MDS Alert

These strategies will help you cover the pain assessment and care planning bases.

Problem: Facilities are finding that "what the resident says in the interview isn't always consistent with documentation made by the IDT members during the same lookback," cautions Mary Chiles, RN, RACCT, principal of Chiles Healthcare Consulting LLC in Richmond, Va.

"For example, when we do a pain interview, we ask the resident first whether he has experienced" any pain or hurting during the last five days, Chiles says. "And if he says, yes, we proceed to ask several more questions" (see the interview questions on page 76).

"I think nursing facility staff are beginning to understand that even though residents can clearly understand the question, they may say they did not have pain in the last five days" because they don't remember for whatever reason, Chiles says. "For example, someone may have had minor pain and asked for and received [PRN medication] -- and that didn't leave a lasting memory in the person's mind that it was something to be reported."

"The interview process is valuable when used as a piece of the whole pie, but you can't always view it as the gospel truth," observes Joel VanEaton, BSN, RN, RACCT, a reimbursement and RAI consultant with Extended Care Products Inc. For example, "some people may have fairly good BIMS scores but actually don't function that well cognitively in some situations."

The RAI User's Manual "allows for a small bit of probing," says Ron Orth, RN, RAC-MT, CPC, president of Clinical Reimbursement Solutions in Milwaukee. He points out that the instructions on page J-7 of the RAI manual note that "if the resident is unsure about whether the pain occurred in the 5-day time interval, prompt the resident to think about the most recent episode of pain and try to determine whether it occurred within the look-back period."

But "as the material in Appendix D instructs: 'Do not try to talk the resident out of an answer'" (page D-3), adds Orth, president of Clinical Reimbursement Solutions in Milwaukee.

More instructions: The RAI User's Manual also directs the interviewer to "use other terms for pain or follow-up discussion if the resident seems unsure or hesitant. Some residents avoid use of the term 'pain' but may report that they 'hurt.' Residents may use other terms such as 'aching' or 'burning' to describe pain" (page J-7).

Coding example: The manual directs you to code J0300 (pain presence) 1 for "yes," when Mr. T says No when asked if he'd had pain, but goes on to say that he had "a terrible burning sensation all down my leg" (page J-8).

Tip: Chiles notes that the MDS 3.0 Video on Interviewing Vulnerable Elders (VIVE) provides an example of how to interject a comment when a residentsays No to a question on the pain interview (see page 76 for details).

When there's a "disconnect" between the interview and documentation during the lookback, "investigate and explain it in the clinical record or through the care plan or pain assessment," Chiles advises.

"You have to code the interview based on what the resident tells you," she adds, "but the plan of care should encompass both what the resident tells you and theoverall assessment by the professional team. Just because you code no for pain on the MDS doesn't give the facility the permission not to have a pain care plan."

Bottom line: "The goal is to make sure the care plan accurately reflects what's happening with the resident," adds Roberta Reed, RN, MSN, senior consultant with Plante & Moran Clinical Group in Cleveland, Ohio.

Care plan tip: "Educating the resident about pain and exploring how he or she views pain helps to increase the reliability and validity of the interview," advises consultant Lisa Hohlbein, RN, RAC-CT, MSCN, in Anna, Ohio.