MOUNT PLEASANT, PA - Federal inspectors identified significant deficiencies in medication administration, infection control protocols, and safety procedures at Harmon House Care Center during a June 2024 inspection, citing violations that affected multiple residents receiving critical treatments.
Medication Administration Errors Put Residents at Risk
The most concerning violations centered on repeated failures to follow physician-prescribed medication protocols. Inspectors documented four separate cases where nursing staff failed to properly administer medications according to doctors' orders, potentially compromising resident health and safety.
Blood pressure medication administered when contraindicated presented a particularly serious risk. One resident with dementia and high blood pressure was prescribed metoprolol tartrate with specific instructions to withhold the medication if their systolic blood pressure dropped below 100 mmHg. Medical records showed staff administered the medication on 10 separate occasions between February and June 2024 when the resident's blood pressure was dangerously low, ranging from 81 to 98 mmHg.
When blood pressure medications are given to patients with already low blood pressure, it can cause a precipitous drop that leads to dizziness, falls, fainting, or in severe cases, shock. This is particularly dangerous for elderly residents who are already at high risk for falls and injuries.
Insulin administration errors posed additional risks for a diabetic resident. The facility inappropriately withheld insulin when the resident's blood sugar levels were between 82-101 mg/dL, despite physician orders specifying insulin should only be held when blood sugar dropped below 80 mg/dL. This pattern occurred on eight documented occasions between April and June 2024.
Inadequate insulin administration can lead to dangerous blood sugar spikes, potentially causing diabetic ketoacidosis, increased infection risk, delayed wound healing, and long-term complications affecting the cardiovascular system, kidneys, and eyes. Proper glucose management is essential for preventing these serious health consequences.
Staff also administered antibiotics beyond the prescribed duration. One resident received 11 days of Cipro when the physician ordered only 10 days of treatment. Antibiotic overuse contributes to medication resistance and can disrupt beneficial bacteria in the digestive system.
Oxygen Therapy Deficiencies Affect Respiratory Care
The facility failed to provide proper oxygen therapy for two residents with serious respiratory conditions, administering incorrect flow rates that could have impacted their breathing and recovery.
One resident with asthma and respiratory failure was prescribed continuous oxygen at 2 liters per minute but consistently received 4 liters per minute - double the ordered amount. Another resident with pneumonitis and anxiety, who was receiving hospice care, was ordered 2 liters per minute but received 3 liters per minute.
Oxygen therapy requires precise dosing because too little oxygen can worsen respiratory distress and organ function, while excessive oxygen can be toxic to lung tissue and interfere with the body's natural breathing mechanisms. For hospice patients, comfort and symptom management through proper oxygen delivery is particularly important for quality of life.
Controlled Substance Accountability Lapses Raise Safety Concerns
Significant gaps in controlled substance tracking created potential for medication diversion and compromised resident care. The facility failed to maintain proper documentation when controlled medications were removed from secure storage.
Documentation showed controlled pain medications and anti-anxiety drugs were signed out for administration to residents on multiple occasions, but no corresponding records existed to confirm the medications were actually given to the residents. This occurred with oxycodone for pain management and diazepam for anxiety, both controlled substances with strict federal tracking requirements.
Proper controlled substance management protects residents by ensuring they receive prescribed pain relief and prevents potential medication diversion. Federal regulations require complete documentation from storage to administration to protect both residents and staff.
Infection Control and Safety Protocol Violations
Intravenous therapy safety was compromised when staff failed to change a loose IV dressing despite facility policy requiring weekly changes and immediate replacement when dressing integrity is compromised. The transparent dressing protecting a midline catheter insertion site remained loose for three consecutive days while the resident received intravenous antibiotics for a blood infection.
Compromised IV dressings create entry points for bacteria that can cause life-threatening bloodstream infections. This is particularly dangerous for residents already fighting infections, as additional bacterial exposure can lead to sepsis or treatment failure.
Food safety violations included kitchen staff working without proper beard coverings and sanitizer concentrations exceeding safe levels. The three-compartment sink sanitizer measured 500 parts per million on multiple occasions when manufacturer specifications required 200-400 ppm. Higher concentrations can cause chemical burns and other injuries.
Assessment Documentation Problems Affect Care Planning
The facility completed inaccurate resident assessments that form the foundation for care planning. These Minimum Data Set assessments contained coding errors that misrepresented residents' actual medical conditions and medication needs.
One assessment incorrectly indicated a resident had post-traumatic stress disorder when documentation showed they had never experienced traumatic events. Another failed to document that a resident was receiving anticoagulant medication, despite clear evidence of daily blood thinner administration.
Accurate assessments are essential because they determine staffing levels, care plans, and federal funding. Incorrect information can lead to inadequate care planning and inappropriate resource allocation.
Additional Issues Identified
Beyond the major violations, inspectors documented additional concerning practices including unsecured medication carts left unattended with expired medications still in circulation, unmarked medication cups containing unidentified pills, and failure to complete required head-to-toe assessments for a resident with cognitive impairment.
The facility's Quality Assurance Performance Improvement committee also failed to prevent recurring violations, with similar deficiencies cited in previous surveys indicating systemic problems with corrective action implementation.
These violations highlight the critical importance of strict adherence to medical protocols in nursing home settings, where residents depend on staff for proper medication management, infection prevention, and basic safety measures. Each violation represents a breakdown in the complex systems designed to protect vulnerable residents who cannot advocate for themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harmon House Care Center from 2024-06-27 including all violations, facility responses, and corrective action plans.
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