Why Pain Goes Untreated and the Drug War Gets Fought in Our Nursing Homes

Recommended reading for all long-term care leaders is a recently published report by the Quality Care Coalition for Patients in Pain about what the U.S. Drug Enforcement Agency is doing and how it runs counter to effective pain management in long-term care. The study, Patients in Pain: How U.S. Drug Enforcement Administration Rules Harm Patients in Nursing Facilities, points out that current DEA rules:

• Categorize nursing home residents as outpatients 
• Require nursing facility residents to be treated under restrictive provisions designed to prevent diversion of drugs for street use, rather than view the nurse in the long-term care facility as the prescriber’s agent, as is the case in hospitals and clinics

It further states that a nurse employed by a long-term care facility, even after receiving a verbal order from a physician for a controlled substance:

• Cannot use emergency kit medications for immediate administration
• Must wait until the doctor personally has either called or faxed a prescription order to the pharmacy and the nurse has called the pharmacy to confirm that the pharmacy has received the doctor’s order

According to the study, “These additional steps can significantly delay and even deny patients needed treatment, leaving sick and dying patients without adequate symptom relief to treat pain, seizures, psychiatric conditions, and end-of-life symptoms, among others. Some reports indicate that patients have been left suffering for hours and even days as their caregivers struggle to comply with these and other DEA requirements.”

Why doesn’t the DEA recognize nursing facilities as health care institutions?
It is outrageous that the DEA fails to recognize the capability of today’s long-term care nurses’ ability to assess and act in the best interests of residents. The DEA rules explicitly permit prescribers to rely on agents, but then does not treat the licensed nurse in the skilled nursing facility as such.

Why is the DEA Fighting the Drug War in the hallways of nursing homes?
Since 2009, the DEA has audited long-term care pharmacies and nursing facilities to ensure compliance with the Controlled Substances Act rules for prescribing and dispensing controlled substances to nursing home residents. As they audit our facilities, you’d think they’d notice the hospital-like environment and the tremendous involvement of skilled nursing staff in all aspects of resident care.

How the DEA Puts Clinicians in Conflict with Standards for Quality Care
The QCCPP study surveyed over 900 clinicians nationwide and revealed that “delays in treatment caused by DEA rules are forcing nursing facilities to send some patients back to the hospital for treatment and readmission. These practices are costly, difficult for the patients and completely avoidable” and that, “Physicians, nurses, pharmacists and other clinicians also find that the DEA rules put them squarely in conflict with federal and state requirements establishing quality standards for nursing facility care. Some are questioning whether they can continue to practice in an environment where they are unable to provide appropriate care to their patients.”

Why do these extra DEA rules apply in this environment?
As a compliance officer, I firmly support the regulation and monitoring of nursing facilities. And as a compassionate human being, I think that DEA officials need to take a hard look at this question and make rules that fit what is actually going on. The DEA misapplication of the Controlled Substances Act in the nursing home environment is a case in point.

The 11th Deadly Sin of the Nursing Home Administrator

Mark Tuggle’s article, 10 Deadly Sins of the Nursing Home Administrator, is a must-read. His commentary is broad-based, ranging from marketing to financial management to personal emotional reactions and the challenge of “managing friends.”  Let me propose, however, the Eleventh Deadly Sin: 

Failure to see quality as a compliance issue.

Long-term care administrators are, too often, fire fighters. Responding reactively to one problem after another day after day, they see no opportunity to manage differently because they're too busy putting out fires. While it's true that there's an aspect of reactivity built into our industry as the external environment of regulators and customers who “drop in” with ever-increasing demands, the frequency of fire fighting is also contingent upon our willingness to accept them as the way we do business.

As Stephen Covey says, when we say “yes” to one thing, we are de-facto saying “no” to another because there is only so much time and energy to spread around. So, for Long-Term Care Administrator to continually say “yes” to spending time managing crises, means they are continually saying “no” to investing time on organizational performance improvement.  This gives rise to the deadly sin of failure to see quality as a compliance issue.

Another way to say it is that the administrator chases after regulations, regulators, and customers instead of stepping back and taking a broader view that would include capacity building, trending and tracking, critical analysis, and quality improvement action planning.

Let’s face it, the only answer to the ever growing demands upon leaders is to work smarter, not harder. And for nursing home administrators, this means making performance improvement a way of life. For those who have been engulfed in crisis management, it will mean doing both for a while. This requires effort above and beyond the ordinary day-to-day. But the payoff is huge—getting out ahead of crises, of regulators, of customers—and managing things instead of things managing you.

Wouldn’t that feel better?