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Pain mismanagement

June 1, 2007
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Pain has been clinically defined as “whatever the experiencing person says it is, existing whenever the experiencing person says it does.” Unfortunately, this definition is inadequate for understanding pain in long-term care residents, as many have cognitive deficits and/or are conscious of pain but are unable to express it. Moreover, residents often don't know how to get relief and staff members are unaware of the problem because they fail to adequately and routinely assess residents for pain. Therefore, both groups misunderstand the importance of managing pain.

Some recent findings from the Centers for Medicare & Medicaid Services suggest that pain experienced by nursing home residents is prevalent but is often not fully reported, recognized, assessed, or treated. Studies have shown that 45–80% of nursing home residents have substantial pain that is undertreated as a result of suboptimal compliance with guidelines for treating pain in geriatric populations. Among those with pain who are assessed, 41% of nursing home residents are in persistent, severe pain at the next assessment.

Poor pain management can trigger survey citations for abuse, violation of residents’ rights (per the self-determination act), and substandard care. In addition, many states have proposed or enacted statutes that address pain management, which has spawned a new trend of lawsuits against healthcare providers that have inadequate pain management policies and services. Please review the following situation in which some caregivers unintentionally mismanaged a resident's chronic pain for several months. Plan to make changes as appropriate in your facility.

The Situation

After suffering a stroke that left him with right-sided paralysis and difficulty speaking, a man sold his home and moved to an independent living facility in a continuing care retirement community (CCRC) near his daughter. He had chronic pain in his ribs from previous fractures and took three medications daily for muscle relaxation and nerve pain relief. As the years went by, he became more dependent on others for assistance with his daily living, so he reluctantly moved again—to the CCRC's skilled nursing facility.

The independent living facility did not keep charts or medical records, so upon admission to the nursing unit a note was faxed to the man's attending physician requesting a current copy of his admission and medi-cation orders, a physician plan of care (PPOC), and an updated history and physical (H&P) to reflect his current status.

When the information was faxed back to the facility, the muscle relaxant and pain medications were listed on the H&P, which read “current with no real changes.” The physician also wrote “see attached” on the man's PPOC in the current medications section. The attachment was a list of medication orders that were written according to diagnosis. Since chronic pain was not a diagnosis, the three medications were not listed. The nurse transcribed the orders as indicated on the PPOC and attached medication orders, omitting the three medications because she did not compare those documents with the H&P.

Later that day, the man's daughter gave the nurse a bag of his medications from the old apartment. The nurse said she would send the medications to the pharmacy for “repackaging,” as was custom in these situations. When the pharmacist saw the three medi-cations, he placed them in storage because he did not have any orders for them.

Although the man was alert, oriented, and able to direct his own care, his daughter acted as his Power of Attorney for Health Care Decisions because of his communication difficulties. His daughter could understand him, so she bridged the communication gap and signed all of the detailed, business-type forms within his healthcare records. A note in the man's chart alerted the staff that he had expressive aphasia and his daughter should be consulted for all decision making. The staff complied and consulted his daughter whenever needed, such as having her sign the disclosure list for health records many times and asking her to be present whenever the physician visited her father.

While at the nursing facility, the man occasionally became frustrated whenever staff members could not understand what he was trying to tell them. He also was in constant pain. Among the man's medication orders was hydrocodone, a narcotic analgesic to be given as needed (prn). Since that was his only pain reliever, he asked for it frequently, to the extent that the nursing staff asked that it be administered three times a day, as well as prn. The prn doses were used on an average of one out of every three days for the next four months.

At the end of the fourth month, the daughter felt that her father was having increased leg pain at night and asked that he receive a routine dose of pain medication at bedtime. This was ordered and as the daughter reviewed her father's list of medications, she discovered the three missing pain medications. The pharmacist was immediately contacted, and he explained that he was holding the medications for the man until he received an order for disbursement. The man's attending physician promptly wrote the order and the three medications were dispensed and restarted.

As a result, the man's chronic pain began to subside, and a month later the daughter asked for the bedtime dose of hydrocodone to be discontinued. When the physician examined him, he noted that the man was “far more comfortable now that the medications have been restarted—may be able to reduce the scheduled narcotics.” Within the next month the hydrocodone was discontinued altogether, and the man's appetite increased and his weight jumped from 121 pounds (upon admission) to 138 pounds. Overall, he appeared happier and more social than ever since being admitted.