Harmar Village: Medication Failures Leave Residents - PA

Resident R65 hadn't had a bowel movement since March 25. By March 27, she'd gone three full days without relief, despite having physician orders for two different medications specifically designed to address her constipation.

Her doctor had been clear about the treatment protocol. The orders dated March 2 specified 17 grams of Miralax if no bowel movement occurred by day two. A second order called for 17 grams of Miralax twice daily as needed for constipation. A third order required 8.6 milligrams of Senna twice daily as needed if no bowel movement by day two.

Staff administered none of these medications on March 27, according to the facility's own medication records.

The resident's bowel documentation showed the stark timeline: no movement March 25, none March 26, none March 27. Three consecutive days of mounting discomfort while prescribed relief sat unused.

Nobody notified the physician that his patient had failed to have a bowel movement for three days, despite the clear medical orders requiring intervention by day two.

When inspectors interviewed Resident R65 on March 30, her distress was immediate and raw. She told them her "bum hole was so sore." She said she couldn't poop because it was "hard as a rock" and her stomach hurt "so bad."

The facility's own leadership acknowledged the breakdown during inspector interviews on March 31.

Assistant Director of Nursing Employee E10 confirmed at 12:51 p.m. that the facility had failed to implement the bowel protocol ordered for both Resident R65 and another resident, R31.

Thirteen minutes later, the Nursing Home Administrator delivered an even broader admission. The facility had failed to ensure residents received treatment and care according to professional standards of practice. They had failed to follow physician orders for two of the six residents inspectors examined.

The violations weren't isolated to one resident or one shift. The pattern affected multiple people under the facility's care, suggesting systemic problems with medication administration and care plan implementation.

Constipation in elderly residents poses serious health risks beyond discomfort. Extended periods without bowel movements can lead to fecal impaction, bowel obstruction, and other complications requiring emergency medical intervention.

The facility's failure extended beyond simply missing medication doses. Staff failed to recognize the escalating situation despite clear documentation showing three consecutive days without bowel movements. They failed to escalate the concern to medical staff. They failed to notify the physician as the resident's condition worsened.

The inspection revealed a facility where physician orders existed on paper but weren't translated into actual patient care. Where documentation systems tracked the problem but didn't trigger appropriate responses. Where residents' expressions of pain and discomfort didn't prompt immediate review of their care plans.

Resident R65's case illustrates how administrative failures translate directly into human suffering. While her doctor had provided specific, graduated interventions designed to prevent exactly this situation, the facility's systems broke down at the most basic level of medication administration.

The March inspection found the facility violated multiple Pennsylvania health codes governing resident care policies, nursing services, and the fundamental responsibility of healthcare licensees to provide appropriate care.

For Resident R65, the regulatory violations meant three days of increasing pain and a condition that had progressed from manageable to severe. Her description of being unable to defecate because it was "hard as a rock" suggested her constipation had advanced to a potentially dangerous stage requiring more aggressive medical intervention.

The facility's admission that they failed to follow professional standards of practice for multiple residents raises questions about how many other physician orders went unimplemented and how many other residents experienced preventable suffering while prescribed treatments remained unused.

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.

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