Pain: Facility Assessment Checklists A facility system assessment is a starting point for a quality improvement project. The checklists included in this booklet will be most useful if you take a critical look at your current practices. Directions for Pain: Facility Assessment Overview Questionnaire To be completed by a direct care or interdisciplinary team. Consult with appropriate staff in answering certain questions and completing checklists. If you answer to any of the questions below, please proceed immediately to the checklist referenced by the page after the question. If you answer to a question, the process is always complete and done so consistently. Please continue to the next question. If you answer In Progress to any of the below questions, the need is being addressed but needs improvement. Pain: Facility Assessment In Progress Does your facility have a process for when and how the staff will screen residents for pain? (page 2) Does your facility complete a comprehensive assessment for pain for residents who are found to have pain upon screening? (page 3) Does your facility have a process for developing and implementing a care plan for pain for residents who have been found to have pain upon screening? (page 4) For residents who are being treated for pain, does your facility have a process for monitoring their pain on at least a daily basis? (page 5) Does your facility have a process for reassessing a resident s pain to determine if the resident s care plan is effective or needs revision? (page 6) Does your facility have a policy for pain assessment and management? (page 7) Does your facility have initial and ongoing education on pain assessment and management to both nursing and non-nursing staff? (page 8) When completing each checklist on the following pages: If you answer to all of the questions, the process is always complete and done so consistently. Continue to the next checklist. If you are not sure, or answer to one of the questions, choose one or more elements on which to focus your quality improvement. If you answer to one or more of the questions, the process is not always complete and/or not always done consistently. page of 8
Pain: Screening for Pain A screening assessment is a brief assessment or questions that determine if the resident has pain or the potential for pain. It does not include a thorough assessment about the pain symptoms or reasons for the pain that needs to be done if the resident is found to have pain upon screening. Basic questions to use as a screening assessment: 1. Do you have pain now? 2. Do you have pain that recurs? 3. If unable to answer questions 1 and 2, a) Is there evidence of pain? b) Are there diagnoses that suggest potential for pain? 4. Are there diagnoses that suggest potential for pain? Does your facility have a process for screening that addresses all the below listed areas? Does your facility have a policy and procedure for when and how the staff will screen residents for pain? Does your policy and procedure state that residents should be screened for pain at the following times: Within 24 hours of admission Within 24 hours of readmission At each MDS assessment With each change in condition If unable to answer questions 1 and 2, a) Is there evidence of pain? b) Are there diagnoses that suggest potential for pain? Do you have a variety of pain evaluation tools available to allow individualization (e.g., the Faces, numerical, verbal scales, or the PAINAD tools for the cognitively impaired)? Are residents screened (assessed) using the tool determined to be appropriate for each resident?
Pain: Assessing Pain A comprehensive assessment for pain is done when pain is identified on screening, someone develops new symptoms of pain, or worsening pain that warrants a thorough assessment for this new complaint or improvement of the condition causing the pain. Does your comprehensive pain assessment include all of the below elements? If pain is identified during screening, does your facility have a process that will lead to a comprehensive assessment within 24 hours? Are the following elements included in your comprehensive assessment? Description of the pain Location of the pain Intensity/severity of the pain using an accepted pain scale Frequency of pain Current pain Pain at its least Pain at its worst Aggravating factors (what makes it worse) Alleviating factors (what makes it better) Effects of the pain on the resident s life (ADLs, sleep, appetite, physical activity, emotions, mood, nausea) Current treatment Response to current treatment When a comprehensive assessment is done, are all these elements completed and recorded on your assessment form and in a timely manner?
Pain: Monitoring Pain For residents who are being treated for pain, does your facility have a process for monitoring their pain on at least a daily basis? Does your facility s process for monitoring pain include these components? Do you ask residents to rate their pain using a pain scale identified as appropriate for the resident? Does your facility use an appropriate pain scale to monitor for pain on a daily basis for those with cognitive impairment (e.g., the PainAD scale)? Do you use nonverbal cues to monitor for pain? Do you record a monitored pain scale score: At least every 24 hours? Before giving a prn pain medication? Approximated 30 minutes after giving a prn pain medication? With each complaint of pain? Do you have a system for tracking in the medical record the results of your monitoring?
Pain: Reassessing Pain Does your facility have a process for reassessing a resident s pain to determine if the resident s care plan is effective or needs revision? Does your facility s process for reassessing the care plan for pain address all the below areas? Does your facility have a policy and procedure defining when a comprehensive reassessment of pain will be completed? (A complete reassessment should be performed for any persistent or worsening pain.) Does the reassessment include all the components in the comprehensive assessment? (See page 4, Monitoring Pain) Does your staff follow the policy and procedure for reassessing pain when the resident is complaining of persistent or worsening pain? Is the resident reassessed for pain at regular intervals after being assessed initially as having pain? Do you reassess residents who are taking increasing doses of prn medication (including those who are also on regularly scheduled medications for pain)?
Pain: Developing Pain Care Plans Does the plan of care for pain address all the below areas? If pain is identified in admission, is a plan of care put into place within 48 hours of admission? Does the care plan for any resident identified with pain include a pain control goal as defined by the resident/caregiver/family member? Does the care plan include education of the resident and family related to these areas of pain management: Goal of therapy Side effects (e.g., drowsiness) Constipation Overall treatment plan For residents with daily pain, does the plan provide for medication on a regular schedule (e.g., around the clock), not just prn? Does the plan provide for medication use by mouth if at all possible? Does the plan provide for using non-pharmacological approaches to pain management (e.g., massage, music, aromatherapy, ice or heat, etc.)? Does the plan provide for keeping the resident as mobile as possible? Does the plan address positioning and proper movement to minimize the resident s pain? Does the plan provide for regular monitoring of resident s response to pain medications at least every 24 hours? Does the plan outline when the reassessment of resident s pain and responses to pain will be completed?
Pain: Assessing Pain Management Policies Does your facility s policy for pain assessment and management include the following components? Does your facility s policy include a statement regarding your facility s commitment to pain management? Does your facility s policy include screening, assessment, and reassessment of residents for pain? Does your facility s policy include the goals of the pain assessment and management program such as: Prompt assessment and diagnosis of pain Specification of appropriate pain scale tools for both cognitively intact and cognitively impaired residents Steps to be taken to monitor treatment effectiveness Pain treatment techniques based on clinically accepted guidelines, including non-pharmacological therapies Improving the resident s well being by increasing comfort and reducing depression and anxiety Optimize the resident s ability to perform ADLs and participate in activities Monitoring for side effects prevention/treatment related to the use of pain medication (i.e., constipation, nausea, vomiting, sedation, respiratory depression) Does your facility s policy address who, how, and when pain management program effectiveness should be monitored and evaluated? Does your facility s policy address a protocol for ongoing monitoring of pain? Does your facility s policy address a protocol for communication of reporting of pain to the designated MDS personnel to ensure correct coding?
Pain: Facility Assessment Checklists page 8 of 8 Pain: Assessing Staff Education and Training Does your facility s education program for pain assessment and management include the following components? Are new nursing staff assessed for their need for education on pain screening, assessment, and management? Are current staff provided with ongoing education on the principles of pain management? Does education staff provide discipline specific education for pain assessment and management? Is there a designated clinical expert available at the facility to answer questions from all staff about pain assessment and management? Does education take into consideration the personal, ethnic, cultural, and religious beliefs surrounding pain management? Is the education provided at the appropriate level for the learner (i.e., CNA vs. RN)? Does the education include staff training on documentation methods related to pain (i.e., location, duration, intensity, frequency, aggravating/alleviating factors, pain scales)? Document available at www.primaris.org MO-06-15-PAIN July 2006 This material was prepared by Primaris, the Medicare Quality Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.