MILLINGTON, TN - Federal inspectors documented serious deficiencies in pain management at Millington Healthcare Center after two cognitively impaired residents experienced inadequate treatment for severe pain, including one who developed a brain hemorrhage following an unwitnessed fall.
Delayed Pain Treatment Following Hip Fracture
A resident with advanced dementia experienced hours of untreated pain after sustaining a fracture near her hip prosthesis, according to a March 27, 2025 complaint investigation by state surveyors. The resident, identified in records as Resident #9, had a documented history of dementia, anxiety, and previous hip surgery complications.
The incident began in the early morning hours when the resident experienced an unwitnessed fall at 1:15 AM. Staff discovered the fall but did not immediately recognize the severity of the injury. Four hours later, at 9:15 AM, the resident began exhibiting clear signs of significant pain, including hollering when her right leg was moved, grimacing, and protective guarding of her right hip and thigh area.
Despite these obvious pain indicators, nursing staff did not immediately notify the resident's physician and failed to administer any pain medication. An x-ray was finally ordered at 11:31 AM—more than two hours after the pain symptoms became apparent—but was not actually performed until 1:32 PM, roughly four and a half hours after staff first observed the resident's distress.
The imaging revealed a periprosthetic fracture, a break that occurs in bone tissue surrounding an orthopedic implant. This type of fracture typically causes severe pain and requires prompt medical intervention. The resident was transferred to a hospital at approximately 3:40 PM, more than six hours after staff first observed her pain symptoms. Records indicate she received no pain medication before leaving the facility.
Periprosthetic fractures represent a particularly painful orthopedic emergency because the break occurs in bone that has already been compromised by previous surgery. The presence of hardware creates additional pressure and inflammation at the fracture site. For elderly patients with dementia, the inability to verbally communicate pain effectively makes visual assessment of pain behaviors by trained staff critical.
The resident's cognitive impairment, documented as severe in facility assessments, meant she was rarely understood when attempting to communicate and exhibited both short-term and long-term memory problems. This level of impairment requires nursing staff to be particularly vigilant in recognizing nonverbal pain indicators such as facial grimacing, protective guarding, and vocalizations.
Post-Surgical Pain Inadequately Managed
A second resident experienced days of uncontrolled pain following a below-knee amputation, which inspectors determined contributed to behavioral changes that preceded a serious fall. Resident #17 had been readmitted to the nursing home on March 11, 2025, following hospital discharge after undergoing a right below-knee amputation.
The resident's physician had ordered two pain medications: Hydrocodone to be given every six hours as needed for moderate pain (rated 4-6 on a standard pain scale), and Ibuprofen 800 milligrams every eight hours as needed for mild pain (rated 1-3). The admission assessment completed at 6:30 PM on the day of readmission documented the resident was experiencing pain rated at level 5, which was frequently causing difficulty sleeping and limiting day-to-day activities.
Like Resident #9, this individual had severe cognitive impairment and was dependent on staff for all aspects of care. Despite physician orders for appropriate pain medication and documented pain levels that met the threshold for Hydrocodone administration, the resident did not receive the stronger pain medication during the days following admission.
The consequences of inadequate pain management became evident through changes in the resident's behavior. Staff observed increased restlessness and trembling of the resident's extremities. Beginning on March 14, the resident developed a new behavior of attempting to climb out of bed—an action the resident had not previously exhibited.
On March 17, 2025, six days after admission, Resident #17 sustained an unwitnessed fall that resulted in head trauma. The resident was transferred to the hospital and diagnosed with a subarachnoid hemorrhage—bleeding in the space surrounding the brain—and a periorbital fracture near the eye socket. Both injuries carry significant risk of serious complications or death, particularly in elderly patients.
Subarachnoid hemorrhages can result from traumatic head injuries when someone falls and strikes their head. The bleeding occurs between the brain and the thin tissues covering it, causing dangerous increases in intracranial pressure that can damage brain tissue. Symptoms may include severe headache, loss of consciousness, seizures, and neurological deficits.
Pain is a well-established contributor to delirium, agitation, and behavioral changes in cognitively impaired nursing home residents. When individuals cannot verbally express their discomfort, pain often manifests as restlessness, sleep disturbance, or attempts to reposition or move frequently. The resident's new behavior of attempting to climb from bed aligned with classic pain-related agitation patterns.
Systemic Failures in Pain Assessment
During interviews with surveyors, the facility's Director of Nursing acknowledged that Resident #17 had not received the prescribed Hydrocodone despite physician orders and documented pain levels warranting its use. The Director of Nursing also confirmed that after the resident's hospital discharge, documentation indicated staff should pick up the ordered medication at a local pharmacy near the facility, but this did not occur.
In an interview on March 27, the Director of Nursing stated: "I would have said, whoa, I could have the family go get it and use it...she [the Licensed Practical Nurse] could have called me, and I could have given her direction...something would have happened, even if I called a Nurse Practitioner...she could have put in something [for pain]. They call me for a million things...night and day, but they didn't call me for this."
The Director of Nursing indicated she only learned of the situation on the Monday after the resident's fall and hospitalization. This revelation pointed to broader communication failures within the facility's nursing structure, where significant clinical issues were not being escalated to nursing leadership.
The facility's Administrator told surveyors she had only become aware of the pain management failures when she returned from a pre-planned trip, having been absent from the facility during part of the survey period from March 23-27. This administrative absence during a time when critical clinical issues were occurring raised additional concerns about oversight and accountability structures.
Regarding Resident #9's experience with the hip fracture, the Director of Nursing confirmed the resident did not receive pain medication on the day of the fracture and acknowledged that nursing staff should have contacted the Nurse Practitioner to obtain an order for pain medication. The failure to make this basic clinical decision represented a fundamental breakdown in nursing judgment and protocol.
Regulatory Standards for Pain Management
Federal regulations require nursing facilities to ensure each resident receives appropriate treatment and services to manage pain. This includes systematic pain assessment, particularly for residents with communication barriers, and timely administration of ordered pain medications when assessment indicates their need.
For residents with cognitive impairment, facilities must implement specialized pain assessment tools that evaluate behavioral indicators including facial expressions, body movements, vocalizations, changes in activity patterns, and vital sign changes. The absence of verbal pain reports cannot be interpreted as absence of pain in this population.
Standard nursing practice requires immediate assessment and intervention when residents exhibit acute changes suggesting pain, particularly following known trauma such as falls. Orthopedic injuries require prompt imaging and pain control while awaiting diagnostic results. The several-hour delay in obtaining imaging and complete absence of pain medication for Resident #9 fell well below accepted standards of care.
Post-surgical pain management protocols emphasize aggressive pain control during the immediate recovery period to facilitate healing, maintain function, and prevent complications. Adequate pain control following amputation is particularly critical due to the risk of phantom limb pain developing if acute pain is inadequately treated. The failure to administer prescribed pain medication to Resident #17 represented a missed opportunity to prevent both immediate suffering and potential long-term pain complications.
Additional Issues Identified
Surveyors determined the facility failed to implement systems ensuring appropriate pain management consistent with professional standards of practice. The investigation also found the facility had not created a safe environment to prevent accidents, as evidenced by Resident #17's fall while experiencing uncontrolled pain that may have contributed to behavioral changes.
The deficiencies revealed gaps in multiple areas: nursing assessment and clinical judgment, medication management processes, communication between nursing staff and leadership, physician notification protocols, and administrative oversight of clinical care quality. Inspectors documented these failures represented more than isolated incidents, indicating systemic problems with how the facility identified and responded to resident pain.
The facility received citations for failing to provide appropriate care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with the comprehensive assessment and plan of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Millington Healthcare Center from 2025-03-27 including all violations, facility responses, and corrective action plans.
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