2Joan Williams, MS, CRNPDirector of Clinical Services
3QUALITY OF CARE42 CFR (F309)Effective Date: 3/31/09
4Quality of CareEach 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.
5Includes: General Investigative Protocol covers care of residents where amore specific regulation orprotocol does not applyPain Management Protocolcovers all aspects of painmanagement
6Additions to Non Pressure-Related Skin Ulcer/Wound Quality of Care F-309 now also includes hospice andESRD services (formerly inAppendix P; moved, not changed).
7Nursing ProcessBoth protocols—General Investigative and Pain Management—are based in the Nursing Process.For any symptom the resident has: are you assessing, care planning with outcomes, implementing care management strategies, evaluating the outcomes, and revising the plan/care given?
8DOCUMENT Will be observing and interviewing first hand. Will be reviewing DOCUMENTATION of any kind related to the symptom, e.g. will review facility protocols if referenced in the treatment plan.All documents used for the resident must be available to staff and caregivers
9Care/Treatment Plan Decisions Appropriate?All-inclusive based on resident assessment?Achieved Outcomes?Modified based on the resident’s abilities?Evaluated regularly and on-going?
11Compliance Is:Recognition and assessment of factors placing the resident at risk for specific conditions, causes, and/or problems.(actual and potential)Defining and implementing interventions in accordance with resident needs, goals, and recognized standards of practice(justified)
12Compliance Is:Monitoring and Evaluating care and the resident’s responses(document)Revising and Re-Planning(restarts the assessment circle)
13Investigation May Include: An investigation into Quality of Care may include any additional concern related to care provisionStructureProcessOutcome
14Deficiency Categorization Key elements:Presence/Potential of harm/negative outcomesDegree of actual/potential harm R/T non-complianceImmediacy of correction requiredUtilizes determination of Immediate Jeopardy first (Appendix Q), then the general guidance (Appendix P) if no other guidance available
15So the resident has a symptom… What is the standard of care for the assessment of that symptom?
16Complaint in the resident’s words Time Frames— Duration or history of the symptomOnset (when)Manner of initiation (how)
17Symptom Characteristics: Quality (what feels like)Location and/or radiationIntensity or severity (rating scale, relate it to..)Timing (continuous, intermittent)Precipitating and Relieving FactorsAggravating Factors (makes it worse)Associated Symptoms (simultaneous, pre/post)ProgressionEffect of TreatmentWhat does the symptom keep you from doing?
18Assess the symptomMake clinical judgmentDevelop planImplement plan/treatmentsEvaluate effectiveness of plan and expected outcomes
19For every symptom…there is a plan, intervention, and evaluation.
21Defining pain… Pain is- “an unpleasant sensory and emotional experience associated with actual orpotential tissue damage, or described interms of such damage”International Association for the Study of Pain (IASP)
22Pain is… Acute-initially present due to the onset of symptoms or treatment of a diseaseChronic-persistent beyond the usual ofexpected course of a disease orafter a reasonable time for aninjury to heal
23Pain is…known to be present in approximately 80% of institutionalized elderly clients.2008 American Conference on Pain
24Pain is…Often chronic in the elderly; in point of fact the elderly are believed to have twice the prevalence of chronic pain as the general population.Most importantly– approximately 45-80% of LTC residents are estimated to havesubstantial pain that is undertreated.American Geriatrics Society
25So, what’s the problem? Pain is a major factor in the QUALITY OF LIFE each of our clients.
26In order to effectively manage pain, we must believe that it is possible to control and manage this symptom on an ongoing basis with positive outcomes for our residents.
27Assess Pain… Regularly Consistently Methodically Non-judgmentally With the goal of control
28Assess Pain…….regularly…..according to your policy and procedure. This may be daily, every shift, every x-number of hours, or however frequently your policy states.….regularly is not once a month (MDS).
29Assess Pain… Methodically (with a method)… Analyze in order to communicate withthe provider to get effectivetreatments.
30Assess Pain…Symptom analysis is the simplest way.
31Symptom Analysis… Complaint in client’s words. Onset (when, gradual or sudden?)Precipitating/Relieving factors (what makes it better/worse?)Quality (sharp, dull, aching?)Radiation/Location (where and where go?)Severity/Intensity (use scales)Timing (when, continuous, intermittent)
32Symptom Analysis… Aggravating factors Associated symptoms (N/V, numbness)Progression of symptomsEffect of treatmentOther: when did you last feel well?what does this keep you fromdoing?what level of pain is tolerable?
33Assess Pain… With consistency or uniformity…. By using a format or scale which can bevalidly and reliably used by yourpersonnel.
34The trick is… Do what works in your facility. Do it regularly, consistently, and methodically.
35Pain Relief Plans… If pain is identified as a client problem, then the care plan must address it.The RAP does not have a specific place labeled ‘pain’ right now. However pain may come out in a number of areas. If you have a number of these noted, look for pain.
36Pain Relief Plans… Should address physical, emotional, social, and spiritual aspects of pain.
37Interventions for Pain Relief… Non-pharmacologic interventionsPharmacologic interventions
38Evaluation of Pain Management Restarts the circle of pain control.We really keep assessing/working and reworking the plan/evaluating its effectiveness and re-assessing the client’s needs.
39Evaluation of Pain Management Analysis of Pain Control may use different types of documentation, but the net goal is to try to see what works, how long it worked, what factors affected it working, and what the client thought of the pain relief.
40Evaluation of Pain Management Freestyle Summary of Pain EpisodesPain Assessment Tracking (with sample tracking form)
41Evaluation of Pain Management Outcomes Desiredvs.Outcomes Achieved
42KEY POINTS---One key point in the pain management protocol is the emphasis placed not only on current, known pain symptoms, but also on POTENTIAL pain symptoms.
43KEY POINTS---Another key point is the specific definitions included in the section regarding recognition and management of pain—in order for your staff to manage pain effectively, they will need to understand these definitions (especially the ones regarding types of pain like acute and incident pain types)
44KEY POINTS--The reference sections included in the CMS 1/23/09 guidance section related to the pain management protocol are excellent and provide many varied approaches to supplement your personal and staff education.
45KEY POINTS--Timing-If the problem occurs, you assess and care plan a strategy according to your policy and procedure. Make sure you communicate the plan as well.
46Compliance Is…Recognition and evaluation of all aspects of pain management for residents who experience painDevelopment and implementation of a pain management plan for/with the resident (or a rationale for why not)
47Compliance Is…Anticipatory recognition and prevention of pain where it can be anticipatedMonitoring and modifying interventionsFurther investigation and communication regarding inadequately managed pain or adverse consequences of pain management
48Investigation May Include: An investigation into Quality of Care may include any additional concern related to care provisionStructureProcessOutcome
49Deficiency Categorization Presence of harm or actual/potential negative outcome because of lack of appropriate treatment and carePersistent/recurring pain and discomfort R/T failure to recognize, assess, or implement interventionsDecline in function from failure to assess after awareness of new onset of moderate to severe pain
50Deficiency Categorization Degree of actual or potential harm related to the non-compliance.The immediacy of correction required.
51Severity Levels… Level 4: facility allowed, caused, or situation resulted in serious injury, harm, impairment, or death to a resident and requires immediate correction. ‘severe, unrelenting, excruciating, and unrelieved pain’
52Severity Levels… Level 3: indicated non-compliance resulting in actual harm related to clinical compromise, decline, or inability to maintain and/or reach his/her highest practicable well-being ‘compromise of function with subsequent additional symptoms, or episodic pain related to treatments or interventions’
53Severity Levels… Level 2: Noncompliance resulting in resident outcomes of minimal discomfort, potential inability to reach/maintain highest level of well-being, or complaints of moderate discomfort/ pain. Potential for greater discomfort.Level 1:None