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Study Reveals Nursing Home Patients Chronic Pain Is Not Adequately Controlled

iStock_000002544887XSmallThe results from a five-year study addressing the ability of care-givers and family to perceive pain in nursing home patients has revealed both parties fail to accurately assess chronic pain levels. In reaching this conclusion, researchers in the Netherlands studied 174 nursing home patients with and without cognitive impairments.  The study also concluded that family members were better at accurately assessing pain levels in their loved ones compared with nursing home staff.

Perhaps most disturbing, the study concluded most nursing home patients suffer from pain– even while resting.  When researchers questioned resting patients, most scored their pain as four out of 10, compared with a median pain assessment of zero by family and caregivers.

Study author, Dr. Rhodee van Herk summarizes the findings well,

“Our study shows that nurses and relative find it hard to accurately assess pain in nursing home residents, especially if the resident has a cognitive impairment, such as dementia or is unable to speak. Pain seemed to differ, not only on an individual basis but also in different daily situations.  It is clear that pain at rest is a particular issue that needs addressing as residents rated this much higher than caregivers and relatives.  Using a simple pain intensity scale, like the zero to ten scale employed in our study, is clearly not enough.  We would like to see nurses use a combination of the existing pain scale, together with multidimensional pain observational scales to judge how much discomfort a patient is experiencing.”

Nursing Homes Duty To Provide Pain Relief

Nursing homes have an obligation to provide pain relieving measures to their patients. While certain medical conditions such as bed sores (decubitus ulcers, pressure ulcers or pressure sores) may cause staff to implement pain relieving measures, staff must be diligent to look for signs of distress in patients with less visible condition that require pain relief.

In particular with disabled nursing homes patients, staff should take note of patients facial expressions, involuntary motor actions, moans and changes in behavior as potential indicators that the patient may indeed be suffering and contact a staff physician.

Pain relief is required pursuant to federal regulation of nursing homes.  F-Tag 309 (Quality of Care) requires nursing homes to provide ‘necessary care and services to attain or maintain the highest practical physical, mental and psychological well being, in accordance with the comprehensive assessment and plan of care.’

Although the term ‘highest level of practicable care’ is fairly vague, proposed interpretive guidelines to F-Tag 309 provide more specific guidance for providing pain relief.

Recognition and Management of Pain

In order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, to the extent possible, the facility:

  • Recognizes when the resident is experiencing pain and identifies circumstances when pain can be anticipated;
  • Evaluates the existing pain the cause(s), to the extent possible; and
  • Manages or prevents pain to the extent possible, consistent with with the resident’s goals, the comprehensive assessment and plan of care, and current clinical standards of practice.

As a nursing home attorney, I consistently see facilities that fail to provide compassionate pain relief. Many times I will see a written description of an obviously painful medical condition, yet the Medication Administration Record indicates the staff failed to notify the attending physician and no pain relief was provided.

Source:

van Herk et al, Assessment of pain: can caregivers or relatives rates pain in nursing home residents? Journal of Clinical Nursing, 2009; 18 (17): 2478 DOI:

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What is an F-tag?  Here’s a great chart from Dad’s, The Texas Department of Aging and Disability Services, that concisely summarizes each tag and the applicable federal code.

Federal Health Regulations for Long Term Care Facilities (“F Tags”) – September 2008
F Tag Tag Title CFR
0000 INITIAL COMMENTS
0150 DEFINITION OF LTC FACILITY 483.5
0151 EXERCISE OF RIGHTS 483.10(a)(1)&(2)
0152 EXERCISE OF RIGHTS 483.10(a)(3)&(4)
0153 NOTICE OF RIGHTS AND SERVICES 483.10(b)(2)
0154 NOTICE OF RIGHTS AND SERVICES 483.10(b)(3), 483.10(d)(2)
0155 NOTICE OF RIGHTS AND SERVICES 483.10(b)(4)
0156 NOTICE OF RIGHTS AND SERVICES 483.10(b)(5) – (10), 483.10(b)(1)
0157 NOTIFICATION OF CHANGES 483.10(b)(11)
0158 PROTECTION OF RESIDENT FUNDS 483.10(c)(1)
0159 PROTECTION OF RESIDENT FUNDS 483.10(c)(2)-(5)
0160 CONVEYANCE UPON DEATH 483.10(c)(6)
0161 ASSURANCE OF FINANCIAL SECURITY 483.10(c)(7)
0162 PROTECTION OF RESIDENT FUNDS 483.10(c)(8)
0163 FREE CHOICE 483.10(d)(1)
0164 PRIVACY AND CONFIDENTIALITY 483.10(e), 483.75(l)(4)
0165 GRIEVANCES 483.10(f)(1)
0166 GRIEVANCES 483.10(f)(2)
0167 EXAMINATION OF SURVEY RESULTS 483.10(g)(1)
0168 EXAMINATION OF SURVEY RESULTS 483.10(g)(2)
0169 WORK 483.10(h)
0170 MAIL 483.10(i)(1)
0171 MAIL 483.10(i)(2)
0172 ACCESS AND VISITATION RIGHTS 483.10(j)(1)&(2)
0173 ACCESS AND VISITATION RIGHTS 483.10(j)(3)
0174 TELEPHONE 483.10(k)
0175 MARRIED COUPLES 483.10(m)
0176 SELF ADMINISTRATION OF DRUGS 483.10(n)
0177 REFUSAL OF CERTAIN TRANSFERS 483.10(o)
0201 TRANSFER AND DISCHARGE REQUIREMENTS 483.12(a)(2)
0202 DOCUMENTATION 483.12(a)(3)
0203 TRANSFER AND DISCHARGE REQUIREMENTS 483.12(a)(4)-(6)
0204 ORIENTATION FOR TRANSFER OR DISCHARGE 483.12(a)(7)
0205 NOTICE OF BED HOLD POLICY & READMISSION 483.12(b)(1)&(2)
0206 PERMITTING RESIDENT TO RETURN TO FACILITY 483.12(b)(3)
0207 EQUAL ACCESS TO QUALITY CARE 483.12(c)
0208 ADMISSIONS POLICY 483.12(d)(1)-(4)
0221 PHYSICAL RESTRAINTS 483.13(a)
0222 CHEMICAL RESTRAINTS 483.13(a)
0223 ABUSE 483.13(b), 483.13(b)(1)(i)
0224 STAFF TREATMENT OF RESIDENTS 483.13(c)
0225 STAFF TREATMENT OF RESIDENTS 483.13(c)(1)(ii)-(iii), (c)(2) – (4)
0226 STAFF TREATMENT OF RESIDENTS 483.13(c)
0240 QUALITY OF LIFE 483.15
0241 DIGNITY 483.15(a)
0242 SELF-DETERMINATION AND PARTICIPATION 483.15(b)
0243 PARTICIPATION IN RESIDENT & FAMILY GROUPS 483.15(c)(1)-(5)
0244 PARTICIPATION IN RESIDENT & FAMILY GROUPS 483.15(c)(6)
0245 PARTICIPATION IN OTHER ACTIVITIES 483.15(d)
0246 ACCOMMODATION OF NEEDS 483.15(e)(1)
0247 NOTICE BEFORE ROOM CHANGE 483.15(e)(2)
0248 ACTIVITIES 483.15(f)(1)
0249 ACTIVITY DIRECTOR QUALIFICATIONS 483.15(f)(2)
0250 SOCIAL SERVICES 483.15(g)(1)
0251 QUALIFICATIONS OF A SOCIAL WORKER 483.15(g)(2)&(3)
0252 ENVIRONMENT 483.15(h)(1)
0253 HOUSEKEEPING/MAINTENANCE 483.15(h)(2)
0254 ENVIRONMENT- LINENS 483.15(h)(3)
0255 ENVIRONMENT- CLOSET SPACE 483.15(h)(4)
0256 ENVIRONMENT- LIGHTING 483.15(h)(5)
0257 ENVIRONMENT- TEMPERATURE 483.15(h)(6)
0258 ENVIRONMENT- SOUND LEVELS 483.15(h)(7)
0271 ADMISSION ORDERS 483.20(a)
0272 COMPREHENSIVE ASSESSMENTS 483.20, 483.20(b)
0273 RESIDENT ASSESSMENT- WHEN REQUIRED 483.20(b)(2)(i)
0274 RESIDENT ASSESSMENT- WHEN REQUIRED 483.20(b)(2)(ii)
0275 RESIDENT ASSESSMENT- WHEN REQUIRED 483.20(b)(2)(iii)
0276 QUARTERLY REVIEW ASSESSMENT 483.20(c)
0278 RESIDENT ASSESSMENT 483.20(g) – (j)
0279 COMPREHENSIVE CARE PLANS 483.20(d), 483.20(k)(1)
0280 COMPREHENSIVE CARE PLANS 483.20(d)(3), 483.10(k)(2)
0281 COMPREHENSIVE CARE PLANS 483.20(k)(3)(i)
0282 COMPREHENSIVE CARE PLANS 483.20(k)(3)(ii)
0283 DISCHARGE SUMMARY 483.20(l)(1)&(2)
0284 DISCHARGE SUMMARY 483.20(l)(3)
0285 PREADMISSION SCREENING 483.20(m), 483.20(e)
0286 RESIDENT ASSESSMENT – USE 483.20(d)
0287 AUTOMATED DATA PROCESSING 483.20(f)
0309 QUALITY OF CARE 483.25
0310 ACTIVITIES OF DAILY LIVING 483.25(a)(1)
0311 ACTIVITIES OF DAILY LIVING 483.25(a)(2)
0312 ACTIVITIES OF DAILY LIVING 483.25(a)(3)
0313 VISION AND HEARING 483.25(b)
0314 PRESSURE SORES 483.25(c)
0315 URINARY INCONTINENCE 483.25(d)
0317 RANGE OF MOTION 483.25(e)(1)
0318 RANGE OF MOTION 483.25(e)(2)
0319 MENTAL AND PSYCHOSOCIAL FUNCTIONING 483.25(f)(1)
0320 MENTAL AND PSYCHOSOCIAL FUNCTIONING 483.25(f)(2)
0321 NASO-GASTRIC TUBES 483.25(g)(1)
0322 NASO-GASTRIC TUBES 483.25(g)(2)
0323 ACCIDENTS AND SUPERVISION 483.25(h)
0325 NUTRITION 483.25(i)
0327 HYDRATION 483.25(j)
0328 SPECIAL NEEDS 483.25(k)
0329 UNNECESSARY DRUGS 483.25(l)
0332 MEDICATION ERRORS 483.25(m)(1)
0333 MEDICATION ERRORS 483.25(m)(2)
0334 INFLUENZA AND PNEUMOCOCCAL IMMUNIZATION 483.25(n)
0353 NURSING SERVICES – SUFFICIENT STAFF 483.30(a)
0354 NURSING SERVICES – REGISTERED NURSE 483.30(b)
0356 NURSE STAFFING 483.30(e)
0360 DIETARY SERVICES 483.35
0361 DIETARY SERVICES – STAFFING 483.35(a)
0362 DIETARY SERVICES – SUFFICIENT STAFF 483.35(b)
0363 MENUS AND NUTRITIONAL ADEQUACY 483.35(c)
0364 FOOD 483.35(d)(1)-(2)
0365 FOOD 483.35(d)(3)
0366 FOOD 483.35(d)(4)
0367 THERAPEUTIC DIETS 483.35(e)
0368 FREQUENCY OF MEALS 483.35(f)
0369 DIETARY SERVICES – ASSISTIVE DEVICES 483.35(g)
0371 SANITARY CONDITIONS 483.35(i)
0372 SANITARY CONDITIONS – GARBAGE DISPOSAL 483.35(i)(3)
0373 PAID FEEDING ASSISTANTS 483.35(h)
0385 PHYSICIAN SERVICES 483.40(a)
0386 PHYSICIAN VISITS 483.40(b)
0387 FREQUENCY OF PHYSICIAN VISITS 483.40(c)(1)-(2)
0388 FREQUENCY OF PHYSICIAN VISITS 483.40(c)(3)-(4)
0389 AVAILABILITY OF PHYSICIANS FOR EMERGENCY CARE 483.40(d)
0390 PHYSICIAN DELEGATION OF TASKS 483.40(e)-(f)
0406 SPECIALIZED REHABILITATIVE SERVICES 483.45(a)
0407 SPECIALIZED REHABILITATIVE SERVICES 483.45(b)
0411 DENTAL SERVICES – SNF 483.55(a)
0412 DENTAL SERVICES – NF 483.55(b)
0425 PHARMACY SERVICES 483.60(a),(b)
0428 DRUG REGIMEN REVIEW 483.60(c)
0431 PHARMACY SERVICES 483.60(b), (d), (e)
0441 INFECTION CONTROL 483.65(a)
0442 PREVENTING SPREAD OF INFECTION 483.65(b)(1)
0443 PREVENTING SPREAD OF INFECTION 483.65(b)(2)
0444 PREVENTING SPREAD OF INFECTION 483.65(b)(3)
0445 INFECTION CONTROL – LINENS 483.65(c)
0454 PHYSICAL ENVIRONMENT 483.70
0455 EMERGENCY POWER 483.70(b)
0456 SPACE AND EQUIPMENT 483.70(c)(2)
0457 RESIDENT ROOMS 483.70(d)(1)(i)
0458 RESIDENT ROOMS 483.70(d)(1)(ii)
0459 RESIDENT ROOMS 483.70(d)(1)(iii)
0460 RESIDENT ROOMS 483.70(d)(1)(iv)-(v)
0461 RESIDENT ROOMS 483.70(d)(1)(vi)-(vii)
0462 TOILET FACILITIES 483.70(e)
0463 RESIDENT CALL SYSTEM 483.70(f)
0464 DINING AND RESIDENT ACTIVITIES 483.70(g)
0465 OTHER ENVIRONMENTAL CONDITIONS 483.70(h)
0466 OTHER ENVIRONMENTAL CONDITIONS – WATER 483.70(h)(1)
0467 OTHER ENVIRONMENTAL CONDITIONS – VENTILATION 483.70(h)(2)
0468 OTHER ENVIRONMENTAL CONDITIONS – HANDRAILS 483.70(h)(3)
0469 PHYSICAL ENVIRONMENT- PEST CONTROL 483.70(h)(4)
0490 ADMINISTRATION 483.75
0491 LICENSURE 483.75(a)
0492 ADMINISTRATION 483.75(b)
0493 GOVERNING BODY 483.75(d)(1)-(2)
0494 REQUIRED TRAINING OF NURSING AIDES 483.75(e)(2)-(3)
0495 REQUIRED TRAINING OF NURSING AIDES 483.75(e)(4)
0496 REQUIRED TRAINING OF NURSING AIDES 483.75(e)(5)-(7)
0497 REGULAR IN-SERVICE EDUCATION 483.75(e)(8)
0498 PROFICIENCY OF NURSE AIDES 483.75(f)
0499 STAFF QUALIFICATIONS 483.75(g)
0500 USE OF OUTSIDE RESOURCES 483.75(h)
0501 MEDICAL DIRECTOR 483.75(i)
0502 LABORATORY SERVICES 483.75(j)(1)
0503 LABORATORY SERVICES 483.75(j)(1)(i-iv)
0504 LABORATORY SERVICES 483.75(j)(2)(i)
0505 LABORATORY SERVICES 483.75(j)(2)(ii)
0506 LABORATORY SERVICES 483.75(j)(2)(iii)
0507 LABORATORY SERVICES 483.75(j)(2)(iv)
0508 RADIOLOGY AND OTHER DIAGNOSTIC SERVICES 483.75(k)(1)
0509 RADIOLOGY AND OTHER DIAGNOSTIC SERVICES 483.75(k)(1)(i-ii)
0510 RADIOLOGY AND OTHER DIAGNOSTIC SERVICES 483.75(k)(2)(i)
0511 RADIOLOGY AND OTHER DIAGNOSTIC SERVICES 483.75(k)(2)(ii)
0512 RADIOLOGY AND OTHER DIAGNOSTIC SERVICES 483.75(k)(2)(iii)
0513 RADIOLOGY AND OTHER DIAGNOSTIC SERVICES 483.75(k)(2)(iv)
0514 CLINICAL RECORDS 483.75(l)(1)
0515 CLINICAL RECORDS 483.75(l)(2)
0516 CLINICAL RECORDS 483.75(l)(3), 483.20(f)(5)
0517 DISASTER AND EMERGENCY PREPAREDNESS 483.75(m)(1)
0518 DISASTER AND EMERGENCY PREPAREDNESS 483.75(m)(2)
0519 TRANSFER AGREEMENT 483.75(n)
0520 QUALITY ASSESSMENT AND ASSURANCE 483.75(o)(1)
0522 DISCLOSURE OF OWNERSHIP 483.75(p)
9999 FINAL OBSERVATIONS
 

For more information on nursing homes in Texas look here. For laws related to Texas nursing homes, look here.

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    Keep fighting the good fight.

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