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Comprehensive Pain Mangement: Beyond F-Tag 309. Debra Bakerjian PhD, RN, FNP President and CEO, geriHEALTHsolutions Chair, Clinical Advisory Workgroup, Advancing Excellence Postdoctoral Fellow, University of CA, Davis Assistant Adjunct Professor, University of CA, San Francisco. Objectives.

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comprehensive pain mangement beyond f tag 309

Comprehensive Pain Mangement:Beyond F-Tag 309

Debra Bakerjian PhD, RN, FNP

President and CEO, geriHEALTHsolutions

Chair, Clinical Advisory Workgroup, Advancing Excellence

Postdoctoral Fellow, University of CA, Davis

Assistant Adjunct Professor, University of CA, San Francisco

  • Recognize specific strategies to improve pain management
  • Identify best-practice resources to improve pain care for nursing home residents
  • Learn how to access resources and set goals on the Advancing Excellence web site and the Geriatric Pain web site to manage pain
  • Understand the regulatory requirements for pain management in NHs –Ftag 309
the problem
The Problem
  • Pain is under-recognized and undertreated
  • The prevalence of pain is reported as high as 85% in NHs
  • Some reported improvement in prevalence of pain
    • Over 75,000 long stay residents have mod-severe pain
    • Ove 150,000 short stay residents with mod-severe pain
  • Develop systemized approach to pain management
    • Consists of “program of care”
    • Requires ongoing evaluation and refinement
  • Program based on “evidence based care” and “best practices” in pain management
the intent of quality of care regulatory guidelines
The Intent of Quality of Care Regulatory Guidelines

“Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. “

what is f tag 309
What is F-tag 309?
  • F-tag 309 focus is overall quality of care – much of the f-tag has not changed
  • Requires that NHs provide for the highest practicable level of function & well being
    • Comprehensive resident assessment
    • Care plans must address mental, physical, & psychosocial needs
  • Ensure residents obtain optimal improvement or do not deteriorate
    • Within resident’s right to refuse
    • Limits of recognized pathophysiology & normal aging
new aspects of f tag 309
New Aspects of F-tag 309
  • Revised general investigative protocol
    • Any QOC issue not covered specifically by another F-tag is covered here
  • Added Hospice guidelines
  • Added dialysis guidelines
  • Removed unintended weight loss – now in F tag 325
new pain aspects of f tag 309
New Pain Aspects of F-tag 309
  • Pain management has specifically developed guidelines within this F-tag
    • New definitions of terms
    • New investigative protocol
    • Defining care processes for pain management
    • Defined steps in pain recognition, assessment, management, interventions, care plans
    • Investigative protocol for surveyors specific to pain
definition of terms
Definition of Terms
  • Addiction
  • Adverse consequence, adverse drug reaction
  • Adjuvant analgesics
  • Complimentary and Alternative Medicine (CAM)
  • Non-pharmacological interventions
  • 4 types of pain – acute, breakthrough, incident, persistent or chronic
  • Physical dependence
  • Standards of practice
  • Tolerance
overview of pain recognition management
Overview of Pain Recognition & Management
  • Facilities & staff must be committed to effective pain management
  • Pain can be acute or chronic & staff must evaluate resident reports of pain or nonverbal signs of pain
  • Residents with cognitive impairment must also have their pain recognized & managed
  • Facilities must break down myths about pain in older adults
  • Staff, resident & family misperceptions about effective pain management
care processes for pain management
Care Processes for Pain Management
  • Assess for potential for pain
  • Recognize the onset or presence of pain
  • Address & treat underlying cause for pain
  • Develop & implement pain interventions
  • Identify & use specific strategies for different levels or sources of pain
  • Monitor appropriately
  • Modify pain interventions/strategies as needed
pain recognition
Pain Recognition
  • All staff are responsible for recognizing pain upon admission and throughout the stay
  • Recognition efforts must go beyond asking the question “are you in pain”
    • Verbalizations may be nonsensical
    • Non-verbal indicators
    • Aberrant behaviors
    • Functional decline
    • Loss of appetite
    • Difficulty sleeping
  • Observations should be at rest & with movement
  • Observing during care, activities & treatments can detect presence of pain, location, & limitations on residents
  • MDS must be completed as “part” of the comprehensive assessment
  • Facilities must document a more detailed assessment that identifies problem, needs, monitors condition, records treatment & response to treatment
pain assessment standards
Pain Assessment Standards
  • History of pain & its treatment
  • Characteristics of pain
  • Impact of pain on quality of life
  • Factors that precipitate pain
  • Strategies or factors that reduce pain
  • Associated pain symptoms
  • Physical examination
  • Current medical condition & medications
  • Resident goals for pain management
management of pain
Management of Pain
  • Based on assessment, facility, attending prescriber, staff collaborate to manage pain
  • Develop appropriate interventions to prevent or manage pain
  • Interventions may be integrated into care plan or included as a specific pain management need or goal
  • IDT & resident develop pertinent, realistic & measurable goals for treatment
  • Pain management approaches must follow clinical standards of practice
non pharmacological interventions
Non-Pharmacological Interventions
  • Alterations in environment for comfort
  • Physical modalities – cold/heat, positioning
  • Exercises to reduce stiffness, prevent contractures
  • Cognitive/behavioral interventions
  • CAM – herbal supplements if ordered
pharmacological interventions
Pharmacological Interventions
  • IDT is responsible for developing individualized pain management regimen
  • A systematic approach for meds and doses is important
  • Addressing underlying cause of pain
  • Administration timing – PRN vs routinely
  • Combining short & long acting
  • All medications including opioids or other potent analgesics must be dosed according to standards
  • Clinical record should reflect ongoing communication with prescriber
monitoring reassessment care plan revision
Monitoring, Reassessment, Care Plan Revision
  • Monitoring response over time helps to determine effectiveness of treatments
  • Adverse consequences to medications can be anticipated & reduced
  • Identification of target signs of pain
  • Inadequate control of pain requires a revision of intervention
  • Resolution of pain should be documented and treatment tapered or discontinued
investigative protocol
Investigative Protocol
  • QOC related to recognition & management of pain
    • Determine whether facility has provided & resident has received care & services to address & manage pain
    • Applies to residents who state they have pain, who display indicators of pain, are assessed with pain, receives pain treatment, has elected hospice benefit for pain management
survey procedures
Survey Procedures
  • Observe residents
  • Interview residents or family
  • Interview nurse aides
  • Review records
    • Assessment
    • Care plan, including revisions
  • Interview health care practitioners & other health professionals
determining compliance
Determining Compliance
  • Facility is in compliance if EACH resident has their pain managed in alignment with their goals to attain the highest practicable physical, mental, & psychosocial well-being
  • Recognize, evaluate pain to determine cause
  • Developed & implemented comprehensive care plan
  • Provided measures to minimize, prevent, or treat pain
  • Monitor effects of interventions
  • Communicate with health care practitioner when appropriate to obtain new orders or revise current orders
noncompliance determination
Noncompliance Determination
  • Failure to show adequate proof that ALL of the previous steps are followed is non-compliance
  • Non-compliance can be at any one step along the way
    • Recognize & evaluate
    • Intervene & treat
    • Prevent or minimize
    • Monitor
    • Communicate & coordinate
related or associated f tags
Related or Associated F-tags
  • F155 – Right to refuse treatment
    • Facility must assess reason, clarify & educate resident of consequences, offered alternatives & documented these steps
  • F157 – Notification of changes
    • Health care practitioner notified if pain persisted or there were adverse consequences
    • Notified responsible party of changes
  • F242 – Self-determination & participation
    • Facility provided resident with relevant options to manage pain
related or associated f tags27
Related or Associated F-tags
  • F246 – Accommodation of needs
    • Adopted resident’s physical environment to reasonably accommodate resident’s pain
  • F272 – Comprehensive assessments
    • Was a comprehensive assessment done
  • F278 – Accuracy of assessments
    • Does the assessment reflect the resident’s condition
related or associated f tags28
Related or Associated F-tags
  • F279 – Comprehensive care plan
    • Did care plan include measureable objectives, time frames, & specific interventions/services
    • Was it consistent with resident’s risks, needs, goals, preferences, & current standards of practice
  • F280 – Comprehensive care plan revision
    • Ensure periodic review of plan & revision as needed by qualified TEAM with input from resident or responsible party
related or associated f tags29
Related or Associated F-tags
  • F281 – Services meet professional standards of quality
  • F282 – Care provided by qualified person in accordance with plan of care
  • F329 – Unececessary drugs
    • Are medications monitored for effectiveness & adverse consequences
    • Are symptoms resident has related to meds
related or associated f tags30
Related or Associated F-tags
  • F385 – Physician supervision
    • Is pain management supervised by physician, including participation in comprehensive assessment process, development of treatment regimen, monitoring & response to notification of changes in resident status
  • F425 – Pharmacy services
    • Were medications available & administered as indicated, ordered at admission & throughout stay
related or associated f tags31
Related or Associated F-tags
  • F501 – Medical Director
    • Did Medical Director help develop & implement appropriate policies c/w standards of practice
    • Did Med Director interact with resident’s physician supervising the care if requested by facility
  • F514 – Clinical records
    • Did clinical records accurately & completely document resident status, care/services provided, in accordance with standards & resident goals
    • Did records provide a basis for determining & managing resident progress & responses to care
knowledge of pain
Knowledge of Pain
  • Know principles of pain management
  • Types of pain & pain terminology
  • How to perform a comprehensive assessment
  • Correct documentation of findings
  • Understand both pharmacological & non-pharmacological interventions
  • How to monitor & revise plans
  • Effective communication
pain principles
Pain Principles
  • Pain is under-recognized & undertreated
  • Older adults have the right to have pain assessed & treated in accordance with their goals for pain management
  • Pain is subjective- self-report of pain is most reliable indicator
  • Physiological & behavioral signs are neither sensitive nor specific & can’t replace self-report
  • Assessment tools & treatments need to be appropriate & individualized each resident
  • Pain tolerance varies & is individual
  • Prevent &/or manage medication side effects
  • Worry about addiction to opioids is not a credible reason for withholding opioid pain medication
pain terminology
Pain Terminology
  • Pain characteristics are used to describe pain
  • Duration – how long pain has been present
  • Frequency – number of occurrences in a given time period
  • Intensity – descriptive rating based on scale
  • Location – anatomic site
  • Onset – how does pain start
  • Pattern – how does pain vary throughout the day, what affects pain – makes it worse or better
  • Quality – use the resident’s description; provide examples such as aching, cramping, sharp, throbbing, dull, sharp, burning, radiating, shooting
pain recognition36
Pain Recognition
  • Staff must recognize pain or potential pain
  • All staff are responsible for helping with pain management
    • Therapy
    • Activities
    • Social services
    • Pharmacy consultants
  • Staff must act on their observations
    • All staff must be educated to recognize pain
    • Once staff know individual resident triggers – all staff must be told about what to observe
indicators of pain
Indicators of Pain
  • Verbal indicators – words & vocalizations
  • Written indicators – written interpretations in native languages, written notes from residents
  • Non-verbal indicators – facial expressions, behavioral abnormalities, fidgeting, withdrawal, non-movement
comprehensive assessment
Comprehensive Assessment
  • All residents must have comprehensive pain assessment upon admission
  • Residents who trigger for pain (through MDS/RAI) or have diagnosis of chronic pain or exhibit frequent pain must have comprehensive pain assessment
  • Most pain experts recommend weekly assessments
comprehensive assessment39
Comprehensive Assessment
  • Should be appropriate based on cognitive status
  • If resident cognitively intact – use verbal descriptors in their words to describe the pain
  • If cognitively impaired – use a screening tools
    • PACSLAC – screens for behaviors that may be pain related
    • PAINAD – monitor directly observable behaviors in adults with chronic pain
  • Comprehensive includes history descriptions, functional status & physical exam
  • Evaluate of impact on pain on ADLs, sleep, other functional activities
major categories of pain
Major Categories of Pain


  • Source: peripheral nerve or CNS pathology
  • Examples: postherpetic neuralgia, diabetic neuropathy, spinal stenosis
  • Character: shooting, burning, electric shock, tingling
  • Requires different types of medications than nociceptive pain


  • Sources: organs, bone, joint, muscle, skin, connective tissue
  • Examples: arthritis, tumors, gall stones, muscle strain
  • Character: dull, aching, pressure, tender
  • Responds to traditional pain medicines & therapies
documentation reporting
Documentation & Reporting
  • Forms should include resident goal, pain characteristics, history, & physical exam related to location & causes of pain
    • Ex. If pain in abd – check for bowel sounds, pain with palpation
    • If pain in leg – observe the site & look for s/sx trauma
  • Report to MD, NP or PA & other nurses should be complete but concise
  • Be sure to include CNAs in reporting & care planning
principles of pain management
Principles of Pain Management
  • Should be individualized & match the need
  • Chronic pain should be treated with long-acting medications routinely
  • Breakthrough pain should be treated with short acting meds with rapid onset
  • Treat with lowest strength med to achieve pain control based on resident goals
  • Minimize side effects & adverse effects
managing pain
Managing Pain
  • Frequent reassessment of resident & review of care plan
  • Determine what works & what doesn’t work
  • Discontinue what doesn’t work
  • Revise care plan to try new interventions
  • Collaborate with IDT & resident/family
  • Try new things or new ways such as changing the timing or dosing of medications
non pharmacologic interventions
Non-pharmacologic Interventions
  • Traditional
    • Positioning
    • Massage
    • Environmental – lighting, room temperature, noise
    • Heat and/or cold applications
    • Diversion – social interaction
  • CAM
    • Now recognized as a part of therapy
    • May involve herbals & that must be communicated
medication management
Medication Management
  • Non-opioid
  • Opioids – mild to moderate
  • Opioids – moderate to severe
  • Repositioning
  • Heat and Cold
  • Breathing & Guided Imagery
  • Distraction
  • Massage
  • Music
  • Relaxation



pharmacologic interventions
Pharmacologic Interventions
  • Non-opioids
    • Tylenol
    • NSAIDs such as Ibuprofen
    • Side effects in older adults (damage to kidneys, GI bleed)
  • Opioids
    • Types of opioids, routes of administration
    • Length of action
    • Side effects – constipation, confusion
  • Adjuvant therapy
    • Muscle relaxants
    • Seizure meds for neuropathic pain
managing side effects
Managing Side Effects
  • Most pain meds have potential side effects, particularly opioids
  • Side effects need to be anticipated and managed
  • Common opioid side effects include
    • Drowsiness
    • Respiratory depression
    • Constipation
    • Nausea
    • Delirium – particularly in residents > 85 yrs
    • Itching
managing side effects48
Managing Side Effects
  • Side effect management should be part of the care plan
  • Side effect treatments need to be individualized
    • Reduced dosages
    • Alternate opioid
    • Bowel regimens
    • Medications to treat side effect if necessary
  • Obtain appropriate orders from prescribers
  • Care plan effective management techniques
resident centered care plan
Resident Centered Care Plan
  • Includes residents goal for pain management
    • I want my pain relieved so I can sleep
    • I want pain treatment before my therapy
    • I would like my pain reduced to level 4-5
  • Care plan should include both drug and non-drug interventions
  • Care plan should include managing side-effects, decreased respirations,
effective communication
Effective Communication
  • Nurses need to be able to understand resident pain issues and to use the right language in describing
  • Pain related problems need to be effectively communicated to prescribers
  • Pain related issues need to be documented accurately using appropriate language
communication with health care provider
Communication with Health Care Provider
  • Communicating with the health care provider is not a “one time” deal
  • Most health care providers do not mind multiple communications IF nurse is prepared with the right information
  • Before calling, gather the information together; then even if provider has to call back later, information will be in one place
elements of pain best practice
Elements of Pain Best Practice
  • Recognition/Assessment
  • Cause identification/Diagnosis
  • Management/Treatment
  • Monitoring
  • Sustainment
recognition assessment
  • Initiate appropriate pain assessment on admission
  • Identify pain related risk factors
  • Identify & document pain characteristics- include behaviors
  • Report signs & symptoms
  • Ensure that assessment forms available for cognitively intact & impaired
  • Ensure training on risk factors, pain characteristics & behaviors
  • Create policies & procedures to support the correct processes



cause identification diagnosis
Cause Identification/Diagnosis
  • Interview resident and/or family to understand characteristics of pain
  • Perform a physical exam
    • Palpate sites
    • Check ROM
    • Determine what makes pain worse, what makes it better
  • Create policies & procedures requiring resident interviews (required by MDS 3.0)
  • Provide training on physical exam for pain



management treatment
  • Identify resident/family goals of care
  • Incorporate resident goals into the pain care plan
  • Consider both drug & non-drug treatments
  • Document results of treatment
  • Create a culture of resident centered care
  • Adopt care plans that focus on resident perspective
  • Develop policies, procedures & training related to drug & non-drug treatments
  • Require rechecks after all pain treatments



  • Assess and reassess for pain every shift
  • Perform comprehensive pain assessment regularly – weekly is advised
  • If pain response inadequate revise treatment
  • Monitor for side effects or complications
  • Provide training on pain reassessment & require documentation
  • Ensure forms, policies & procedures require ongoing monitoring



  • Reassessments should be ongoing
  • Review & revise care plans regularly
  • Meet with resident & family regarding pain management
  • Communicate changes to prescriber
  • Systemize processes so there is no variance in procedures
  • Consider a pain related quality improvement project
  • Audit documentation
  • Report audit results to DON & NHA
  • Revise program if needed



geriatricpain org
  • Website specifically designed for NH staff
  • Resources are evidence based
  • Resources are free
  • Go to
  • Registration is required but takes about 2 minutes
advancing excellence
Advancing Excellence
  • National volunteer initiative to help NHs improve quality
  • 30 organizations
    • Gov’t – CMS Survey & Certification, Quality
    • Consumer – Pioneer Network, NCCNHR, Alzheimer’s Association
    • Professional – AMDA, GAPNA, NADONA, AANAC
    • Provider – AHCA, AAHSA
purpose of campaign
Purpose of Campaign
  • To provide resources and guidance to NHs to improve the quality of care
  • To assist in quality improvement efforts
campaign data
Campaign Data
  • Campaign publishes quarterly data on pain
  • Data available to individual NHs and consumers
  • Data can be used for quality improvement
  • Data are graphed by quarter over time
campaign resources
Campaign Resources
  • Implementation Guide – offers guidance in how to implement a quality improvement process
  • Webinar
  • Fast Facts for Staff
  • Consumer guide for families and residents
  • New resources are coming
campaign website
Campaign Website

case study hazel p
Case Study – Hazel P

72 yr old female admitted to facility late Friday afternoon from acute hospital after fall at home. In hospital she had ORIF of Rt hip 2 days ago. Other pertinent diagnoses include diabetes mellitus, COPD, CAD, CHF, HTN, anemia, osteoporosis, depression, peripheral vascular disease, osteoarthritis, dementia & morbid obesity.

anticipating pain issues
Anticipating Pain Issues
  • Review of current diagnoses is one way to anticipate potential pain
  • Some residents come in with diagnoses that are recognized as pain producing
  • Hospital discharge planners should communicate pain related issues to admitting home
what do we know already
What do we know already?
  • Pain is likely to be an issue
  • Different types of pain are likely
    • Acute post operative pain (rt hip fx)
    • Chronic muscle & joint pain from (osteoarthritis)
    • Potential cardiac pain (CAD, CHF, HTN)
    • Potential neuropathic pain (DM, Morbid Obesity, CAD)
    • Potential psychogenic pain (Depression)
  • Communication may be an issue (Dementia)
what is the approach
What is the Approach
  • Screening for immediate pain & treat if needed
  • Perform comprehensive pain assessment
  • Communicate with health care provider, resident, family, IDT
  • Develop comprehensive care plan to include intervention
  • Implement the plan
  • Monitor & revise plan as needed
hazel s assessment
Hazel’s Assessment
  • Upon admission Hazel is found to be suffering from rt hip pain rated 9/10 – transfer orders include an opioid pain medication
  • Before continuing with admission interview:
    • Nurse checks Hazel’s allergies (none)
    • Checks the order with Hazel’s PCP & gets approval
    • Gives Hazel the medication.
hazel s assessment81
Hazel’s Assessment
  • The nurse comes back to continue the interview about 45 minutes later – asks if pain med effect & asks about any side effects
  • Nurse reviewed Hazel’s diagnoses ahead
    • Anticipated that Hazel might have several types of pain issues
    • Included all questions to include potential sources of pain
  • Used comprehensive pain assessment form
individualized care plans
Individualized Care Plans
  • Involve residents and help them set goal (s)
    • Families may also need to be involved
    • Ex: I don’t want to be too sleepy but I want my pain to be relieved so it is mild to moderate
  • Individualize care plan around that goal
  • Collaborate with other members of the IDT
    • Prescribers & pharmacy consultant
    • Therapy, activities, social services
    • Other nurses
hazel s care plan
Hazel’s Care Plan
  • Hazel had several types of pain, so the care plan addressed those issues
  • Acute post op pain – opioid pain med, particularly prior to therapy
  • Osteoarthritis- a non-steroidal was contraindicated, so a plan to assist with frequent repositioning was initiated
  • Potential cardiac pain – nitroglycerine was available, Hazel was assessed & determined not to be safe for self-administration, Oxygen was also ordered as treatment
  • Neuropathic pain – daily medications were ordered for neuropathic pain and to promote improved circulation
  • Depression – Hazel was on an age appropriate anti-depressant
care plan continued
Care Plan continued
  • Care plan included anticipation of pain at specific times of increased movement such as therapy, so coordination with rehab dept was done
  • Monitoring of pain was ongoing – charge nurse was careful to review how many times she requested pain meds & how well they were working, documented that in the record & communicated with her health care provider & family, & other staff as necessary
hazel s management
Hazel’s Management
  • Hazel responded well to opioids for her acute pain management
  • She had a worsening of her neuropathic pain that required increasing the dosages of medication (Neurontin)
  • Hazel did not progress well with therapy and could not regain her pre-fall function and so was admitted to custodial care
  • Her charge nurse reassessed her upon the change in status – therapy was replaced with RNA
revising care hazel s plan
Revising Care Hazel’s Plan
  • Hazel’s entire care plan was reviewed and revised with her change of status
  • Her family was notified of her change of condition & participated in care plan revision
  • Recommendations were communicated to her health care practitioner
in summary
In Summary
  • Facilities & staffs are responsible for ensuring that residents obtain their highest practicable level
  • Residents must be involved in their pain management & their individual needs & goals should be basis of care plan
  • Care provided must be individualized based on a comprehensive assessment and MUST meet clinical standards of quality
  • Staff must monitor continuously, revise processes and plans when necessary and in a timely manner
  • Staff must communicate resident status or change of condition with health care practitioners, resident, & family
  • Staff must document accurately and descriptively