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Regulations Update

Federal Regulation - F309 Quality of Care

Marci Pederson, RN, BSN, Nurse Educator/Consultant

F309 Quality of Care was the 7th most cited regulation as a deficiency during 2009 in long term care facilities in South Dakota. There were 21 deficiencies written for F309.

F309 states, ““Each 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.”

Points To Be Aware Of

F309 includes, but is not limited to, care such as end of life, diabetes, renal disease, fractures, congestive heart failure, non-pressure-related skin ulcers, pain, or fecal impaction.

The survey team must determine if a lack of improvement or decline was unavoidable or avoidable.  A determination of unavoidable decline or failure to reach highest practicable well-being may be made only if all of the following are present:

  • An accurate and complete assessment
  • A care plan which is implemented consistently and based on information from the assessment
  • Evaluation of the results of the interventions and revising the interventions as necessary

Since the Guidance to Surveyors for F309 contains 49 pages, I chose to address how a facility improves in compliance with pain management for the residents. I will address how a facility can achieve compliance with pain management for the residents. In order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, the facility, to the extent possible:

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

Effective pain recognition and management requires a facility-wide commitment to promoting resident comfort. Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. It is important to note that while pain medication can reduce pain and enhance the quality of life, they do not necessarily address the underlying cause of pain. Sometimes we miss the boat on this one. The pattern of behavior we may see in regards to treating pain is to take an ibuprofen or acetaminophen and continue on with our daily routine. This can be a barrier to taking a pro-active approach to addressing underlying causes of pain. When we address underlying causes for pain, pain management may occur with fewer pain medications, lower doses, or medications with a lower risk of serious adverse consequences. There also may be attitudes that pain is an inevitable part of aging, a sign of weakness, or a way just to get attention. With those types of attitudes, residents may not receive the care needed for effective pain management.

Other challenges to successfully evaluating and managing pain may include communication difficulties due to illness or language. We might think cognitive impairment would be one of the biggest barriers to effectively assessing for pain status, but actually some individuals with advanced cognitive impairment can accurately report pain and/or respond to questions regarding pain. One study noted that 83 percent of nursing residents could respond to questions about pain intensity. It is important to evaluate (touch, look at, and move) the resident in detail to confirm whether their signs and symptoms are due to pain.

Communication Barriers

There are still some residents who are not able to tell us in a direct way when they have pain. In those instances we need to remember expressions of pain may be verbal or nonverbal in nature. Words used to describe pain may differ depending on the area of the country, culture, and/or language. We actually have a variety of culture types in our small town communities in the Mid-west which include but are not limited to Danish, Irish, French, German, Russian, Czechoslovakian, and Native American. Individuals in some cultures are hesitant to express pain whereas in other cultures the behavior expression of pain may be very emotional. We must believe what the resident says about his/her pain because it is a very subjective symptom. Another priority in pain management is to avoid making judgments about residents who are experiencing pain. The symptoms of pain are real to each and everyone who experiences it.

The many examples of words for pain include heaviness, pressure, stabbing, throbbing, hurting, aching, gnawing, cramping, burning, numbness, tingling, shooting or radiating, spasms, soreness, tenderness, discomfort, pins and needles, feeling “rough”, tearing or ripping. Other possible indicators of pain include, but are not limited to the following:

  • Negative verbalizations and vocalizations such as groaning, crying/whimpering, or screaming
  • Facial expressions (e.g., grimacing, frowning, fright, or clenching of the jaw)
  • Changes in gait (e.g., limping), skin color, vital signs (e.g., increased heart rate, respirations and/or blood pressure), perspiration
  • Behavior such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities. I would like to invite you to look at the “difficult resident” in a different way and ask “Could this resident be experiencing pain – could that be the cause for the behavior of resisting care? “ When this question is explored by the healthcare team, the team has found that in many situations the resident has a lot of pain when being transferred into and out of the tub. In other situations it was found depression was directly related to the chronic pain the person was experiencing.
  • Loss of function or inability to perform Activities of Daily Living (ADLs), rubbing a specific location of the body, or guarding a limb or other body parts
  • Difficulty eating or loss of appetite
  • Difficulty sleeping (insomnia)

Resources Related to Pain Management

The Guidance to Surveyors lists a number of clinical resources available for guidance regarding the assessment and management of pain and this list includes:

The information available in these resources is provided by the experts in pain management and is evidence-based.

Care Processes Needed for Effective Pain Management

Assessing the potential for pain, recognizing the onset or presence of pain, and assessing the pain

Something I have found to be helpful regarding potential for pain is to remember there are certain illnesses which predispose the residents to having pain. I wish there were only a few such illnesses, but that is not the case. Illnesses such as arthritis, pressure ulcers, fibromyalgia, cancer, osteoporosis, Huntington’s Disease, post-surgery recovery, constipation, diabetes with neuropathic pain, immobility, amputation, post-CVA, venous and arterial ulcers, multiple sclerosis, oral health conditions, and infections. When we learn to recognize the secondary problem of pain with the majority of the illnesses which the elderly experience, we tend to make pain management a priority in the planning of all residents’ care.

Treating pain with physician’s orders

Those orders may include but are not limited to pain medication, physical therapy, restorative therapy, prescribed hot or cold therapy or complementary medical services such as massage therapy, acupuncture, reflexology, healing touch, guided imagery, etc.

Developing and implementing interventions/approaches for pain management depends on whether it is continuous or episodic, or both

Does the resident need regularly scheduled pain medication or does the resident need the pain medication only as requested or as needed?

Monitoring appropriately for effectiveness and/or adverse consequences (e.g., constipation, sedation, and fall risks)

When pain medication is administered, the resident must be assessed after administration for effectiveness of the medication. This must be consistently documented on the Medication Administration Record. This is a professional standard that must become routine but at the same time specific to the resident’s needs and preferences. By consistently documenting the resident’s response, the healthcare team is more able to assess the effectiveness of the resident’s pain management program.

Modifying the approaches as necessary

Common sense says we make changes in interventions for pain management when the resident is still crying out, moaning, grimacing, or says it hurts too much to venture out to the dining room for a meal.

Nursing assistants, dietary staff, activities staff, physical therapy staff, housekeeping, family, and friends who all have direct contact with the resident are needed as part of the team to recognize a change in the resident’s functioning and to report the changes to a nurse for follow-up. Pain management is a team effort in long term care.

Complementary and Alternative Medicine

Non-pharmacological Interventions

The Guidance to Surveyors includes a number of definitions related to recognition and management of pain. One of the terms included in the definitions is “Complementary and Alternative Medicine” (CAM). This is a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine. Another term to take note of is “Non-pharmacological Interventions.” This term refers to approaches to care that do not involve medications, generally directed towards stabilizing or improving a resident’s mental, physical, or psychosocial well-being.

Recently I provided a presentation to a facility for their competency days on non-pharmacological interventions for pain management. Usually when a resident has symptoms of pain the staff tells the medication nurse that the resident is having pain. The medication nurse then administers the prescribed pain medication to the resident and then a half hour later checks with the resident to see if the medication was effective. That has been our process. A shift is slowly occurring in the process of pain management. Pain management requires more than administering medication. In order for pain management to provide optimum results, we need to incorporate non-pharmacological interventions along with pain medication. It is possible we will see this being reinforced more and more through the survey process. This is a good thing. Change is difficult so here are some examples of non-pharmacological interventions:

  • Altering the environment for comfort (such as adjusting the room temperature, tightening and smoothing linens, using a pressure redistributing mattress and positioning, comfortable seating, and assistive devices)
  • Physical modalities, such as ice packs or cold compresses (to reduce swelling and lessen sensation), mild heat (to decrease joint stiffness and increase blood flow to an area), neutral body alignment and repositioning, baths, trans-cutaneous electrical nerve stimulation (TENS), massage, acupuncture/acupressure, healing touch techniques, chiropractic or rehabilitation therapy, guided imagery, relaxation exercises
  • Exercises to address stiffness and prevent contractures
  • Cognitive/Behavioral interventions (e.g., relaxation techniques, reminiscing, diversions, activities, music therapy, coping techniques and education about pain)

The list of Complementary and Alternative Medicine (CAM) options is evolving, as those therapies that are proven safe and effective are used more widely.

Note: Information on CAM may be found on the following sites

Please contact me for all of your Regulatory Compliance and Survey Preparation needs. Do the math! The facility bottom line improves when resident care continually improves.

The Avera Solutions’ Blog contains writings from Marci and other Avera Education & Staffing Solutions staff and consultants.

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Marci Pederson, RN, BSN

Marci Pederson, RN, BSN

As a former health facilities senior surveyor, Marci served a variety of health care facilities. Her experience includes nursing education, medical/surgical nursing, psychiatric nursing, infection control, utilization review and quality assurance.

Have a question for Marci? A topic idea for her next column? Need more information on having a mock survey at your facility? Send her an email at