Long-Term Care Survey Alert

Surefire ways to improve your pain assessment program — and be rewarded at survey time.

Poorly treated pain is a concern in every medical setting — but the challenges mount in the nursing home, where advanced age, co-morbidities, and residents’ declining ability to communicate often complicate caregivers’ efforts to ferret out — and fight — pain.

Rather than retreat, redouble your commitment to assessing and treating pain, coaches Alexis Roam, MSN, RN, Program Manager, Nursing Home Services, with Primaris, Missouri’s quality improvement organization. Nursing homes have made progress on the pain front, but there’s still room for improvement, especially when it comes to pain assessment for residents with dementia.

Invest in your pain management program, and in addition to improving the quality of care, you are likely to fare better at survey time. Immediate jeopardy citations are often rooted in the lack of a comprehensive assessment, experts say.

Added incentive: The feds continue to call for better assessment of pain in nursing homes, particularly for residents with dementia. In February, “proper pain assessment” was a featured topic of an MLN National Provider Call sponsored by the National Partnership to Improve Dementia Care in Nursing Homes. Furthermore, the panel noted the “critical role of both state and federal surveyors in the implementation of the partnership to improve pain assessment and other aspects of dementia care in nursing homes.

In other words: Surveyors have been put on alert to watch for shortcomings in pain assessment.

How Big Is The Problem?

The first step to better pain assessment is to cast outdated preconceptions out the door.

Don’t be influenced by the incorrect belief that the elderly do not feel as much pain as younger people and cannot tolerate pain medications, urges Betty Frandsen, RN, NHA, MHA, C-NE, writing in a recent publication of the American Association of Nurse Assessment Coordinators.

In fact, the ability to read between the lines is vital when considering statistics about the pain nursing home residents feel, experts say. According the Centers for Medicare and Medicaid Services’ Nursing Home Data Compendium: 2012, 15.3 percent of residents report having experienced “moderate to severe” pain in the previous 5 days, on average. But it’s important to dig even deeper, pain experts say, looking at the numbers as they break down by age. Among residents aged 31 to 64 years of age, the rate of pain (moderate to severe in the last 5 days) was 24 percent, but among residents aged 85 to 94 years, the rate was just 11 percent — and the rate for those 95 years and older was an even lower 8 percent.

Does that mean that older nursing home residents are likely to be experiencing pain at much lower rates than their younger counterparts? Decidedly no.

Rather, the statistics that show less reported pain in the older age group is likely to reflect an underreporting of pain among older residents — many of whom fall into the category “unable to self report,” says Keela Herr, PhD, RN, FAAN, AGSF, professor and associate dean at the University of Iowa College of Nursing and a nationally recognized expert of pain assessment.

To ensure that your pain management program will stand up the toughest scrutiny, start by revisiting these essential components:

Screening: Because residents with dementia aren’t reliably able to self-report pain, it’s important to use a team approach to screening. Careful observation is essential to keeping tabs on a resident’s pain, says Roam. With this in mind, remember that frontline caregivers and family can both be important sources of information on resident’s pain. Formal assessment of pain is outside the nursing assistant’s scope of responsibility; CNA use of a pain behavior tool can be viewed as screening, notes Herr.

Recommended reading: A recent research paper highlights the value of one such CNA-friendly tool, the CNA Pain Assessment Tool (CPAT): “The role of the CNA pain assessment tool CPA/T in the pain management of nursing home residents with dementia,” (Geriatric Nursing, 2012;33:430-438).

Comprehensive assessment: Have evidence-based tools for pain assessment at the ready, specifically ones validated for use in the nursing home and for use among residents with dementia, Herr tells Eli. Armed with research to back up her recommendations, she points clinicians to the Pain Assessment for Advanced Dementia tool (PAINAD) for daily assessments including follow-up evaluations, and to a second tool for use as a baseline and periodic (monthly or quarterly) maintenance assessment tool: the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). The PACSLAC also works well with MDS assessments as a way to capture boarder changes in resident behavior and activity.

Monitoring: To ensure great care and survey results, be sure that you document your efforts to monitor residents’ pain. Primaris calls on providers to monitor pain with attention to the following questions:

• Does your facility use an appropriate pain scale to monitor for pain on a daily basis for those with cognitive impairment (e.g., PAINAD)?
• Do you use nonverbal cues to monitor for pain?
• Do you record a monitored pain scale score at the following times? At least every 24 hours, before giving a PRN pain medication, approximately 30 minutes after giving a PRN pain medication, with each complaint of pain?

Don’t forget: Other aspects of managing pain include reassessment of resident’s pain, development of the care plan, staff training, and assessing pain management program.

Related: Pain may also be under-reported and under-assessed among residents with psychiatric diagnoses, including depression, suggests the recent work from a team of researchers in Palo Alto, California.

“Nursing home residents with psychiatric disorders, especially male, non-white, and longer-stay residents, should be targeted for improved pain care, concluded the authors of a 2013 report titled “Psychiatric Disorders and Pain Treatment in Community Nursing Home.”