Harmar Village Health: Missing Catheter Orders - PA

Resident R72 had been hospitalized on March 25 after spitting up copious amounts of mucus and saliva, with his oxygen levels dropping to dangerous lows. When he returned to the facility four days later, his catheter remained in place with a leg bag attachment.

But the physician orders that had governed his catheter care expired the day he left for the hospital.

State inspectors found that R72's original catheter orders from October 27 specified monthly changes of his supra-pubic catheter using specific sizing requirements. The orders detailed when to change the catheter and required documentation of the 18 French, 10 ml size inserted.

Those orders ended March 25 — the same day R72 was sent to the hospital.

When R72 returned March 30, his re-admission orders contained no catheter care instructions. No sizing specifications. No change schedule. No irrigation orders.

The resident had diagnoses including an enlarged prostate that impacted urine flow, repeated falls, anxiety disorder, and history of lung cancer. His care plan from January indicated he had a history of obstructive uropathy and required catheter care to remain free from catheter trauma.

Inspectors observed R72 on March 30 at 11:31 a.m. with his catheter in place via leg bag. They returned at 2:21 p.m. after lunch. Same setup.

A nursing aide confirmed the obvious: "He has a leg bag."

The next morning, inspectors found R72 again in bed with his catheter and leg bag at 9:24 a.m.

R72's medical complexity made the oversight particularly concerning. His hospitalization had involved serious respiratory distress, with oxygen saturation dropping to 81 percent even with supplemental oxygen. The nursing supervisor had called the doctor twice that day — first for increased oxygen, then for hospital transfer orders.

The facility's own policy, dated August 15, 2025, stated that clinical staff may provide urinary catheter care to help prevent catheter-associated urinary tract infections and prolong the life of the catheter system.

But without physician orders, staff had no guidance on catheter sizing, change frequency, or care protocols for a resident whose enlarged prostate created ongoing urinary complications.

During the inspection, the Director of Nursing confirmed what the documentation already showed: the facility had failed to obtain appropriate physician orders for R72's urinary catheter as required by state regulations.

The violation occurred despite clear care planning that recognized R72's catheter needs. His January care plan specifically addressed his obstructive uropathy history and outlined goals to keep him free from catheter trauma through routine catheter care and physician-ordered changes.

For three days after his return, R72's catheter operated in a regulatory void. Staff continued providing care to the complex medical device without the physician oversight required for safe operation.

The facility's policy emphasized preventing catheter-associated infections and extending catheter system life. But those goals require proper medical supervision, particularly for residents with R72's urinary complications.

Inspectors documented the deficiency as causing minimal harm or potential for actual harm to few residents. But the gap in physician oversight left R72 vulnerable to catheter complications that his medical history suggested he was already prone to developing.

The state found Harmar Village had violated Pennsylvania regulations requiring proper clinical records and nursing care standards. The facility must now develop a plan to correct the deficiency and prevent similar lapses in physician order management.

R72's case illustrates how administrative oversights can compromise medical care for vulnerable residents. His catheter continued functioning, but without the medical supervision that regulations require to keep it functioning safely.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Harmar Village Health & Rehab Center from 2026-04-03 including all violations, facility responses, and corrective action plans.

Additional Resources

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