In Part 1 of CMSCG’s Ftag of the Week – F697 Pain Management, we discussed how potential issues with pain recognition can be identified by surveyors on interview and observation. We also looked at the importance of evaluations and ongoing assessments for pain recognition. In Part 2, we will continue to explore effective pain management.
What Should We Think About to Recognize Pain?
Expressions of pain may be verbal or nonverbal, and the Interpretive Guidance for F697 reminds us that the MDS can also provide insight into potential pain indicators, so having a comprehensive picture of what is going on with a particular resident can provide insight into whether a resident may be in pain. Here are some things to look for:
- Verbal – The IG provides a list of descriptive words that may used to describe pain, and these descriptions may provide insight into identifying the type of pain, its source and other helpful characteristics.
Citation Example (S/S: D): During a pressure ulcer treatment observation, the resident was observed stating, “Don’t do that, it hurts.” The LPN asked the resident if she was ok but continued to remove the dressing. The resident was not assessed for pain severity or offered a pain medication. It is important to acknowledge the resident’s communication of pain and address it rather than continue with a treatment that may be painful.
- Nonverbal – The IG provides a list of possible non-verbal indicators of pain but notes that these should be looked at within the entire clinical context since they may be indicators of pain but may also be related to another clinical issue or diagnosis.
Citation Example (S/S: G): During a meal, a resident was observed by a surveyor to be grimacing, guarding his leg, moaning with his eyes closed and would not eat his meal. A staff member seated with the resident told the surveyor the resident was in a lot of pain and so she was trying to help him eat, but at no time did she inform a nurse of the resident’s pain. The surveyor then observed multiple staff members (at approximately 845 AM) attempting to assist with resident with transfer from his wheelchair to the bed, and the resident was in so much pain that he was yelling out and stopped trying to help transfer. All the staff members picked him up and moved him, and then he was administered his pain meds (scheduled for 830 AM), nearly 10 hours after his last dose.
- Has the resident experienced a change in his/her mood?
- Has the resident experienced a decline in functioning, including inability to perform ADLs?
- Has the resident experienced a weight loss?
- Does the resident have any skin conditions that could cause pain?
- Has the resident’s sleep cycle been disrupted?
- Has the resident been exhibiting decreased participation levels related to usual physical or social activities?
- Have staff who have been in contact with the resident observed any changes to the resident’s behavior or noticed anything different?
Surveyors are also expected to look for symptoms of pain during the observation process. The following observations during the Initial Pool Process may warrant follow up by the surveyor – and should be indicators to your own staff that something may be amiss:
- Pained facial expression
- Changes in breathing – labored/strenuous/negative noise heard upon inhalation/expiration
- Positioning – is resident in a strained or inflexible position
- Restless motion/rocking/rubbing body part/guarding/forceful touching of body part
- Altered gait
The Pain Recognition and Management CE Pathway also guides surveyors to look for:
- If/how staff assess pain and the effectiveness of pain interventions for non-verbal or cognitively impaired residents
- How staff responds if there is a report from the resident/family/staff that a resident is experiencing pain
- How long a resident waits to receive PRN pain meds after requesting
- Staff responsibility for pain recognition, including many ways to recognize and identify pain.
Pain Recognition and Management for Non-Verbal or Cognitively Impaired Residents
Staff needs to be aware of their responsibility to recognize and assess pain in residents who are living with moderate to severe cognitive impairment since pain may be less apparent or the resident may be unable to verbalize his/her pain.
Citation Example (S/S: G): A facility was cited for failure to ensure that a cognitively impaired, nonverbal resident’s pain management regimen was followed in accordance with physician’s orders when the resident was not assessed for pain during a wound care treatment. A surveyor observed the resident “moaning, grimacing and flailing their arms in an excessive motion,” but the LPN providing care did not stop the treatment to assess the resident’s pain. The resident had been provided with pain medication 1 hour before treatment, which was not in accordance with the physician’s orders, and the LPN had not used the PAINAD scale which was the facility’s protocol for nonverbal residents.
We know what should happen to manage a resident’s pain and how to recognize ineffective pain management, but for some reason we are inconsistent in making sure that we carry out the plan of care when we see signs of pain. Effective pain management requires ongoing monitoring to assess the effectiveness of the plan, including assessing staff knowledge of the plan and understanding of their responsibility when there is evidence that the resident’s pain is not being well managed or staff are failing to follow the plan of care.