PORT SAINT LUCIE, FL - A federal inspection of Palm Garden of Port Saint Lucie completed in July 2024 identified significant care deficiencies involving inadequate monitoring of a resident who experienced substantial weight gain, progressive edema, and deteriorating health conditions over a five-month period before family members intervened to request hospital transfer.
Resident Experienced 16-Pound Weight Gain Without Intervention
Federal inspectors documented that a resident admitted to the facility on December 18, 2023, gained approximately 16 pounds over five months, representing a 13% increase in body weight. Despite nutritional notes in the progress records acknowledging the weight gain, staff recommendations simply stated to "continue the plan of care" without implementing additional interventions or investigating underlying causes.
The resident remained on a regular diet with no nutritional modifications despite consuming only 26-75% of meals. The medical record contained no explanation for the significant weight gain, which in skilled nursing settings often signals fluid retention, cardiac issues, or other serious underlying conditions requiring prompt evaluation.
Weight changes of this magnitude in elderly nursing home residents warrant thorough medical investigation. A 13% weight gain over five months, particularly when combined with reduced food intake, typically indicates fluid accumulation rather than nutritional gain. This pattern commonly suggests cardiac dysfunction, kidney problems, or medication side effects that require immediate physician assessment and intervention.
Edema Documentation Revealed Limited Follow-Up
On May 15, 2024, nursing staff documented that the resident had developed pitting edema bilaterally in the lower extremities. The provider was notified and ordered Lasix, a diuretic medication, at 20 milligrams to be administered each morning for three days.
However, inspectors found no further assessments documented in the nurses' notes regarding the edema after this initial observation. Neither physician nor nurse practitioner notes addressing the edema appeared in the medical record following the May 15 order.
Pitting edema—where pressing on swollen tissue leaves a visible indentation—indicates significant fluid accumulation in body tissues. When present in both lower extremities, this finding typically signals systemic issues such as heart failure, kidney disease, or venous insufficiency. Standard medical protocols require ongoing monitoring of edema, including daily assessment of severity, measurement of affected areas, and evaluation of response to diuretic therapy. A three-day course of medication without subsequent monitoring fails to meet accepted care standards.
Vital Signs Documentation Gap Spanned Months
The inspection revealed a particularly concerning gap in basic health monitoring. Inspectors found no evidence that vital signs were documented for this resident since March 4, 2024, despite a physician's order requiring vital sign checks twice daily on morning and evening shifts beginning March 5, 2024.
This documentation gap persisted until the day the resident was transferred out of the facility—a period spanning approximately two and a half months during which ordered vital sign monitoring apparently went unperformed or unrecorded.
Vital signs including blood pressure, heart rate, respiratory rate, and temperature provide essential baseline information for detecting health changes in nursing home residents. For a resident with hypertension and developing edema, regular blood pressure monitoring is particularly critical. Elevated readings can indicate worsening cardiac function, while changes in heart rate or respiratory rate may signal declining cardiopulmonary status. The absence of this fundamental monitoring data prevented early detection of the resident's deteriorating condition.
Family Intervention Prompted Hospital Transfer
On May 19, 2024, the resident was transferred to a higher level of care following a family request. According to the inspection report, family members expressed concern because the patient was "not speaking clearly and all extremities were red and swollen."
Review of the medical record revealed no assessments related to the edema, respiratory status, or speech concerns documented prior to the assessment conducted by the weekend supervisor on May 19—and that assessment occurred only after the family's request to send the resident to the hospital.
The resident's most recent quarterly Minimum Data Set assessment, completed April 21, 2024, indicated the resident had clear speech and could make herself understood. No subsequent nursing notes documented any changes to the resident's speech patterns, despite the family's observation of unclear speech prompting their intervention.
Speech changes in elderly patients can indicate serious conditions including stroke, severe infection, metabolic disturbances, or cardiac events affecting brain perfusion. The apparent lack of staff recognition or documentation of this change until family members raised concerns represents a significant monitoring failure.
Care Plan Existed But Implementation Fell Short
Inspectors reviewed the resident's care plan dated January 29, 2024, which addressed potential complications related to hypertension diagnosis and diuretic use. The plan specifically instructed staff to observe and report to the nurse or physician any edema, headache, tingling or numbness in extremities, dizziness, pain, lightheadedness, blurred vision, palpitations, urinary retention, shortness of breath, or generalized weakness.
The care plan also directed that if edema was present, staff should encourage the resident to elevate the affected extremity as tolerated. However, no additional care plans related to the resident's edema were developed even after the condition was identified on May 15, 2024.
Effective care planning requires updating interventions when new conditions emerge. When a resident develops bilateral pitting edema significant enough to warrant diuretic therapy, care plans should be revised to include specific monitoring protocols, elevation schedules, fluid intake tracking, and daily weight measurements to assess treatment effectiveness.
Additional Issues Identified
The inspection also documented that on March 25, 2024, nursing progress notes revealed a rash on the right side of the resident's back. Inspectors found no physician notification or follow-up pertaining to this skin finding documented in the medical record.
Skin changes in nursing home residents require prompt evaluation to rule out infections, allergic reactions, pressure-related injuries, or other conditions requiring treatment. The absence of documented follow-up for this finding reflects broader patterns of incomplete assessment and monitoring identified throughout the inspection.
The deficiency was classified at a level indicating minimal harm or potential for actual harm, affecting few residents. Palm Garden of Port Saint Lucie is required to submit a plan of correction addressing the identified deficiencies to maintain participation in Medicare and Medicaid programs.
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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