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Q&A: Where is it defined in the SOM that you need to document the pain rating and medication effectiveness each time before and after administering scheduled pain medications?

Q: We recently had survey and we are waiting for our statement of deficiencies. In the meantime, I am gathering information to submit to defend that this citation is not justified. The surveyor feels that, for scheduled pain medications, you should have documented proof that pain rating and medication effectiveness was documented in the record before and after administering SCHEDULED pain medications, and at the minimum for EVERY Shift. We do have this established related to PRN pain medications. Help me understand where the surveyor is seeing or referring to this in writing and where it is defined in a standard of practice for scheduled pain medications that you need to document that frequently every time you administer a scheduled pain med or at least every shift. I do not find this defined in the AMDA guidelines for pain management or elsewhere. I do not read that in the F697 Interpretive Guidelines either.

Any information that can assist me will be greatly appreciated.

A:  Suggest that your team had processes in place, but consider the following for further review:

1. Nursing process should be followed whether it is scheduled or prn pain medication. Facility nurses ask the resident on rounds about their pain. See section §483.25(k) F697 Pain Management, Key Elements of Noncompliance. Review the Pain Recognition and Management CE Pathway as well.

2. Do you have any documentation for the days of the survey to support your nurses assessed her pain? What is current policy? MDS and Care Plan – what were the resident’s goals and preferences?

3. Geriatricpain.org has some great education resources and tools.

4. AADNS has an in-service tool on understanding pain in dementia residents as well.

5. Review with the medical director and PCP to see if either of them was evaluated during survey as well.

Consider adding the pain evaluation for scheduled medication to your EHR as well. We adopted that and it works well for our facilities.

The best next step is to wait for the 2567 to see your actual deficiency statement. I applaud you for being proactive in gathering your supporting documents for IDR.

Author:  Glenda Nelson BSN, RN
Quality Director
Dallas TX

Interested in reading more FAQs? Visit the AADNS Network where you can review questions and answers on pressing topics from peers and experts in long-term care nursing leadership.

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