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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!

JL

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As mentioned in the other posts talking of this issue, CMS has guidance in the SOM for nursing home surveyors to follow. The third piece of the investigation is the review of the resident’s record and other facility documents. The nursing home surveyor will review the resident’s assessment, the history and physical and other portions of the clinical record. These items should include the information needed to determine the resident’s needs and the interventions needed to meet the resident’s needs. The surveyor should be looking for consistency among the various parts of the record as well as with the observations that have been made and the interviews that were conducted.

The plan of care should be reviewed to see if it contains the detail needed to meet the resident’s needs. Each care plan should be individualized to each resident, so the surveyor is going to be looking to see that the care plan is not the same for most residents in the facility. An example of this would be “Toilet the resident before and after meals and at bedtime”. When I see this as a surveyor it starts ringing bells. Again, as mentioned before in this series of posts, everyone has their own pattern of needing to use the bathroom. Residents don’t fit into a cookie cutter. The plan should be based upon the goals, needs, and strengths specific to the resident and it should reflect the comprehensive assessment. It should identify objectives, timeframes, potential complications, and even environmental obstacles that affect the resident. Every care plan, whether for this issue or another, should identify specific approaches and interventions and should include input by the resident and/or the responsible person.

The information I have provided in the posts on this topic are just the “tip of the iceburg”. You will find much more information in the SOM and I encourage you to take some time to read and review it, especially if you are in a nursing home or have a loved one in a nursing home.

Be safe and informed!

JL

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In the previous posts we started talking about how nursing home and hospital surveyors investigate issues surrounding incontinence in nursing homes. I continue that discussion here.

Another element to investigations is interviews.

Interviews: During the review and investigation the surveyor will be conducting interviews with the resident, family or responsible party when possible. These interviews will help identify:

  1. Involvement in care plan development including defining the approaches and goals, and whether interventions reflect preferences and choices;
  2. Awareness of the existing continence program and how to use devices or equipment;
  3. If timely assistance is provided as needed for toileting needs, hydration and personal hygiene and if continence care and/or catheter care is provided according to the care plan;
  4. If the resident comprehends and applies information and instructions to help improve or maintain continence;
  5. The presence of urinary tract-related pain, including causes and management;
  6. If interventions were refused, whether consequences and/or other alternative approaches were presented and discussed; and
  7. Awareness of any current Urinary Tract Infections (UTI), history of UTIs, or perineal skin problems.

 

Interviews of the nursing assistants will be conducted to determine if they:

  1. Are aware of, and understand, the interventions specific to this resident (such as the bladder or bowel restorative/management programs);
  2. Have been trained and know how to handle catheters, tubing and drainage bags and other devices used during the provision of care; and
  3. Know what, when, and to whom to report changes in status regarding bowel and bladder function, hydration status, urine characteristics, and complaints of urinary-related symptoms.

It is best for the nursing home surveyor to interview the direct care staff first rather than the Director of Nursing or other administrative staff. This allows the surveyor to see if the “front-line” staff, who provide the care, are knowledgeable about what is needed for each resident. The physician, medical director, charge nurse, director of nursing, and other administrative staff can be interviewed also, but many times the most valuable interviews come from the direct care staff.

We will continue this in the next post.

Be safe and informed!

JL

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I mentioned in Part I that CMS has guidelines for the Nursing Home Surveyor. We started discussing these guidelines, and the list of actions CMS expects a surveyor to take when investigating urinary incontinence issues in a nursing home. The first of these expectations is the need to do observations in a nursing home.

During the review and investigation during a survey or a complaint, the nursing home surveyor will be observing whether the facility staff implement the interventions indicated in the plan of care for that resident. The interventions need to be consistent and on all shifts and days. When needed, nursing home surveyors will go into the facility on “off-hours”, meaning during the evening and night shifts or during the weekend, in order to look at issues over all time frames. While making observations of the interventions, the nursing home surveyors will take note of and follow up on deviations from the plan of care or from current standards of practice, as well as potential negative outcomes.

Some observations made by the nursing home surveyor include whether staff make appropriate resident accommodations consistent with the assessment, such as placing the call bell within reach and responding to the call bell, in relation to meeting toileting needs; maintaining a clear pathway and ready access to toilet facilities; providing (where indicated) elevated toilet seats, grab bars, adequate lighting, and assistance needed to use devices such as urinals, bedpans and commodes. The nursing home surveyors will observe whether assistance is provided to try to prevent incontinence episodes, such as whether prompting, transfer, and/or stand-by assist to ambulate are provided for each resident who needs that type of assistance for toileting.

For some residents their assessment indicates they have the potential to regain some degree of continence. For those residents who are put on a program to restore continence the nursing home surveyor will gather information on the frequency of breakthrough or transient incontinence, how staff respond to the resident’s incontinence episodes, and whether the staff provide care in accord with current accepted standards of practice (including infection control practices). The nursing home investigator will also see if the staff provide care with respect for the resident’s dignity.

After the staff does a clinical assessment, some residents are found to be unable to participate in a program to restore continence or in a scheduled toileting program. These residents require care due to incontinence of urine. For these residents, the nursing home surveyor will see if the staff put the resident on a regularly scheduled check and change program, which is matched to the resident’s voiding pattern. (The nursing home staff should be determining what that pattern is. As you can imagine, people don’t all go to the bathroom at the same time; everyone has his or her own pattern.) The nursing home surveyors will check to see whether the nursing home staff check and change residents in a timely fashion.

If a resident has an incontinent episode the surveyor will observe a variety of things such as:

  1. the condition of the pads/sheets/clothing (a delay in providing continence care may be indicated by brown or yellowish rings/circles, saturated linens/clothing, odors, etc.),
  2. the resident’s physical condition, (such as the integrity of the skin, openings, rashes, redness, erosion, etc.,
  3. the psychosocial outcomes which could include such things as embarrassment or expressions of humiliation, or resignation about being incontinent,
  4. whether the nursing home staff provide appropriate hygiene measures including cleansing, rinsing, drying and applying protective moisture barriers or barrier films to try to prevent skin breakdown from prolonged exposure of the skin to urine, and
  5. the staff’s response to the resident’s incontinence episodes. All of the care provided by the nursing home staff should be consistent with current accepted standards of practice (including infection control practices) and with respect for the resident’s dignity.

Some residents end up with an indwelling catheter. In these cases the nursing home surveyor will be observing the care to evaluate:

  1. Whether staff use appropriate infection control practices regarding hand washing, catheter care, tubing, and the collection bag;
  2. Whether staff recognize and assess potential evidence of symptomatic Urinary Tract Infections or other related changes in urine condition;
  3. How staff manage and assess urinary leakage from the point of catheter insertion to the bag;
  4. How the staff assess and manage any catheter-related pain;
  5. What interventions the staff use to prevent inadvertent catheter removal or tissue injury from dislodging the catheter.

All residents who have continence have an indwelling or intermittent catheter should be well hydrated (i.e. receive enough fluids). To look at this the nursing home surveyor will observe to ensure enough fluids are provided and encouraged.

We will continue this discussion of urinary incontinence and how a nursing home and hospital surveyor looks at it.

Be safe and be informed!

JL

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