ALBANY, NY - Hudson Park Rehabilitation and Nursing Center was cited for several significant health and safety violations during a June 2024 state inspection, including failures in wound care management, improper oxygen administration, and infection control breaches that put residents at risk.
Serious Wound Care Management Failures Put Resident at Risk
The most concerning violation involved a resident who sustained a fall-related wound that was inadequately monitored and documented for 14 days. The case reveals a cascade of clinical failures that allowed a minor injury to worsen significantly.
On May 22, 2024, Resident #524 was found on the floor near the nurse's station with a lacerated wound on their right shin measuring 1.4 centimeters by 0.6 centimeters. While the nursing staff applied initial treatment with a steri strip and wound dressing, subsequent care fell far short of medical standards.
The wound more than doubled in size over the following two weeks, growing from 1.4 centimeters to 4 centimeters in length. When inspectors observed the resident on June 5, the wound appeared approximately 7.62 centimeters long and 1.27 centimeters wide with thickened, reddened edges.
Most troubling was the complete absence of required wound care documentation. Despite standing physician orders requiring wound dressing changes every three days, nursing staff failed to document any wound care activities from May 22 through June 5, 2024. The resident's care plan wasn't updated to address the skin integrity issue until 14 days after the injury occurred.
Proper wound care protocols require immediate assessment, accurate measurement, appropriate treatment, regular monitoring, and timely documentation. Wounds should be measured using standardized tools, not improvised methods. The registered nurse who initially assessed this wound admitted to using "the side of a piece of gauze to measure the size" and acknowledged lacking proper training in wound measurement techniques.
Delayed wound care can lead to serious complications including infection, tissue death, and prolonged healing times. Open wounds provide entry points for bacteria, and inadequate monitoring can allow treatable conditions to become life-threatening. The facility's wound nurse noted that tracking wounds for changes and signs of infection is essential for preventing complications.
Oxygen Therapy Administered Incorrectly
Two residents received oxygen therapy at incorrect levels, violating fundamental respiratory care standards. Oxygen is classified as a medication and must be administered precisely as prescribed by physicians.
Resident #98 had a physician order for continuous oxygen at 4 liters per minute but was observed receiving only 2-3 liters per minute on multiple occasions during the inspection. This 25-50% reduction in prescribed oxygen could result in inadequate blood oxygen levels, potentially causing confusion, shortness of breath, or other serious complications.
Resident #20 was receiving oxygen therapy despite having no physician orders for oxygen treatment whatsoever. The resident had been prescribed oxygen informally after requesting it during a recent pneumonia episode, but no formal medical order existed in their treatment records.
Proper oxygen therapy requires specific physician orders detailing the flow rate, delivery method, and frequency. Healthcare professionals emphasized that oxygen levels must be maintained within prescribed parameters to ensure adequate oxygenation without risking oxygen toxicity. Too little oxygen can cause hypoxemia, while excessive oxygen can lead to respiratory depression in certain patients.
Infection Control Breaches Create Cross-Contamination Risks
Multiple observations revealed serious lapses in infection prevention protocols that could facilitate disease transmission between residents. Staff members repeatedly violated basic infection control principles designed to prevent the spread of communicable diseases.
Inspectors documented a resident assistant wearing the same pair of gloves while moving between multiple resident rooms, including a room under Enhanced Barrier Precautions. The staff member touched clean linen carts and entered several rooms without changing gloves, creating significant cross-contamination risks.
Another serious incident involved a certified nurse aide entering a room designated for Contact Precautions without donning required protective equipment. "The room was under contact precautions, and I went into the room to assist, and should have gowned up," the aide acknowledged when questioned.
Additional violations included staff failing to perform hand hygiene after removing gloves, leaving soiled gloves scattered in resident rooms, and handling contaminated materials without proper sanitization procedures.
Contact Precautions are implemented when residents have infections that can spread through direct contact. These protocols require staff to wear gowns and gloves before entering rooms and to remove all protective equipment before leaving. Failure to follow these procedures can spread antibiotic-resistant bacteria, respiratory infections, and other serious diseases throughout the facility.
The Centers for Disease Control and Prevention emphasizes that proper hand hygiene and personal protective equipment use are fundamental to preventing healthcare-associated infections. These basic measures become even more critical in nursing home settings where residents often have compromised immune systems.
Medical Context and Industry Standards
These violations represent failures in fundamental healthcare practices that nursing homes are required to maintain. Wound care management requires systematic assessment, appropriate treatment, regular monitoring, and comprehensive documentation to prevent complications and ensure healing.
Oxygen therapy administration follows the same principles as medication management, requiring precise adherence to physician orders and regular monitoring of patient response. Healthcare professionals must understand that oxygen is a drug with specific indications, contraindications, and potential side effects.
Infection control protocols exist to break the chain of disease transmission in healthcare settings. These evidence-based practices have been developed through decades of research and are essential for protecting vulnerable populations like nursing home residents.
Additional Issues Identified
The inspection revealed several other concerning violations:
Food Safety Problems: The main kitchen's dishwashing machine was operating at 150 degrees Fahrenheit instead of the required 180 degrees, potentially failing to properly sanitize dishes and utensils. Kitchen equipment, floors, and storage areas showed evidence of food particles, dirt, and grime buildup.
Hearing Aid Access Failures: One resident had been without a functioning hearing aid since December 2023 despite care plan goals to maintain adequate communication. Scheduled audiology consultations were not documented, leaving the resident severely hearing impaired.
Physical Safety Hazards: Handrails were loose and improperly secured on multiple floors, creating fall risks for residents who depend on these supports for mobility and stability.
These violations collectively demonstrate systemic issues in quality assurance and staff training that require immediate attention to ensure resident safety and wellbeing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hudson Park Rehabilitation and Nursing Center from 2024-06-12 including all violations, facility responses, and corrective action plans.
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