Harmar Village: Pressure Sore Care Failures - PA

The resident, identified as CR42, was non-weight bearing and required a sling on his right arm. Despite clear protocols for checking skin under medical devices, staff allowed pressure sores to develop in the elbow area, causing what inspectors classified as minimal harm.

The problems extended beyond the elbow. On January 12, the resident was found with newly developed ankle and foot wounds. He didn't begin wound care treatment until January 16, four days after the wounds were discovered.

Staff interviews revealed confusion about basic care requirements. When asked about skin monitoring protocols, wound consultant Employee E16 explained the standard: "The expectation to check under the sling include removing the sling, looking up around the neck, look at all the parts of the skin that you cannot see with the sling on. I worry most about where the straps are under the neck."

But the facility's own records showed gaps. Wound measurements from January 10 couldn't be located during the inspection. When asked about the missing documentation, one staff member stated: "I do not see the measurement here."

Licensed Practical Nurse Employee E1 acknowledged knowing proper procedure during an April 1 interview. Asked whether non-weight bearing residents should use slings and how to monitor them, the nurse responded: "Yes, one resident is Resident R124. He has a sling on his right arm. We check the skin by carefully taking off the sling and looking. I would imagine the record has skin check order."

The occupational therapist confirmed the resident had the sling when first encountered, telling inspectors during a March 31 interview: "Resident CR42 was non-weight bearing and he had a sling on."

Yet the sling itself wasn't ordered until January 10, according to facility records. This timing raises questions about how long the resident went without proper arm support while non-weight bearing.

The wound consultant's concerns about strap placement proved prescient. Pressure ulcers commonly develop where medical devices create sustained pressure against skin, particularly around the neck area where sling straps rest.

During the final interview on April 1, Regional Risk Employee E9 and administrators were informed that the facility had failed to provide necessary treatment and services consistent with professional standards to prevent pressure ulcer development.

The case illustrates a fundamental breakdown in preventive care. Staff understood the protocols for monitoring skin under medical devices. The wound consultant articulated specific concerns about high-risk areas. The nursing staff claimed to follow proper checking procedures.

But Resident CR42 still developed pressure ulcers.

The facility's documentation problems compounded the care failures. Missing wound measurements meant inspectors couldn't track the progression of skin breakdown or verify whether staff had actually performed the monitoring they described.

Federal regulations require nursing homes to ensure residents receive necessary care to prevent avoidable complications like pressure ulcers. When residents need medical devices like slings, facilities must implement monitoring protocols that account for the increased skin breakdown risks these devices create.

The inspection found the facility violated multiple Pennsylvania health codes governing resident rights, care policies, and nursing services. The violations affected what inspectors classified as "few" residents, suggesting similar monitoring failures may have occurred with other patients requiring medical devices.

Resident CR42's case demonstrates how seemingly minor oversights in daily care can lead to painful, preventable complications. Pressure ulcers cause significant discomfort and can lead to serious infections if left untreated. For elderly residents with limited mobility, these wounds often heal slowly and may never fully resolve.

The resident's ankle and foot wounds, discovered four days before treatment began, suggest the monitoring failures extended beyond the sling area to general skin assessment practices throughout his care.

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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