuries, the employee should be fired. There is no place in the care of our senior citizens for employers that cannot assure the safety of their patients in nursing homes. Here are some tips to recognize accidental abuse:

  • New employee.
  • Awkward movements when attempting to complete basic tasks.
  • Genuine guilt and remorse over the damage.
  • The employee reports the damage.
  • Backing from an honest staff member that does not have a history of keeping silent about abuse.

Consciously Done

 It’s an unfortunate reality that some employees choose to verbally or physically abuse the elderly. It is the responsibility of all the employees to watch out for abuse, especially if the elderly individual is incapable of speaking out about the abuse. Employees are mandated reporters and must report known or suspected abuse. An investigation must be done and the resident’s responsible party must be informed.  If you discover that the individual was maliciously choosing to abuse your family member, I say go all out. Your family deserves justice, and the perpetrator deserves to pay for his or her decision to engage in abuse.

Here are some tips to recognize malicious abuse:

  • Exhibits competence when he or she chooses.
  • Constantly verbally abrasive to patients.
  • Has been reported by a trustworthy staff member of abusive behavior before.
  • Engages in multiple abusive behaviors: verbal, financial (including theft), and physical. One might be an accident, but all three is not.

Looking to the Nursing Home

Regardless of whether or not the abuse was accidental or malicious, you should attempt to discover if the nursing home fosters an environment that allows abuse. My mother worked in a nursing home for a few years, so I know better than most that some nursing homes do not discourage abusive behavior. Here are a few unofficial and official policies that could affect the amount of abuse that can occur:

  • The lack of an official abuse policy that highlights the repercussions.
  • Multiple abuse charges in the past that were unresolved.
  • A constant stream of new employees could lead to more accidental abuse.
  • Employee shenanigans may distract employees and leave an opening for abuse and neglect.
  • An employee work place that discourages employees from speaking out about abuse.
  • A “me” “me” “me” employee mindset may lead to a bending of the rules and procedures about the numbers of employees that should lift an individual. Improper processes and procedures in lifting and transferring residents can cause injuries for both the resident and the staff.

Abuse is an unfortunate reality. As the family of a nursing home resident, you can prevent abuse by ensuring that the nursing home you choose will not condone any form of abuse—whether it is accidental or consciously done.


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Effective pain recognition and management requires a continuous facility-wide commitment to every resident’s comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain. As discussed previously, 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.

Care plans for pain should be developed and the resident’s needs and goals as well as the cause, type, and severity of pain are needed to develop an adequate and appropriate plan of care for pain management. It is also important to consider treating the underlying cause, where possible in order to remove the cause of the pain. Understanding the underlying causes of pain is an important step in determining optimal approaches to prevent, minimize, or manage pain. Addressing those underlying causes may permit pain management with fewer analgesics, lower doses of analgesics and narcotics, or the use of 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 for the nursing staff 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 and others cannot. Those who cannot report pain may exhibit nonspecific signs such as grimacing, increase 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 such as 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 for facility nurses to evaluate the resident in detail, to confirm that the signs and symptoms are due to pain. Nursing assistants may be the first to notice a resident’s symptoms; therefore, it is important that they too 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.

Nurses and other healthcare practitioners should look for interventions that are resident specific since the cause of pain is different for each person. Staff should try to prevent and minimize pain that is anticipated to occur due to a process or procedure. Non-pharmacological interventions should also be planned and implemented to complement the use of pharmacological interventions.

Remember – be your own advocate!


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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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