Ftag of the Week – F697 Pain Management (Pt. 1)

This week’s Ftag of the Week on the CMSCG Blog is F697 Pain Management, which is part of the Quality of Care regulatory group. Nursing home providers are required by regulation to ensure that residents who require pain management receive necessary treatment and care in a manner that is consistent with professional standards of practice, is reflective of what is in the comprehensive care plan and considers the residents’ preferences and goals. Implementing an effective pain management protocol is a complex task, and as such, we will be digging into F697 Pain Management over the next couple of weeks.

On survey, there are many opportunities for surveyors to identify issues with pain management whether it is through visual observation, interview or record review. For instance, during the Initial Pool Process, residents will be queried as to whether they have any pain or discomfort. If so, the surveyor will ask about the following:

• Location of pain
• Frequency of pain
• What is being done to manage the resident’s pain
• Resident’s involvement in developing the pain management regimen
• If the pain is relieved
• If the pain prevents the resident from doing things he/she would like to do, including attending activities
• If the resident receives pain meds when needed, including before treatments or therapy
• If pain meds are provided timely after a resident requests them
• Side effects, if any
• If the resident is on opioids – what did the facility try before the med was started

Before the observations and interviews, surveyors are reminded to (among other things):

• Review physician’s orders for:
  • Pain management interventions
  • PRN or routine pain meds
  • Type of pain meds – opioid/ non-steroidal anti-inflammatory
  • Route of administration

• Review the care plan for:
  • Measurable goals for pain management – what level of pain is acceptable for the individual resident
  • Current pain management interventions
  • Pharmacological interventions
  • Non-pharmacological interventions
  • Timeframes
  • Approaches for monitoring the resident’s pain status
  • Approaches for monitoring effectiveness of interventions in place to manage the resident’s pain

So, let’s start with the basics – pain recognition.

Pain Recognition

Per the State Operations Manual Appendix PP Interpretive Guidance (IG), since nursing home residents are at a high risk for having pain, it is important to ensure that a plan for pain management is developed, when necessary, that includes the resident’s needs, goals, and information about the pain itself, including etiology, type and severity.

The facility should be able to show – through documentation – that it has:

• Recognized when a resident is experiencing pain.
• Identified circumstances when a resident’s pain can be anticipated.
• Evaluated the resident’s existing pain and the cause or causes of that pain. Attempts to treat the underlying cause should have been attempted, even though analgesics may have been provided to reduce pain and enhance quality of life.
• Evaluated the resident’s reports of pain or nonverbal signs of pain, since pain may impact the resident’s function, impair his/her mobility, alter his/her mood, diminish the resident’s quality of life, and/or disturb sleep, which is important to address.
• Managed or prevented pain in a manner consistent with the comprehensive assessment and care plan, in accordance with professional standards of practice and the resident’s goals and preferences.

Pain Recognition – Evaluations and Ongoing Assessments

The prompt recognition of pain so it can be addressed is essential to ensuring residents do not experience diminished quality of life. Thus, providers need to ensure that the resident’s admission evaluation includes an evaluation for pain, and that ongoing assessments are conducted to ensure a current and effective plan for recognizing and addressing plan is in place.

An assessment should be completed whenever a resident experiences a change in condition, or if there is new pain or an exacerbation of existing pain expected. It is important to note that pain is subjective and individualized to each person, and a resident’s expression of pain may be verbal or nonverbal. Even if the resident is able to verbalize his/her pain, the resident may use different descriptive words for what is occurring other than describing it as “pain.”

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Let’s look at what happened during a recent survey.

Citation Example (S/S: J – Immediate Jeopardy): provides a good example of what happens when evaluations and ongoing assessments are not completed. The findings impacted 2 residents, one of whom ultimately left the facility against medical advice to get pain relief, and the other who experienced such excruciating pain that he was ultimately sent to the Emergency Room for pain management. Despite it being obvious as to why this facility was put into Immediate Jeopardy regarding its pain management practices, here are some additional details:

• One resident was newly admitted and had multiple hospital discharge orders for pain meds, which she did not receive. A complete nursing assessment for the resident was not conducted by the admitting nurse who was on shift at the time, and she did not report the new admission to the on-coming nurse. On interview, the resident states that she remembered “crying and screaming into my pillow because the pain was so terrible throughout the night” even though she had requested pain meds. After 11 hours of unrelieved pain, the resident left the facility with a family member and noted to the surveyor that she felt neglected. The nurses assistant assigned to the resident relayed the resident’s request for pain meds to the nurse, but the staff was waiting on the physician to order her pain med.
• The second resident, who regularly received opioid pain meds for chronic back pain, told a surveyor on interview that his pain management regimen had been effective, but the facility had run out of the medication in the morning a week prior and he did not receive an alternate pain med until the middle of the night. The resident told the nurse that the new medication was not working and that his pain level was at a 10+ all day, so he ultimately requested to be sent to the Emergency Room for treatment.

To say the least, there was definitely a negative outcome for the two residents cited in the Statement of Deficiencies. We can all piece together the physical harm to the residents with this high level citation. What also needs to be kept in the back of our minds is the potential for psychosocial harm related to poor pain management.

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