MDS Alert

Heads up:  The survey stakes for keeping pain in check will soon be higher.

Failing to assess or treat pain hurts more than your residents. It can land your facility a G-level or even an immediate jeopardy citation under the new Psychosocial Severity Outcome Guide that goes into effect on June 1.

Surveyors will use the guide to determine the severity of a deficiency that causes a negative psychosocial outcome (for examples of what would constitute a pain-related actual harm or IJ tag, please refer to the article later in this issue).

The good news: You can keep your residents in the comfort zone--and ensure a pain-free survey--by following these key MDS strategies.

Don't Equate Pain With Section J Only

You code a resident's pain frequency and intensity at Section J2. But the MDS can "be a good assessment tool for monitoring pain" and seeing how pain impacts "a person's life," says Barbara Golden, RN, director of nursing for Windsor Place Nursing Center in Daingerfield, TX.

Golden advises checking these additional sections as part of a pain assessment and evaluation of a pain management program:

Section E: Pain may appear as depression or anxiety in Section E, or behavioral symptoms, such as irritability, hostility, cursing, etc., says Golden. The person may cry (E1m) and/or withdraw from activities (E1o). Also look for sleep disturbances (E1j and E1k).

Address this chicken-and-egg dilemma: If a resident in pain shows a lot of depression and anxiety indicators in Section E, dig deeper. You have to ask "Is it pain or depression?" says Golden.

"The relationship between depression and pain is so strong that pain assessment should be part of a depression assessment and vice versa," says Susan Scanland, MSN, APRN, BC-GNP, president of GeriScan Geriatric Consulting in Clarks Summit, PA. Staff may describe a person as a complainer or "somatic" when the person really has a clinical depression, she notes.

Ongoing pain can also be a sign that depression hasn't been treated adequately or hasn't gone into remission, she adds. "People with depression tend to have more headaches, gastrointestinal complaints and backache."

To assess for depression, facilities can administer the Geriatric Depression Scale short form, a 15-item test to screen residents, says Scanland. The patient who flags for depression on that scale may benefit from a psych consult.

Section G (ADL status and mobility): The resident in pain may suffer a decline in ADL function and/or mobility, says Golden.

Section I: Check for often overlooked painful chronic conditions. The list includes diabetes, renal failure, peripheral vascular disease, arteriosclerotic heart disease, osteoporosis and multiple sclerosis, says Golden.

Section O4. You may see a hypnotic coded at O4d to treat insomnia triggered by pain.

Clinical tip: Windsor Place uses melatonin as a sleep aid for residents. Physicians order the over-the-counter supplement. Nurses administer it "at 6 p.m. to enhance the [residents'] own melatonin production," says Golden. The improved quality of sleep helps reduce residents' pain, she adds.

Section K. Check for weight loss (K3a) and decreased food intake (K4). "Pain can trigger weight loss due to loss of appetite caused by pain," says Golden. If a resident isn't eating well, don't forget to assess his oral cavity for an ulcer or other condition causing mouth pain (K1c). Pain assessment starts with the oral cavity, Golden says.

Use Standardized Assessments

The University of Colorado Health Sciences Center uses a tool that includes three different pain intensity scales: a numeric rating of 0 to 10, a verbal description scale with adjectives to describe pain intensity, and the faces scale, says Regina Fink, PhD, AOCN, a researcher and clinician at the center. "All of the scales are on one card."

Translate pain intensity rating into MDS nomenclature: Current recommendations call for rating a 1, 2 or 3 or the equivalent on a pain intensity scale as mild; a 4-6 as moderate, and 7-10 as severe, which helps in coding the MDS, says Fink.

Tip: Windsor Place uses a numeric scale for residents who can quantify their pain in that way--and the Wong-Baker faces rating scale for residents with dementia. Staff also assess residents for nonverbal signs of pain: "frowning, grimacing, moaning, changes in respirations, etc.," says Golden.