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1. DELIRIUMReview of Indicators of Delirium

Changes in vital signs compared to baseline

Supporting Documentation (Basis/reason for checking the item,

including the location, date, and source (if applicable) of that information)

□Temperatures 2.40F higher than baseline or a temperature of 100.40F (380C) on admission prior to establishment of baseline. (J1550A)

Blank

x Pulse rate less than 60 or greater than 100 beats per minute

□ Respiratory rate over 25 breaths per minute or less than 16 per minute (J1100)

□ Hypotension or a significant decrease in blood pressure: (I0800)

□ • Systolic blood pressure of less than 90 mmHg, OR

□ • Decline of 20 mm Hg or greater in systolicblood pressure from person’s usual baseline,OR

□ • Decline of 10 mm Hg or greater in diastolicblood pressure from person’s usual baseline,OR

□ Hypertension - a systolic blood pressure above 160 mm Hg, OR a diastolic blood pressure above 95 mm Hg (I0700)

Abnormal laboratory values (from clinical record) Supporting Documentation

□ • Electrolytes, such as sodium Blank □ • Kidney function□ • Liver function□ • Blood sugar□ • Thyroid function□ • Arterial blood gases□ • Other Pain Supporting Documentation □ • Pain CAA triggered (J0100, J0200) [review

findings for relationship to delirium(C1310)]

Blank

□ • Pain frequency, intensity, and characteristics(time of onset, duration, quality) (J0400,J0600, J0800, J0850 and clinical record)indicate possible relationship to delirium(C1310)

□ • Adverse effect of pain on function (J0500A,J0500B) may be related to delirium (C1310)

Pulse rate below 60 on two occasions during look back period - see MARduring look back.

xx

Thyroid test performed 9/8/18 shows decreases values.Blood sugar fluctuations over lookback period with early am readings of 110-200 over 4 days - See MAR duringlook back. NA level in hospital highwith elevated BUN

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Diseases and conditions (diagnosis/signs/symptoms)

Supporting Documentation (Basis/reason for checking the item,

including the location, date, and source (if applicable) of that information)

□ • Circulatory/Heart Anemia (I0200) Cardiac dysrhythmias (I0300) Angina, Myocardial Infarction (MI)

(I0400) Atherosclerotic Heart Disease (ASHD)

(I0400) Congestive Heart Failure (CHF)

pulmonary edema (I0600) Cerebrovascular Accident (CVA) (I4500) Transient Ischemic Attack (TIA) (I4500)

Blank

□ • Respiratory Asthma (I6200) Emphysema/Chronic Obstructive

Pulmonary Disease (COPD) (I6200) Shortness of breath (J1100) Ventilator or respirator (O0100F) Respiratory Failure (I6300)

□ • Infectious Infections (I1700-I2500) Wound infection other than on foot or

lower extremity (M) (I2500) Isolation or quarantine for active

infectious disease (O0100M) □ • Metabolic

Diabetes (I2900) Thyroid disease (I3400) Hyponatremia (I3100)

□ • Gastrointestinal bleed (clinical record)□ • Renal disease (I1500), Dialysis (O0100J)□ • Hospice care (O0100K)□ • Cancer (I0100)□ • Dehydration (J1550C, clinical record)

Signs of Infection (from observation, clinical record) Supporting Documentation

□ • Fever (J1550A) Blank □ • Cloudy or foul smelling urine□ • Congested lungs or cough□ • Dyspnea (J1100)□ • Diarrhea□ • Abdominal pain□ • Purulent wound drainage□ • Erythema (redness) around an incision

x

x

x

CHF with pulmonary edema just prior to admission per H & P and transfer records. H & P indicates history of MI, Diabetes (Type 2) and Thyroid dysfunction.Current VS within normal limits.On 4 occasions during look back PT notes SOB with exertion during treatment. O2 sats 89% on RA one time during look back - O2 at 2L corrected situation and resident sat back to 93%

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Indicators of Dehydration

Supporting Documentation (Basis/reason for checking the item,

including the location, date, and source (if applicable) of that information)

□ • Dehydration CAA triggered, indicatingsigns or symptoms of dehydration arepresent (J1550C)

Blank

□ • Recent decrease in urine volume or moreconcentrated urine than usual (I and O)(clinical record)

□ • Recent decrease in eating habits – skippingmeals or leaving food uneaten, weight loss(K0300)

□ • Nausea, vomiting (J1550B), diarrhea, orblood loss

□ • Receiving intravenous drugs (O0100H)□ • Receiving diuretics or drugs that may cause

electrolyte imbalance (medicationadministration record)(N0410G)

Functional Status Supporting Documentation □ • Recent decline in ADL status (Section

G0110) (may be related to delirium)(C1310)

Blank

□ • Increased risk for falls (J1700) (may berelated to delirium) (See Falls CAA)

Medications (that may contribute to delirium) Supporting Documentation □ • New medication(s) or dosage increase(s) Blank □ • Drugs with anticholinergic properties (for

example, some antipsychotics (N0410A),antidepressants (N0410C), antiparkinsoniandrugs, antihistamines)

□ • Opioids (N0410H)□ • Benzodiazepines, especially long-acting

agents (N0410B)□ • Analgesics, cardiac and GI medications,

anti-inflammatory drugs□ • Recent abrupt discontinuation, omission, or

decrease in dose of a short or long actingbenzodiazepines (N0410B)

□ • Drug interactions (pharmacist review maybe required)

□ • Resident taking more than one drug from aparticular class of drugs

□ • Possible drug toxicity, especially if theperson is dehydrated (J1550C) or has renalinsufficiency (I1500). Check serum druglevels

x

x

x

30 lb weight loss over one year prior to adm. according to husband. Recent complaints of nausea with decreased appetite. Receives Lasix at 80 mg per day and Potassium.CAA 14 triggered related to potential for dehydration - see CAA 14 - 9/9/18

x

x Likely related to recent illness and hospitalization

x

x

Recent addition of Remeron to improve appetite.

Lab test for Digoxin level pending. Also pending electrolytes

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Associated or progressive signs and symptoms

Supporting Documentation (Basis/reason for checking the item, including the location, date, and source (if applicable)

of that information) □ • Sleep disturbances (for example, up and

awake at night/asleep during the day)(D0200C, D0500C)

Blank

□ • Agitation and inappropriate movements(for example, unsafe climbing out of bed orchair, pulling out tubes) (E0500)

□ • Hypoactivity (for example, low or lack ofmotor activity, lethargy or sluggishresponses) (D0200D, D0500D)

□ • Perceptual disturbances such ashallucinations (E0100A) and delusions(E0100B)

Other Considerations Supporting Documentation □ Psychosocial

• Recent change in mood; sad or anxious (forexample, crying, social withdrawal)(D0200, D0500)

• Recent change in social situation (forexample, isolation, recent loss of familymember or friend)

• Use of restraints (P0100, clinical record)

Blank

□ Physical or environmental factors • Hearing or vision impairment (B0200,

B1000) - may have an impact on ability toprocess information (directions, reminders,environmental cues)

• Lack of frequent reorientation, reassurance,reminders to help make sense of things

• Recent change in environment (forexample, a room or unit change, newadmission, or return from hospital) (A1700)

• Interference with resident’s ability to getenough sleep (for example, light, noise,frequent disruptions)

• Noisy or chaotic environment (for example,calling out, loud music, constantcommotion, frequent caregiver changes)

Blank

x

x

Awakened three nights in last two weeks (since initiation of Remeron with possible hallucinations of colorful murals on walls and heard music - not verified by observer per notes 8/31, 9/2 & 9/5.

x Resident has some difficulty with hearing - does notuse hearing aides currently.

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Input from resident and/or family/representative regarding the care area. (Questions/Comments/Concerns/Preferences/Suggestions)

Blank

Analysis of Findings Blank Care Plan Considerations Review indicators and supporting documentation, and draw conclusions. Document: • Description of the problem;• Causes and contributing factors; and• Risk factors related to the care area.

Care Plan Y/N

Document reason(s) care plan will/ will not be developed.

Blank Blank Blank

Referral(s) to another discipline(s) is warranted (to whom and why): ______________________ ______________________________________________________________________________

Information regarding the CAA transferred to the CAA Summary (Section V of the MDS): □ Yes □ No

Signature/Title:___________________________________ Date:_________________________

HuHusbHusband and son very involved and upset in sudden changes in physical and mental condition of resident.

RecentRecent admission after hospitalization related to CHF &pulmonary edema. Acute mental status change could berelated to Digoxin toxicity, dehydration, need for more comprehensive assessment of diabetes and also possible Remeron initiation as according to pharmacist can cause vivid dreams and hallucinations. Has multiple risk factors that require further assessment. Awaiting lab results.

YY

Y Care Plan will be developed to confirm & eliminate or mitigate causes of resident's delirium causes and risk factors. Meanwhile, continuing rehab therapy & engagement of meaningful activities to mental status. Supports being provided by and for family. Possible referral to audiologist once condition stabilized.

Care

CCCareaC

CareCCare=

Care

Ca

See above

x

Demi Haffenreffer RN Consultant 9/9/18

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Narrative CAA Examples CAA 3 Vision triggers resident has vision problems and is blind in Right eye. In addition, she has an obvious cataract in left eye without diagnosis – see current diagnosis list and H & P of 7/25/18. Other risk factor is related to Diabetes. Well diabetes is well controlled she remains at risk for diabetic retinopathy – see MARS CBG’s for look back period. She wears glasses daily and uses a magnifying glass for reading and other activities. Last vision exam is unknown – will refer to Social Services to assist with appointment for a vision exam. Appears to be doing well in new environment is able to ambulate to bathroom and is very familiar with surroundings. She has arranged things the way she likes. Resident is interested in visual consult, but states she is not interested in having surgery for the cataract. As visual deficit affects safety needs & rehabilitation progress, and further referrals are needed, will proceed to care plan. CAA 4 Communication triggers resident is hard of hearing and uses hearing aids in both ears. Usually communicates needs and understands. However, may miss part of the message r/t anxiety and interviewer still needed to adjust tone during conversation – see nursing progress notes for look-back period and Activities / Social Services admission assessment. She has a diagnosis of anxiety with a long history of agoraphobia – See H & P 8/6/18. This admission to a semi-private room has increased her anxiety and ability to concentrate on what is being communicated. She is receiving antianxiety medication as prescribed by her psychiatrist for her psychiatric condition – see MARS for look back period. The antianxiety is assisting with calming her down so communication can proceed – see CAA 8 Mood and CAA 17 Psychotropic medication. She also has history of wax build-up in ears and apparently had painful removal of wax by audiologist in the past. Complains of some ear pain – will refer to MD. Unknown how long ago last audiology consult was so will therefore refer for exam. Resident fearful about ear procedures due to painful wax removals in the past, but is willing to consider a consult. Will proceed to ensure care plan addresses communication needs and to ensure staff gives her time to process what is being communicated. CAA 5 ADL’s Example 1 Resident triggered ADL as requiring extensive assistance with Bed Mobility, Transfers, Locomotion and Personal Hygiene related to recent hospitalization for fracture Left Hip. Is here for rehabilitation and is receiving both PT and OT. See PT and OT evaluations performed 7/6/2018 for further information and goals. Will proceed to care plan as resident requires assistance and goal is to improve functional status for discharge. CAA 5 ADL’s Example 2 Resident triggered ADL as she requires assistance with all ADL’s except eating. Mrs. Jones has advancing dementia and can no longer remember how to provide care to herself without extensive cueing. She requires SBA for transfers, but is able to walk independently once out of bed. She is able to dress her upper extremities and perform some personal hygiene tasks with extensive cueing. She is receiving cognitive enhancing medications in the hopes of maintaining her current cognitive status for as long as is possible. Functional declines are likely related to her advancing disease. The goal is to prevent problems such as falls related to declines and to maintain nutrition and hydration. Family would like her to remain as independent as is possible. Will proceed to care plan to prevent declines as possible and functional maintenance.

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Narrative CAA Examples CAA 7 Psychosocial Status triggers as resident capable of establishing goals, has strong identification with past roles, has little interest in doing his favorite activities, and is upset with admission. See CAA 8 for review of mood problems – needs referral for Mental Health and I am unsure resident will agree to this. Resident was previously at home when he fell and Fx R hip. He was very active in golf, the golf club, and a local veterans group. He golfed 3 to 4 times per week and attended Veteran’s meetings weekly, in addition to engaging in social activities. However he now states he does not want golf or veteran buddies to “see me like this.” He is not interested in socializing while here for short term rehab. He has a past history of depression per 6/29/18 H & P – not currently being treated. Wife passed on two years ago. Children are very supportive toward discharge but are very concerned about his ability to return to his home and his future ability to play golf. Lacks some resources toward care at home. See PT and OT evaluations 6/30/18 – it appears he is very motivated in therapy participation. See also Social Service admission assessment and social history for further information (6/30/18). Will proceed to CP as resident has social needs and team/family fears social isolation could lead to depression that would be a barrier to discharge. In addition, it is important for team to address Mood Issues prior to fully implementing a social program. Please also see CAA 20 Return to Community.

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Narrative CAA Examples CAA 9 Behavior – Triggered CAA as resident calls (yelling) out to staff and is frequently refusing care which is not redirectable and causing harm to resident with weight loss (refusing many meals - see CAA 12), pressure sores (refusing to turn, and often refusing therapy - see CAA 16) and potential for other serious conditions. Resident appears to have increased anxiety manifested by this calling out and care refusals – has Ativan and Xanax (see CAA 17). It appears behaviors increased on evening shift and occasional nights; although behaviors of care refusals can occur at any time during the day. Currently unclear of interventions most successful in altering behaviors – appears current medications do not work consistently to relieve care refusals that are not redirectable. Behaviors could be related to Delirium (see CAA 1 – 7/30/18), pain, and history of depression with psychotic features – see H & P 7/25/18. In addition has past history of anxiety disorder with known Ativan addiction. Delirium and pain of recent onset with hip fracture repair and readmission to this facility. Receives oxycodone prn 2-4 times daily with increase use on the evening shift. Feel pain is the greatest risk factor affecting resident at this time – see Pain CAA 7/30/18. Yelling decreases with both Antianxiety use and pain med use but care refusals still occurring at least daily. Will refer to team and physician for possible routine pain med as care refusals could be related to fear of pain. Also question psych consult with regards to medication usage given past history of anxiety, past Ativan addiction and depression. Will also place resident on behavior tracking for yelling and care refusals in order to better identify what interventions most likely to modify behavior. Unable if to tell if resident able to understand risks of care refusals. See also CAA 8 7/30/18 – will proceed to care plan as resident behaviors are in need of further intervention and have the potential for causing harm.

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Narrative CAA Examples Investigation Summary 8/25/18 - Falls Ann Jones has had 10 falls since admission 5/22/18 to this memory care unit. Seven of these falls have occurred in her room where she has rolled out of bed 5 times and has slipped from her chair 2 times. She has been found 2 times outside in the grass, apparently both times she removed her shoes to walk barefoot in the grass; and 1 time fell in the dining area (cause was undetermined – while possibly getting up from low chair). Falls occur at various times during the 24 hour period and no particular timing trends can be identified. Ann has multiple internal risk factors including Vascular Dementia, Diabetes, HTN with a history of stroke, Overactive Bladder, Constipation, Pain and GERD. Her Dementia is quite advanced with many recent behavioral issues including throwing and smearing of feces and a recent stay at a Psych. Facility (see H & P 5/22/18). She can follow directions but does have difficulty remembering things such as to use the walker or to call for assistance. Her B/P is stable with no orthostatic drops – see VS sheet for 5/25/18 documentation. Resident did tell me she is often dizzy when attempting to stand. I completed a balance exam – her balance is good even without walker. She is on Lasix every other day and medications for an overactive bladder, as well as the usual HTN medications. I note her ankles are slightly swollen. Her CBG’s are checked every am at this time and run between 83-165. Receives Antianxiety and Antidepressant routinely, has not had drug reduction since psych. Hospitalization – will review with family, pharmacist and physician – drug reduction may not be warranted due to recent behaviors. At this time I do not see a correlation with medications and falls – need to assess orthostatic B/P’s further – will also refer to physician about findings of this CAA as well as to request a pharmacy review of current medications. Resident is receiving Miralax every day and Senna bid. These medications were recently held for diarrhea. I question if behaviors and perhaps some falls might be related to bowel urgency. Feet were examined – there are no problems – she has good shoes and they fit well. Resident continues to be at risk for falls and while all falls may be difficult to prevent related to her cognition status, I do feel further interventions are warranted and will proceed to care plan to review bowel medications; obtain a contour mattress (will need to be observed for transfers with this mattress); check of CBG’s for two to three evenings to ensure she is not bottoming out in the evening; Awaiting urine culture results; and discuss further interventions with team and family.

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Narrative CAA Examples

RAP 13 Feeding Tubes triggers as resident has a feeding tube in order to receive adequate nutrition. Resident is an unfortunate 35 year old MVA currently in a vegetative state and very slow recovery expected, if at all - please see H & P dated 8/6/18 and multiple consults in the H & P section of the clinical record. Family and care staff is all hopeful for some possible recovery in time, however, currently resident is unable to receive adequate nutrition without this intervention. Has had FT for two months and currently she has no complications and no identified psychosocial issues due to vegetative state. Residuals and placement are checked with each medication and feeding. Bowels are being monitored and no diarrhea or constipated is noted. Resident has no behaviors with attempts at removal. Current weight is stable. Will proceed to care plan to ensure adequate monitoring of placement, complications and overall health status. Please also refer to CAA 12 Nutrition – 8/19/18.

RAP 14 Hydration triggers as resident had a UTI with a fever during the look back period. He is on I & O monitoring and currently taking fluids well. His membranes are moist and recent labs do show a slight elevation in his BUN – see labs 7/25/18. His blood pressures were low during initial course of ATB, but now back to normal. Pulses are normal. See Vital Sign sheets between 7/14/18 and present. He has two days left with ATB. Other risk factors include diuretic use and early Dementia. Does not appear dehydrated but is at risk – therefore will proceed to care plan to refer to MD for ongoing monitoring of labs and ensuring adequate fluid intake at meals and with medications.

RAP 15 Dental triggers as resident with mouth lesions past 7 days related to ATB use and diagnosis of thrush. See Physician Progress notes 8/14/18 and orders. Currently being treated and oral cavity is improving. Resident has no current complaints of other oral or dental issues – teeth cleaned daily. Will not proceed as dental issues are not an ongoing problem – current issues being addressed and will continue to monitor for any changes that require additional assessment.

RAP 15 Dental triggers as resident has multiple dental issues - has many cavities and broken teeth. Resident with diagnosis of Dementia and oral care is often difficult related to behavioral issues. A number of interventions have been attempted – see behavioral reviews and Social Service notes past quarter May to August 2018. We have begun using oral topical medication to assist with her possible oral pain that is leading to many of these behaviors – See Treatment sheets for look back. Dental consult has been made and he feels teeth need to be removed under anesthesia, but family is reluctant. Meanwhile, will proceed with care planning to review alternative interventions in order to provide care as possible, and to address this resident’s possible pain and behaviors. See also Pain CAA and Behavior CAA.

RAP 16 Pressure Sores triggers as resident has two pressure injuries. Admitted with both, which developed when lying on ground waiting for help after falling and fracturing hip – see H & P 5/22/18. One pressure injury on left hip (Stage 3) – the other on left ankle (Stage 2). See skin treatment records and skin progress sheets for information (admit to ARD).Resident has a number of Extrinsic and Intrinsic factors that may delay healing and cause additional pressure injuries.Had CVA during surgery and now has a number of cognitive issues (See Delirium & Cognitive CAA’s 1& 2), is incontinent(see CAA 6 – 5/30/18), and with left sided weakness causing immobility – however working with therapy. See CAA 125/30/18 – nutritional status currently WNL. Pain appears controlled with current regimen – see Pain CAA 5/30/18. Anumber of aggressive interventions have been implemented – see baseline care plan developed at admission and skinteam review 5/24/18. Will proceed with care planning as resident is at risk and care plan interventions need to addresshealing as well as prevention.

CAA 17 Psychotropic medications triggers r/t Antianxiety, Antidepressant and Hypnotic use. Long standing psychiatric history of anxiety and depression, however Hypnotic use and insomnia are new. Resident states she is having difficulty falling asleep. Please see Mood CAA 8 – 7/8/18 for further information about anxiety and depression. Diagnoses of HTN and Diabetes, in addition to recent fall at home (prior to admission) pose increased risk for adverse reactions. Currently has orthostatic B/P problems – see Vital Sign sheet 7/5/18 – physician is aware. Due to long standing use of medications – do not feel that tapering of medication is wise at this time given the resident psychiatric diagnosis and adjustment

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problems – Physician and other team members agree. However will explore other antidepressants that could be considered as antidepressant could be causing insomnia – need to discuss this with resident. Insomnia problems could be r/t new environment and questionable discharge plan as family wishes her to move to CBC. Plan to have pharmacy do a full review of resident medications. Will proceed for monitoring of S/E’s and ensuring appropriate medication regimen.

CAA 18 Restraints Mr. Smith is using a lap buddy while in the chair. This device is restrictive in that it does prevent him from rising out of the chair. He is unable to ambulate or stand unassisted due to a past stroke and has dementia causing him to forget he cannot stand. However he is independent with wheelchair locomotion, self-propelling with his left leg and arm unaffected by stroke. He leans forward to ambulate and has often fallen face first out of the chair. Therefore, while the lap buddy prevents rising, it is also providing for his continued functional status of self-propelling. A number of other less restrictive aides and devices have been assessed and attempted, including self-releasing seatbelt – with his leaning the chair was tipping and the belt was too tight around his trunk; tilted back wheelchair – had difficulties self-propelling and became agitated; Therapy and Restorative failed to produce ability to stand or transfer with less assistance. It is our opinion this is the best device for Mr. Smith. He does not appear bothered by the device. His family approves of its use. The device fits well and comfortably across is trunk and there is no risk for entrapment as he sits upright in the chair without sliding. There is no trunk pressure or damage from his leaning forward to self-propel. He is on a pressure relieving cushion to prevent skin problems and a toileting program to reduce incontinence. He has not had a fall from the chair in 4 months. We remove the restraint for meals and supervised activities (see activity assessment 6/28/18); and when he is in bed no restraint is utilized. Will proceed to care plan to continue the use of this device and assess its affect at least quarterly or when there is a change in his status.

CAA 19 Pain triggers as resident is currently experiencing acute pain in left back and leg due to recent fall – see nursing progress notes 8/16/18. Fracture of leg has been ruled out however, does have a possible new fracture of lumbar spine – see X-rays 8/17/18 and physician progress notes for same date. He describes pain as stabbing and radiates down leftleg. Having some difficulty walking greater than 20 feet and he has been limiting his activity attendance – loved walkingoutdoors and attending exercise classes. Physician has ordered therapy referrals – awaiting evaluation results. He isnow on routine pain medications and prn meds – see MAR for look back period. He is also using ice which he says ishelpful. His current goals for pain management are to participate in therapy and attend his favorite activities – feels hecan handle a pain level of 3 to 4. If not controlled at that level he requires more medications and does not like feelinglethargic. Routine pain medication is currently effective at maintaining goals, however with therapy he may require prnmedication prior to treatment. He fears chronic pain related to recent injury. Will proceed to care plan to address painissues, ensure staff monitoring of pain, and to monitor results from therapy. Will reevaluate after therapy treatment hascompleted or with changes.

CAA 20 - Return to Community triggered as resident desires discharge back to home and lacks resources that may be needed for discharge to be successful. Scored 15 on BIMS, however does have some difficulty with decisions given recent hip fracture and mood issues identified on PHQ9 interview with a score of 14, with possible moderate depression and history of depression – see 6/29/18 H & P and CAA 7 - 7/10/18. He will need some support at home at least initially. Family is questioning Independent Living or ALF but has not yet discussed this with the resident. As he will require resources, I have proceeded with referral to State agency. Resident is motivated toward discharge. Therapy will be making a home visit and the IDT is establishing a training and discharge plan. Will proceed to care plan in order to facilitate a successful discharge.

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Pain Assessment Instructions

Pain Screening: Complete this section as part of the admissions process

Overall Objectives

- To determine whether pain is present not or had been present in the last 5 days- To determine necessary monitoring

Pain related diagnoses (check all that apply)

Review the list of pain-related diagnoses against the information provided by the sending or referral source (e.g. hospital transfer form, etc.). Check all that apply and add information as necessary.

Note any pain-related diagnoses and ask the resident the next two questions using those diagnoses as a guide. For example, “I see that you have arthritis. Tell me if that causes you any discomfort or affects your ability to do what you want to do.”

1. Do you have any pain or hurting anywhere now?

- Whether yes or no, go on to question 2.

2. Have you had any pain or hurting in the last 5 days?

- If “yes,” to either, initiate a pain monitoring schedule- If “no,” to both questions, and there are no pain-related diagnoses checked pain monitoring may

not be necessary. Use your clinical judgment to determine if it is necessary to initiate a painmonitoring schedule.

Sign and date the form.

Comprehensive Pain Assessment: Complete this section with the Admission assessment and as an option with each assessment based on resident needs and changes

Overall Objectives

- To evaluate the effectiveness of a resident’s pain management plan since their admissionor last assessment

- To complete a complete a comprehensive assessment of critical pain factors- To determine a person-centered pain management goal

Section I. Staff assessment of pain monitoring data Begin by reviewing all pain monitoring data (MAR, PRN sheet, staff observations, resident self-report, etc.) available for this resident and document your findings here. Use the data to inform your clinical judgment about the effectiveness of the current pain management plan for this resident.

Section II. Pain assessment interview The pain assessment interview begins by repeating the initial screening questions, as the resident’s pain issues may have changed since admission. You must attempt these questions with the resident and/or the resident’s representative.

1. Do you have any pain or hurting anywhere now?• Whether yes or no, go on to question 2.

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2. Have you had any pain or hurting in the last 5 days?• If “yes,” go to question 3.• If “no,” go to Section III, Staff observations for pain, and complete the section.

If none of these signs is observed, go to Section IV, Resident and staff goal(s) for painmanagement. Add other comments, sign and date the form, and update the care planwith any new information as needed.

If one or more signs are observed, note this, then go to Section IV, Resident and staffgoal(s) for pain management. Add other comments, sign and date the form, continuemonitoring and treating pain as needed; update care plan.

3. When you have pain, where is it?• Check all that apply.

4. Tell me what the pain feels like.• Check all that apply. If none of the words provided describes the pain, ask resident and

document the resident’s actual words in “Other.” Indicate whether the pain radiates or islocalized by circling “R” or “L.” Examine the site.

5. How would you rate the intensity of your pain during the last 5 days?• Based on the resident’s preferred pain scale, indicate the resident’s rating for the pain he or

she is experiencing now or during past 5 days.6. How much of the time have you experienced pain or hurting since your admission or the last time

we talked about pain?• Ask the resident to think back over the time interval and tell you how much of that time he or

she was in pain.7. When you have pain, when is it worst?

• Ask the resident whether he or she notices that pain is worse during different parts of the dayand document the time.

8. How does your pain affect your everyday life?• Check all that apply. Ask whether pain has other effects that were not mentioned and

document them after “Other.”9. What medications have relieved your pain in the past?

• Ask the resident what prescription and over-the-counter drugs have been helpful in managingtheir pain. Note whether these are the same or different from the medications they arecurrently using.

10. What nondrug approaches make your pain better?• Ask the resident what nondrug approaches have relieved their pain. Check all that apply. Ask

whether any other approaches make their pain better and document them after “Other.”

11. What makes your pain worse?• Ask the resident what makes their pain worse. Check all that apply. Ask whether other factors

make their pain worse and document them after “Other.”12. Since your admission, how well has your pain been managed?

• Determine whether pain treatment is aligned with goal, timely, and effective.13. What is your goal for pain control in terms of function?

• Check all that apply. Give examples if necessary: “Sleep for 4–5 hours at a stretch”; “Be ableto visit with family and friends.”

What is your goal for controlling the intensity of your pain? • Based on the same pain scale used for question 4, ask what the resident’s goal is for

managing the intensity of his or her pain.

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III. Staff observations for painComplete this section for all residents. Use the categories to inform your clinical judgmentabout whether or not pain is present for residents who are nonresponsive or who deny pain.Consider utilizing a non-verbal assessment tool such as the PainAD tool.

IV. Resident and staff goal(s) for pain managementComplete this section. Update the care plan.

V. Pain assessment interview attempted but not completedIf the resident is rarely or never understood or is nonresponsive, and if a family member orother representative is not available, check the applicable box, then go to Section VI. Utilize thePainAd Tool

VI. Pain management goal for nonverbal residentCheck the appropriate box for who determined the pain management goal.Complete this section, then sign and date the form. Update the care plan.

VII. EducationComplete pain education provided as needed; document date provided and by whom.

Document your plan – sign/date your assessment.

Jointly developed by Acumentra Health and Haffenreffer & Associates; with support from the Oregon Pain Management Commission.

This material was prepared by Acumentra Health, Oregon’s Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

8SOW-OR-NH-07-33 10/29/07

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Pain—Admission Screening and Comprehensive Assessment Resident Name: ______________________________________________________ DOB: _________________

Date: __________________ Time: _________________ New admission Re-admission Other

Pain Screening On Admission or Initially (Attempt the two interview questions with the resident and/or their representative)

1. Do you have pain or hurting anywhere now? Yes No 2. Have you had any pain or hurting in the last 5 days? Yes No

Pain-related diagnoses (check all that apply) AIDS Amputation Arthritis Cancer Compression fractures Contractures

CVA/post stroke Dental problems Fracture Gout Headache Joint replacement/pinning

Lower back disorder Neuropathy Osteoporosis/osteopenia Postoperative Pressure ulcers/skin lesions Shingles

Other musculoskeletal Unspecified Other (describe):______________________________________________________

Signature_____________________________________________Date________

Comprehensive Pain Assessment I. Staff assessment of pain monitoring data collected since admission or last MDSReview the MAR, PRN sheet, resident’s self-report of pain location, quality, and intensity, resident’s self-report of pain relief obtained through drug and nondrug interventions.

II. Pain assessment interview (you must attempt the interview questions with the resident and/or representative)

1. Do you have pain or hurting anywhere now? Yes No2. Have you had any pain or hurting in the last 5 days? Yes No3. When you have pain, where is it? (check all that apply and document examination of the site)

Back pain _____________________ Bone pain _____________________ Chest pain with usual activities Headache _____________________

Hip pain Incisional pain Joint pain (not hip) _______________________ Muscle pain ____________________________

Neck pain Stomach pain Unspecified ______________________ Other (describe): ______________________________________________________

Examination of the site:

4. Tell me what the pain feels like. (Help them w/ words such as numbing, sharp, grabbing & identify if localized or radiating)

5. How would you rate the intensity of your pain now or during the last 5 days? (indicate which scale was used)

Numeric scale 1–10: _____ Numeric scale 1–5: _____ Faces scale: _________ Verbal descriptor: ________

6. How much of the time have you experienced pain or hurting in the last 5 days? (check one) Almost constantly Daily or several times a day Less than daily Rarely Unable to answer

7. When you have pain, when is it the worst? (check all that apply) Early morning Mid-morning Afternoon Late evening Night

8. How does your pain affect your everyday life? (check all that apply) Sleep Appetite Nausea

Therapy or activities of choice Concentration Emotions

Interaction with other people Ability to bathe, groom, dress self

Other: _________________________________________

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9. What medications have relieved your pain in the past? ___________________________________________________________________________________________________________________________________________________________________

10. What nondrug approaches make your pain better? Warm packs Cold packs Breathing and relaxation Distraction

Repositioning Exercise Massage

Rest Other (describe): ___________________________________________________

11. What makes your pain worse? (check all that apply)

Physical activity/exercises Dressing changes Turning/Repositioning

Bathing Rising from a chair, bed Feeling fatigued

Feeling anxious Other (describe): ___________________________________________________

12. Since admission or the last MDS, how well has your pain been managed? (check one)

Very poorly Poorly Moderately Well Very wellAdd additional comments from the resident here:

13. What level of pain relief would you be satisfied with, in terms of function and intensity of pain? (indicate which scale was used) Sleep comfortably Rest comfortably Move comfortably Stay alert Perform activities Total pain control Other: ______________________________________

Numeric scale 1–10: _____ Numeric scale 1–5: _____ Faces scale: _________ Verbal descriptor: ________

III. Staff observations for pain (check all that apply)

Nonverbal sounds(crying, whining,gasping, moaning,groaning)

Vocal complaints ofpain (“that hurts,”“ouch,” “stop”)

Facial expressions(grimaces, winces,wrinkled forehead,furrowed brow, clenchedteeth or jaws)

Protective body movements orpostures (bracing, guarding,rubbing or massaging a bodypart/area, clutching or holding abody part during movement) orbehaviors (yelling, resisting care,etc.)

None of thesesigns observed

IV. Resident and staff goal(s) for pain management & recommendations:Examples: Walk comfortably to dining room for evening meal; participate in 30 minutes of PT twice daily, pain 3–4 on a 10-point scale

Continue with current plan Update current plan of care

V. Pain assessment interview attempted but not completed (check all that apply)

Staff are never or rarely able to understand resident’s speech Resident does not have a representative available at this time

Resident is nonresponsive

VI. Pain management goal for nonverbal resident Determined by staff Determined by resident’s representative

VII. Pain Education – the following has been discussed with Resident and/or family: Completed on__________________ by _______________General Overview of pain & pain management: Fear of addiction; Concerns about side effects; Fear of injections;

Desire to be stoic; Desire to be a “good patient.” Medications; Non-med interventions; Side effects of interventions; Effectiveness of interventions; Other (state):______________________________________________________________________________Further Comments:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________PLAN:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Completed by ___________________________________________________________________________ Date _________________________

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