Long-Term Care Survey Alert

6 ways to stay a step ahead of pain and F tags in your facility.

The pain quality measures provide a gauge for surveyors, plaintiff attorneys and consumers to rate your pain management prowess. Your job here is twofold: First, you need to understand how these measures work and their shortfalls. Second, you need to know how to use them as an effective quality assurance tool. To pull off that feat, keep these key pointers in mind:

1. Don't rely on the pain quality measures as your sole source of "grading" your pain management program. The QMs are going to "miss folks" who have pain, cautioned Steven Littlehale, MSN, RN, chief clinical consultant with LTCQ Inc., in a presentation on QI/QMs at the recent American Medical Directors Association annual meeting held this year in Dallas.

For example, the QMs won't capture residents who might want relief from daily mild pain or moderate pain that doesn't occur daily. And you can bet surveyors can identify residents in pain who didn't trigger the pain QM.

2. Stress the importance of capturing and coding a resident's pain on the MDS. Some nurses say their administrators discourage them from coding pain on the MDS for residents on pain management, reports Diane Brown, CEO of Brown LTC Consultants in Boston.

Not only is that tack a serious F tag in the making, but you want your QMs to identify residents who remain in pain.

Don't penalize the facility unnecessarily: Code the resident's actual pain--not what it would have been if he weren't receiving pain management.

3. Avoid a "one size fits all" approach to pain assessment. Facilities should use different pain assessment tools so they can give residents a choice, comments Regina Fink, RN, PhD, FAAN, AOCN, a pain specialist and research nurse scientist at the University of Colorado Health Sciences Center. To order an Agency for Healthcare Research & Quality-funded pain toolbox, including an instrument that has three pain assessment tools in one (in English and Spanish), go to http://www2.uchsc.edu/son/centers/content/PainToolBoxOrderForm.pdf.

Tip: As part of your quality assurance efforts, document that you have implemented more accurate pain assessment tools geared to the needs of nonverbal residents or those with cognitive impairment. The documentation will explain the temporary bump up in your pain QMs.

4. Get a jumpstart on pain through a preadmission screening. Short-stay residents with pain sufficient to trigger the postacute pain QM will do so on the 14-day MDS. And there can be only three days between the assessment reference dates for the 5-day and 14-day MDS in some cases.

Solution:  Paramount Meadows Nursing Center screens residents for painful diagnoses before admission, says Teresa Caipang, RN, director of nursing for the Paramount, CA facility. "The DON will ... personally talk to the discharge planner or nurse [in the acute-care setting] to inquire about the resident's special needs," she says. The DON will also talk with the resident by phone, if the resident is able, to assess his pain management expectations. The goal is to maintain the person's continuity of pain management as he transitions to the facility, Caipang adds. The facility also performs a pain assessment on each resident at admission. And the interdisciplinary team meets within 72 hours after admission to address the resident's concerns and discuss the effectiveness of pain management.

5. Don't let untreated break-through pain break your pain management quality profile. Facilities should monitor residents closely for break-through pain which can be treated with a medication with a shorter half life or one that may not be as strong as the primary pain medication, says Kenny Powers, the consulting pharmacist for Windsor Place Nursing Center in Daingerfield, TX.

Best-practice tip: To stay on top of residents' pain, Paramount integrates pain assessment into the med pass. "We ask patients every day during every shift when we pass medications to rate their pain on a scale of 0 to 10," says Caipang. "For nonverbal patients we use a nonverbal assessment form. The pain assessment form is on the medication assessment record." For residents who have stage 3 and 4 pressure ulcers, the treatment nurse also uses a pain scale to assess for pain. "The treatment nurse documents the resident's response to the pain questions and communicates with the charge nurse if the resident says he is in pain," says Caipang. 

The interdisciplinary team reviews the effectiveness of the resident's pain management and makes recommendations to the MD for managing break-through pain after conferring with the pharmacist. "Our goal here in conferring with the pharmacist is [to avoid] overly sedating the resident so he can no longer participate in his activities of daily living," says Caipang.

6. Keep an eye on escalating reports of pain in your facility by reviewing your QI/QM report weekly. You don't have to wait until the first Monday of each month to pull your QI/QM reports. "The 'Data was calculated on' date field on the CASPER Reports Submit page will display the last date that the data was calculated," according to information posted on the QIES Technical Support Office Web page (www.qtso.com).