Long-Term Care Survey Alert

How many of your facility’s residents would  tell a surveyor today that they are in moderate pain  daily or in horrible pain at any time?

The answer to that question will be public  knowledge this fall when the government’s new quality  initiative goes live nationwide (see Long-Term Care  Survey Alert, Vol. 4, No. 5, pp. 44-46).

Your facility’s percentage score on the pain  quality measure could win you points with surveyors  and consumers — or leave you holding a potential F  tag (F309) for failing to meet the resident’s right to  receive necessary care and services.

In the pilot quality initiative now underway  in six states, CMS calculated facilities’ percentage  score on the pain measure based on Section J2 of  the MDS, which asks for the frequency and intensity  of a resident’s pain. The proposed pain measure  for the national initiative follows the same formula.

“To be included in the pain quality measures,  a resident has to have moderate pain at least  daily so that’d be a J2a (2) and J2b (2),” explains  Cheryl Field, director of clinical and reimbursement
services at LTCQ Inc. in Bedford, MA. “Or  horrible or excruciating pain — J2b (3) — of any  frequency during the assessment period will include  the resident in the percentage score.”

How would you code a resident whose excruciating  pain is under control thanks to a morphine  pump, as an example?

“There is a frequent misperception among facilities  in the pilot states … that you code a resident as  being in pain even though the person says he is pain  free while on a medication regimen,” says David  Gifford. Gifford is chief medical officer for Rhode  Island Quality Partners, a quality improvement organization  working with facilities on pain management  and other clinical issues as part of CMS’ quality initiative.  “You would code any break through pain the resident  has while on a pain medication and probably many  residents will report some break through pain during
the assessment period,” he tells Eli.

Experts agree that the pain quality measure  will provide some incentive for facilities to undercode  pain, especially horrible pain.

“Over time, one would expect the Centers  for Medicare & Medicaid Services to focus more  on the items that trigger the quality measures,” cautions  Ruta Kadonoff, a quality initiative expert at the
American Associations of Homes & Services for  the Aging. Kadonoff, in fact, predicts that CMS may  develop more specific investigative protocols as the  result of the quality initiative, including  one for pain.  CMS is also focusing on MDS accuracy through its  Data Assessment and Verification Evaluation (DAVE)  initiative, with onsite pilot testing already underway in
Indiana and Georgia.

Take Steps to Ensure Accuracy

To ensure accurate assessment and coding,  MDS coordinators should interview residents about  their pain. “If the MDS assessment nurse relies on the medication administration record [or MAR] to  ascertain the frequency of a resident’s pain,” Field  cautions, “she may assume the resident had minimal  pain because he only received Tylenol for pain  twice in a week. Yet, often residents will only take  medication on a really bad day and, when asked,  report they have learned to live with daily pain.”

Nurses should also routinely ask family  members if they think their resident is comfortable.  Families can oftentimes “read” the body language of  a cognitively impaired member better than anyone can.  Changes in a nonverbal resident’s behavior, such as  pacing, rocking or agitation, may signal pain rather than  worsening dementia, according to the American Geriatrics  Society’s new pain guidelines  (www.americangeriatrics.org/education/ painrelease.shtml).

One clue that the patient may be having serious  daily pain lies in the diagnosis Section (I) of  the MDS. Field notes that certain diagnoses like arthritis  and multiple sclerosis are known to be painful.

Assessing the severity of pain (item J2b) can  be difficult because pain is a subjective experience.  And the Resident Assessment Instrument user’s  manual provides no guidance at this point on how to  define moderate pain. By contrast, the RAI defines  mild pain as allowing residents to usually continue with  their normal activities and “horrible or excruciating”  pain as “the worst possible pain … usually interfering  with the resident’s routine, socialization or sleep.”

“It’d be great if we could just use a scale of  1-10 and report moderate pain as being 4-6,” says Field.  “But some people will say their pain is a ‘4’ and that  pain is actually interfering with their   ability to go to  morning coffee or participate in their usual activities,”  which meets the definition for horrible pain.

Gifford agrees that the RAI does not currently  do a good job of translating a 0-10 scale into mild,  moderate or excruciating pain. Nevertheless, he suggests  facilities use a pain scale to assess   and monitor/track residents’ pain. “Certain individuals or those with  cognitive impairment may respond better to one scale  or another, but as long as the facility is consistent, any sort of scale is fine.”

Some facilities are adapting pain scales to their own unique patient populations. Leesburg Regional Medical Center, Nursing Center in Leesburg, FL, for example, uses a scale of 1 to 5 to asses pain.

“We’ve found that our patients—many of whom are post surgical—either have mild pain or severe pain with little in between,” DON Laura Fain tells Eli. “The nurses screen patients using the scale each time they administer pain medication and then document the pain’s intensity and location on the medical administration record.”