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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!

JL

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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!

JL

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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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Last week Medicare’s Nursing Home Compare website (www.medicare.gov/nhcompare/) launched a five-star rating system for all nursing homes nationwide. Accordig to CMS, individual nursing homes will receive one to five stars in three categories — quality measures, nurse staffing and health inspections — as well as an overall rating. It will be the first time the Centers for Medicare & Medicaid Services (CMS) has used such a rating system. According to CMS the five-star rating system provides a new, simple, easy-to-understand approach to making what might be the hardest decision ever — putting a loved one in a nursing home.

I’ve taken a look at some information about this and want to share it with you. I will review the site more and we can discuss it more later. This has been such a busy month, and sometimes I get home so exhausted from surveys – I don’t get to writing like I should!

So the information, which has been sent to me by what I believe is a firm helping CMS to get the word out, is in the form of an adobe powerpoint slide presentation. The presentation explains that all nursing homes that are Medicare & Medicaid Certified (16,000 in the nation – and counting!) will receive a 1 to 5 star rating (I imagine it is something similar to rating systems used in many other avenues of life.)  The five star rating summarizes specific information for each nursing home. These areas are: 1. An Overall rating, 2. Health Inspections, 3. Quality Measures, and 4. Staffing.

For the health inspections, the star rating takes into account the 3 most recent annual inspections, with the most recent having the most weight, and all complaint investigations for the last three years. The rating considers the number and the Severity and Scope of the deficiencies, with the more serious ones lowering the star rating. If you remember, in July, we discussed Severity & Scope.

CMS selected 10 Quality Measures (we have not yet discussed this, but I will address that in a future post), which are basically what they sound like, measures of the quality of care in a facility. CMS selected the 10 measures with the highest reliability ans uses the three most recent quarters of data to help determine the star rating. I do want to point out that the quality measure data is dependent on the nursing home providing accurate data. The 10 that CMS selected to assist in determining the star rating for nursing homes are: ADL (Activities of Daily Living) change, Mobility change, High Risk Pressure Ulcers, Long Term Catheters, Physical Restraints, Urinary Tract Infections, Pain (for both Long Stay and Short stay), Delirium, and Short Stay Pressure Ulcers.

For staffing data, the star rating takes into account the number of hours of care on average provided to each resdient each day, the nursing staff (meaning RNs, LVN/LPNs and CNAs). CMS has adjusted these to account for differences in the level of care resident of different nursing homes may need.

5 Stars = Much above average, 4 Stars = Above Average, 3 Stars = Average, 2 Stars = Below Average, and 1 star = Much Below Average.

For the Overall rating it appears the calculation of the number of stars is in steps and Step 1 starts with the health inspection rating. Step 2 takes into account the staffing, and they add 1 star for a 4 or 5 star staffing and subtract a star for 1 star rating. The 3rd step adds 1 star for 5 Star Quality Measures and subtracts a star for 1 star Quality Measures.

So it appears each item has its own stars and then an over all star system is also determined.

I’ll take some more time to help you understand the system, and if you have any questions you’d like me to ask, feel free. The group who sent me the information stated I could talk to a CMS spokesperson if there were questions. Although this information is mostly for consumers, I can see an Nursing Home and Hospital Surveyor taking a look at this information during their offsite preparation for a survey.

JL

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