PORT SAINT LUCIE, FL - Federal inspectors found that Palm Garden of Port Saint Lucie failed to document vital signs for a resident for more than two and a half months despite a standing physician order requiring twice-daily monitoring, according to a complaint survey completed on July 25, 2024.
Months Without Vital Sign Documentation
The inspection report details a series of monitoring failures involving Resident #303, who was admitted to the facility on December 18, 2023. The resident's physician had ordered vital signs to be checked twice daily — once on the morning shift and once on the evening shift — beginning March 5, 2024.
However, investigators found no evidence that vital signs were documented from March 4, 2024, through the resident's transfer out of the facility on May 19, 2024. The only vital sign readings recorded during that period came on the day the resident was ultimately sent to the hospital.
Vital signs — including blood pressure, heart rate, respiratory rate, and temperature — are fundamental clinical measurements that allow care teams to detect early warning signs of deterioration. For a resident with a diagnosis of hypertension who was later placed on a diuretic medication, regular vital sign monitoring is particularly important. Blood pressure readings help determine whether medications are effective, while other measurements can reveal complications such as fluid overload or cardiac stress.
The failure to perform these ordered checks meant that clinicians had no baseline data to compare against when the resident's condition began to change.
Unexplained Weight Gain and Worsening Edema
During her five-month stay at the facility, Resident #303 gained 16 pounds — approximately 13% of her body weight. Nutritional notes in the progress record acknowledged the weight gain and indicated the plan of care should continue, with the last such note dated May 5, 2024. The resident was on a regular diet with no additional nutritional interventions and was consuming only 26 to 75% of meals.
Inspectors found no documented explanation for the weight gain. In a clinical setting, rapid or unexplained weight gain in an elderly resident — particularly one with hypertension — can be an indicator of fluid retention, which may signal cardiac, renal, or hepatic problems. When combined with the edema that appeared later, the pattern warranted closer medical investigation.
On May 15, 2024, a nursing progress note documented that the resident had developed pitting edema bilaterally in the lower extremities. The provider was notified and ordered Lasix (furosemide), a diuretic, at 20 mg by mouth every morning for three days. Pitting edema — where pressing on swollen tissue leaves a visible indentation — indicates significant fluid accumulation in the tissues.
Despite this finding, no further assessments of the edema were documented in the nursing notes. There were no physician or nurse practitioner notes in the record addressing the edema beyond the initial Lasix order.
Family Intervenes as Condition Deteriorates
Four days after the short course of Lasix ended, on May 19, 2024, the resident's family requested a transfer to a higher level of care. The family reported that the resident was not speaking clearly and that all extremities were red and swollen.
The development of speech changes is clinically significant. The resident's most recent quarterly Minimum Data Set assessment, completed April 21, 2024, indicated clear speech with the ability to make herself understood. No nursing notes documented any changes to the resident's speech between that assessment and the family's intervention.
Inspectors noted that the facility did not conduct any assessments related to the edema, respiratory status, or speech concerns until after the family requested the hospital transfer. At that point, a weekend supervisor performed an assessment.
Care Plan Gaps
The facility's own care plan for Resident #303, dated January 29, 2024, included interventions for potential complications related to hypertension and diuretic use. Those interventions called for staff to observe and report edema, numbness or tingling in extremities, shortness of breath, and generalized weakness to the nurse or physician.
Despite these written protocols, the care plan was not followed in practice. No additional care plans were created to address the resident's developing edema, and the existing interventions calling for observation and reporting were not carried out as documented.
Inspectors also found that a rash on the right side of the resident's back, noted in a March 25, 2024 nursing progress note, had no physician notification or follow-up documented.
What Standards Require
Under federal regulation F-684, nursing facilities must ensure that each resident receives treatment and care in accordance with professional standards of practice. This includes following physician orders, conducting appropriate assessments when a resident's condition changes, and communicating findings to the medical team.
The deficiency was classified at a level indicating minimal harm or potential for actual harm, affecting few residents. Palm Garden of Port Saint Lucie was required to submit a plan of correction to the state survey agency.
The full inspection report is available through the Centers for Medicare & Medicaid Services. Readers can review the complete findings for additional details about this facility's compliance history.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palm Garden of Port Saint Lucie from 2024-07-25 including all violations, facility responses, and corrective action plans.
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