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Nursing Homes Under Pressure to Improve Pain Management

Emily Beaver, April 13, 2009

When it comes to managing pain, long-term care experts say a proactive approach is best—clinicians should anticipate and treat pain before it becomes too intense. However, it seems that many in the long-term care industry have waited for CMS to dial up the pressure before addressing shortcomings in pain management practices.

But the way nursing homes manage pain is about to come under intense scrutiny with the recent release of new pain management guidance and investigative protocols under the survey deficiency tag F309, Quality of Care. Under the new guidance, which CMS released and implemented April 10, surveyors can cite nursing homes that aren't appropriately managing pain with deficiencies.

In the past, nursing facilities were expected to address and manage pain, but nursing homes and surveyors did not have specific guidelines to do so, says Marilyn Mines, RN, BC, RAC-CT, manager of clinical services for FR&R Healthcare Consulting, Inc. in Deerfield, IL.

"Overall, in the industry, it's been felt that pain has been ignored in the geriatric population, and hence, now we have a [survey] protocol that's extremely complex," Mines says.

The new guidance under F309 states that nursing facilities must assess and address pain in all residents, including the cognitively impaired. To comply with F309, nursing facilities need to reexamine how they assess and manage pain in residents, including the use of pain medications, PRN ("as needed") medication regimens, and complimentary and alternative medicine (CAM).

Assessing and treating pain in cognitively impaired residents, who have difficulty communicating pain through statements or commonly-used pain scales, is a major challenge for nursing facilities.

Nursing homes are most likely to underestimate pain in residents with dementia, says Christie Teigland, PhD, director of health informatics and research for the New York Association of Homes and Services for the Aging (NYAHSA) and EQUIP for Quality in Albany, NY.

Even when residents with Alzheimer's disease and dementia have diagnoses known to cause pain, such as arthritis, neuropathies, and joint disease, their pain is reported only about half as often as in cognitively intact residents with similar diagnoses, according to research Teigland presented to the Alzheimer's Association.

Long-term care experts say some other common shortcomings in many nursing facilities' pain management programs include:

  • Using PRN medications to treat pain when an around-the-clock regimen would be more appropriate
  • Prescribing PRN medications for cognitively impaired residents who may be unable to communicate pain or ask for medication
  • Failing to anticipate pain before pain-inducing activities, such as therapy or wound-dressing changes
  • Dismissing residents' statements of pain based on personal beliefs or attitudes

The good news for nursing facilities may be that the new guidance simply enforces existing clinical practice standards for pain management rather than introducing new standards.

Facilities that address pain with the "nursing process," which involves assessment, problem identification, care planning, implementation, and evaluating outcomes, should be in compliance with F309, says Rena R. Shephard, MHA, RN, RAC-MT, C-NE, founding chair and executive editor of the American Association of Nurse Assessment Coordinators and president of RRS Consulting Services in San Diego.

"Facilities that have been doing this well aren't going to find anything surprising, and they don't have anything to worry about," Shephard says.


Emily Beaver is an associate editor in the long-term care market at HCPro. She writes PPS Alert for Long-term Care and manages MDSCentral.

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