Avoiding a Pain F-Tag Citation

If it Guides Surveyors, Should You Follow?

F-Tag uses evidence-based practice recommendations

Expectations Screening to determine if residents

experience pain

Comprehensively assessing the pain

Identifying when pain can be anticipated

Developing and implementing a plan, using pharmacologic and non-pharm interventions to manage pain and/or try to prevent the pain consistent with the resident’s goals

F 309: Assessment Expectations

Screening Screen for pain at admission,

periodically, when change in condition, anytime pain is suspected

Recognizing pain involves multiple health care professionals, direct care staff, therapists, ancillary staff who have contact with the patient

Observation at rest and activity

Verbal and nonverbal information about pain

F 309: Nonverbal Indicators Negative verbalizations and vocalizations (e.g.

groaning, crying/whimpering, or screaming)

Facial expressions (e.g. grimacing, frowning, fright, or clenching the jaw)

Changes in gait (e.g. limping), skin color, vital signs (e.g. increased HR and BP)

Change in behavior (e.g. resisting care, distressed pacing, withdrawing, inability to perform ADLs, rubbing specific location of body, or guarding a limb or other body part)

Weight loss

Difficulty sleeping

F 309: Current MDS ScreeningFrequency, intensity, symptoms, and

location/site of painOther sections that relate

Sleep cycle Change in mood Functional limitations Instability of condition Weight loss Skin conditions

Nursing Assistants

Often first to notice resident symptoms

Must be trained to recognize most common signs and descriptors of pain

Must be taught to report findings to the nurse for follow-up

Nurse must perform a detailed evaluation, document relevant information and report it to the practitioner (Fax It)

F309: Initial Assessment

At a minimum, an initial pain assessment should include:

A thorough pain history, including▪ A detailed description or symptom analysis

such as the pain PQRSTA mnemonic

▪ The effectiveness of past efforts to relieve pain

▪ Satisfaction with current pain management

P: Palliative and/or provocative factors

Q: Quality of pain and impact on quality of life

R: Region of body affected

R: Radiation of pain

S: Severity of pain

T: Timing of pain

T: Treatments tried

A: Associated symptoms

PQRSTA

Assessment

Facility may adopt one or more standard pain scales

Different scales emphasize different aspects of pain assessment Faces pain scales Numerical rating scales Pain map Brief Pain Inventory PAINAD for non-verbal residents

F309: Initial Assessment

At a minimum, an initial pain assessment should include:

A physical examination including the pain site, the nervous system, and physical, psychological and cognitive functioning

Consideration of co-morbidities and/or diagnoses, especially those which may typically be associated with pain

Diagnostic tests, as indicated

F 309: Initial Assessment At a minimum, an initial pain assessment

should include:

Additional information, which may include but is not limited to:

▪ The degree to which pain interferes with individual’s mental, physical, psychosocial and spiritual being

▪ Medication history including allergies, and whether pain may be associated with any current medications

▪ History of substance abuse such as alcohol, prescription medications and/or illicit drugs

F 309: Management

To the extent possible, resident should participate in developing plan of care and establishing realistic goals for treatment

Facility is expected to address pain if resident says he/she is in pain

Approach to pain management should follow appropriate clinical protocols and guidelines

F 309: Management

Interventions/Treatments should be: Preceded by an assessment Developed with respect for whether the

pain is episodic or continuous Provided or administered to meet

resident’s needs Monitored appropriately for

effectiveness and/or adverse consequences

Modified as necessary

F 309: Care Planning and Implementation

Care plan should include specific, measurable pain management goals

Should indicate how and when more structured, periodic monitoring with standardized assessment tools is to occur

Identifies specific strategies for different levels of pain, who is to implement the care or supply the service, and what symptoms, behaviors, or consequences might indicate need for additional/ alternative approaches

F 309: Non-pharmacologic Interventions or Complementary Therapies

Depending on the nature and intensity of pain, may be more appropriate to start with these approaches

If ineffective in relieving pain, proceed to pharmacologic interventions

If not used at all, resident record should include reasons why not pertinent

May include Complementary and Alternative (CAM)

F309: Pharmacologic Interventions

Identify and address cause of pain, to extent possible

Determine which pain medications and adjuvant medications and doses to use specific to the resident

Balance potential risks and side effects with benefits, including resident’s wishes

Follow a rationale approach, such as the WHO ladder

F309: Pharmacologic Interventions

All pharmacologic interventions should be combined with non-pharmacologic interventions

Persistent pain should be treated around-the-clock rather than PRN

Analgesics should be accessible in the facility and administered when needed

F309: Monitoring

Monitor the effectiveness of the medication(s) being used before adding medications or changing the medication regimen

Dose, frequency, and medication need to be reevaluated if pain not adequately controlled

Periodic use of a facility selected standardized pain assessment tool facilitates determination of success

F309: Monitoring

If no further need for pain medication, discontinuation or tapering to prevent withdrawal

Adverse consequences may be anticipated and require ongoing monitoring

Preventive approaches may be indicated

F309: Monitoring

Staff involved in care should monitor individual closely over time to identify signs/symptoms that could indicate pain and adverse medication consequences

Consistent staff assignment shown to improve pain care

If pain not adequately controlled despite repeated attempts and various approaches, referral to other resources such as a hospice program, if eligible, or pain management specialists

F309: Staff Training

The facility should provide orientation and ongoing staff education to correct misconceptions, myths, and biases about pain. Training may include, but is not limited to: Using standardized scales to promote

objective evaluation and effective management of pain

Recognizing and assessment pain, reporting and documenting findings, and monitoring Interventions

Staff Training

The facility should provide orientation and ongoing staff education to correct misconceptions, myths, and biases about pain. Training may include, but is not limited to:

Overcoming misconceptions and increasing understanding for the distinctions between addiction, physical dependence, and tolerance

Identifying appropriate treatment modalities including the use of and when and how to use non-pharmacologic interventions

Three Aspects to Compliancewith 42 CFR 483.25, F309, Quality of Care for Assessment and Management of Pain

1. Facility must identify each resident having or at risk for pain and anticipate what procedures, care, or treatments might produce pain, and evaluate the resident regarding the characteristics and causes of the pain

Three Aspects to Compliancewith 42 CFR 483.25, F309, Quality of Care for Assessment and Management of Pain

2. Facility must provide the care and services for the resident to attain or maintain his/her goals for pain management and comfort that is consistent with current standards of practice, assessment and plan of care

Three Aspects to Compliancewith 42 CFR 483.25, F309, Quality of Care for Assessment and Management of Pain

3. The level of pain management is consistent with a resident’s potential to achieve or maintain his/her highest practicable level of physical, mental, and psychosocial well-being

Criteria for Compliance

Screened residents on admission and periodically for the presence of pain

Recognized and evaluated residents who are experiencing pain to determine (to the extent possible) causes and characteristics (nature, intensity, location, frequency, duration) of the pain, as well as factors influencing the pain

Developed a care plan to address the pain, consistent with the resident’s goals, risks, and current standards of practice

Provided care and services to control the pain to the greatest extent possible or to the level defined by the resident, in accordance with standards of practice, or explained adequately n the medical record why they could not or should not do so

Criteria for Compliance

Recognized and provided pain control measures for situations such as treatments or activities known to potentially cause or exacerbate pain

Monitored the effects of interventions and modified the approaches as indicated

Contacted the health care practitioner with pertinent information to advise him/her when a resident was having pain that was not adequately managed or was having a potential adverse consequence to the treatment

Revised the approaches as appropriate, or verified their continued relevance

Quality Pain Care for Elders

The Pain F-tag may motivate, but it is all about quality care

Resources and Guidelines

Pain Website for Nursing Homes www.GeriatricPain.org

Advancing Excellence in America’s Nursing Homes http://nhqualitycampaign.org/

End of Life/Palliative Education Resource Center http://www.eperc.mcw.edu/ff_index.htm

City of Hope Pain Resource Center http://prc.coh.org/elderly.asp

Quality Improvement Organizations www.medqic.org

Resources and Guidelines

American Geriatrics Society (AGS): Clinical Guidelines www.americangeriatrics.org

American Medical Directors Association (AMDA): Clinical Guidelines www. amda.com

American Pain Society www.ampainsoc.org

Agency for Health Care Research and Quality (AHRQ): Clinical Guidelines www.ahcpr.gov/clinic/cpgonline.htm

National Guideline Clearinghouse www.guideline.gov

National Pain Education Council (NPEC) www.npecweb.org

Resources and Guidelines

American Academy of Hospice and Palliative Medicine www.aahpm.org

American Academy of Pain Medicine www.painmed.org

Hospice and Palliative Nurses Association www.hpna.org

Partners Against Pain www.partnersagainstpain.com

Resource Center for Pain Medicine and Palliative Care at Beth Israel Medical Center

www.stoppain.org/education_research/resources.html

THANK YOUQuestions?

Adapted and used with permission from K. Herr, PhD, RN, The University of Iowa, 2009.