Avoiding a Pain F-Tag Citation

1. Avoiding a Pain F-Tag Citation

2. 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

3. 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

4. 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

5. F 309: Current MDS Screening • Frequency, intensity, symptoms, and location/site of pain • Other sections that relate • Sleep cycle • Change in mood • Functional limitations • Instability of condition • Weight loss • Skin conditions

6. 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)

7. 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

8. PQRSTA 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. The Pain F-tag may motivate, but it is all about quality care Quality Pain Care for Elders

29. 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

30. 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

31. 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

32. Questions? THANK YOU Adapted and used with permission from K. Herr, PhD, RN, The University of Iowa, 2009.