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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Admin Note: This is in response to MSH’s question to me about a situation occuring with her loved one in a nursing home.

I so understand your frustration. As many good hearted staff as there are in nursing homes, there are still those who think they know it all in their approach to issues. You know first hand how you have to be totally on top of everything that is going on and be an advocate for your loved one who can’t be her own advocate.

You have medical evaluations on your side, so that is a good thing. You will have a struggle if the nursing home is giving out wrong information. Once a resident enters a nursing home – that nursing home is responsible for that resident and it is very hard to “get rid” of them, so to speak. Because of that, nursing homes get “picky” about who they will accept and if they think there is a potential for many problems they can decide not to accept that resident.
You want to look for a nursing home that is experienced with working with Alzheimers dementia. that is the first task. When you find one, you will need to approach them with your story.
 I would suggest you request all your loved ones medical records from the current nursing home, be sure you have the evaluations that show she is not psychotic. You may need to literally go to the DON and administrator of a facility you want to have her in, and gently explain the situation (but don’t “put down” the current DON, that would be a bad sign to the new facility). Show the records and the evaluations and explain that you are looking for a new home because you are looking for someone who is experienced in working with Alzheimers & their special activity needs.  The new facility will want to know why you are moving her. You will need to give an explanation so you will need to decide how much to share and in what tone. A kinder tone may get you further, meaning you don’t want to complain about the current facility but perhaps explain you find they are not understanding your loved ones needs and that is why you are looking for a facility that does understand her needs.
There are some things that will help you, such as do you have power of attorney for healthcare decisions? The facility can’t just put someone on psych medications without a reason and without consent. In addition, you should be talking with your loved ones personal physician (not just the medical director of the facility).  He/She can also tell the new facility that your loved one doesn’t need a locked unit, just a wander guard and activities. In fact, I don’t see in your story anything about if the Medical Director is at all involved. You do want to be sure her personal physician is one who is experienced in Alzheimers dementia.
I hope this helps you.

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Admin Note: Names/places have been redacted to protect privacy. MSH has given permission to share this with you. I will post, later, my answer to MSH.
MSH writes:
My loved one is currently 81-years old and has been in ___ of ___ since 2006 with vascular dementia following a lengthy hospital confinement for a stroke and subsequent reaction to medication, pneumonia and coma.
I was so pleased with the nursing home environment that we selected for her and watched her improve dramatically, she was up walking the full length of the dining room in short and regained a lot of cognitive ability.  We enjoyed a year of going shopping on the weekends, coming home to spend the nights, even back to climbing stairs.  In my experience we had some ups and downs but nothing that I wasn’t able to resolve until ___ was hired as the DON in 200___.  From there to now, things have gotten progressively worse!
This DON doesn’t work with the family members.  She dictates what will be done or not done and basically gives the family no voice in decisions.  At one point she announced that she was sending my loved on out to a psych unit in a city 50+ miles from my home.  She had decided that my loved one was now psychotic.
When I protested … that just wasn’t acceptable.  I won that battle with her being sent out for a full-days evaluation and ____ telling me what the MD at the hospital said would be accepted.  The MD at the hospital agreed with me that there was no evidence of Psychosis.  Two days later the DON contacted the Medical Director and had Risperdal prescribed. 
Fortunately the floor nurse contacted me and I was able to tell her about the reaction to the Ativan back in 2006 when she first had the stroke and that according to the FDA, Risperdal is not approved in the treatment of dementia.  There was a 3-way conversation with the floor nurse talking to me on one phone while she talked to the DON on another phone.  The end result was the DON stating that she was through talking with me and she was going to do what needed to be done.
I complained very loudly all the way up to the CEO of the parent company.  I also immediately began looking for a new facility for my loved one.  In the interim I learned that an in-house psych evaluation had been scheduled which I attended.  During the course of that evaluation, the facilities psychiatrist told me there was no evidence of psychosis and that they needed to provide some busy activity for her.  She has dementia and dementia is a busy disease.
Today I learned from two facilities that the reason the potential facilities are turning her down is that the nursing staff at ___ is telling the admissions people that she requires a locked unit.  She is currently not in a locked unit, but on Alert Guard … and I’m at a loss.
Do you have suggestions how I can overcome this obstacle and find placement in a facility where ___ is not employed?
Thank  you!

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