MOUNT PLEASANT, PA - Federal inspectors have cited Harmon House Health & Rehab Center for serious medication safety violations involving intravenous therapy administration, including failures to properly flush IV catheters and maintain required documentation for patients receiving critical antibiotics.
Critical IV Therapy Violations Identified
The June 5, 2025 federal inspection revealed that Harmon House failed to ensure physician's orders were obtained for flushing intravenous catheters and that IV lines were maintained according to the facility's own policies. Two residents with long-term IV access were affected by these violations, which inspectors classified as having potential for actual harm.
The most concerning case involved Resident 54, who experienced a significant change in condition on May 16, 2025. According to the inspection report, the resident "was lethargic, was not responsive" when nursing staff was called to the room. A Certified Registered Nurse Practitioner ordered an IV catheter insertion with Normal Saline to be administered at 80 milliliters per hour - a standard intervention for patients experiencing dehydration or other acute conditions.
However, despite documented evidence that the IV was successfully inserted, nursing staff failed to record the IV insertion, saline administration, or required catheter flushing in the resident's Medication Administration Records. The Director of Nursing confirmed during the inspection that no documentation existed to verify these critical interventions occurred as ordered.
Antibiotic Treatment Documentation Gaps
A second case involved Resident 61, who was receiving intensive antibiotic therapy for osteomyelitis, a serious bone infection affecting the left heel. The resident had a midline catheter - a type of IV access designed for extended use - and was receiving two powerful antibiotics: 720 milligrams of Daptomycin daily and 1 gram of Cefepime every 12 hours.
Physician orders specifically required nursing staff to flush the midline catheter with 10 milliliters of saline before and after each medication administration, followed by 30 units of Heparin three times daily. These flushes are critical for preventing catheter blockage and ensuring medication effectiveness.
Medication records showed the resident received Cefepime antibiotics from May 29 through June 4, 2025, but no documentation existed to confirm that required catheter flushing occurred before and after antibiotic administration. The Director of Nursing acknowledged this documentation failure during the inspection interview.
Medical Significance of IV Catheter Maintenance
Proper IV catheter flushing represents a fundamental patient safety requirement in healthcare settings. When IV lines are not flushed appropriately, several serious complications can occur. Catheter occlusion - or blockage - can prevent life-saving medications from reaching patients, particularly concerning when treating serious infections like osteomyelitis.
Blood clot formation within IV catheters poses another significant risk when proper flushing protocols are not followed. These clots can break loose and travel through the bloodstream, potentially causing pulmonary embolisms or other vascular complications. For patients receiving multiple medications through the same IV line, inadequate flushing between doses can cause drug incompatibility reactions, where different medications interact harmfully when mixed.
The facility's own policy, dated August 14, 2024, clearly states that flushing maintains catheter patency and prevents mixing of incompatible medications. Normal saline or manufacturer-recommended flush solutions must be used between incompatible medications to ensure patient safety.
Industry Standards for IV Therapy Management
Healthcare facilities are required to maintain comprehensive documentation of all IV therapy interventions. The Centers for Medicare & Medicaid Services mandates that nursing homes document medication administration, including IV medications and required maintenance procedures like catheter flushing.
Best practice protocols require verification that IV catheters remain patent (open and functioning) through regular flushing schedules. For midline catheters like the one used for Resident 61's antibiotic treatment, this typically involves saline flushes before and after each medication dose, plus heparin flushes to prevent clotting between doses.
When treating serious infections such as osteomyelitis, consistent antibiotic delivery is crucial for treatment success. Interruptions in medication administration due to catheter problems can lead to treatment failure, antibiotic resistance development, and prolonged hospital stays.
Quality Assurance System Failures
Beyond the immediate IV therapy violations, inspectors identified systematic quality assurance failures at Harmon House. The facility's Quality Assurance Performance Improvement committee failed to maintain compliance with nursing home regulations and ensure effective corrective action plans.
Previous inspections in June 2024 and April 2025 had identified similar deficiencies regarding medication administration documentation and infection control practices. Despite developing corrective action plans that included audit systems and QAPI committee oversight, the same types of violations recurred in the most recent inspection.
This pattern suggests that while the facility created policies and audit procedures on paper, these systems were not effectively implemented in daily operations. Quality assurance programs are specifically designed to identify potential problems before they affect patient care and to ensure that corrective measures prevent similar issues from recurring.
Additional Issues Identified
The inspection also revealed ongoing challenges with Minimum Data Set assessment accuracy, which affects how resident care needs are identified and addressed. MDS assessments serve as the foundation for individualized care planning in nursing homes, making accuracy essential for appropriate care delivery.
Infection control practice deficiencies were noted as recurring issues, particularly relevant given that one of the IV therapy violations involved a resident receiving treatment for a bone infection. Proper infection control measures are critical in healthcare settings to prevent the spread of healthcare-associated infections.
The facility had previously cited similar violations during inspections ending June 27, 2024, and April 22, 2025, indicating that systemic improvements in clinical oversight and staff training remain necessary to achieve sustained compliance with federal nursing home regulations.
Federal regulations require nursing homes to maintain comprehensive quality assurance programs that can identify deficiencies before they impact resident care and implement effective corrective measures to prevent recurrence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harmon House Care Center from 2025-06-05 including all violations, facility responses, and corrective action plans.
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