Resident 303 at Palm Garden of Port Saint Lucie arrived at the hospital emergency department on May 19 with a body temperature of 91.9 degrees, mumbled speech, and severe swelling throughout all extremities. Emergency physicians diagnosed myxedema coma, a life-threatening condition caused by severe hypothyroidism that required immediate intensive care unit admission.
The resident's extremities were mottled, cold, and pulseless with associated cyanotic changes, according to hospital records reviewed by inspectors. Emergency medical services reported the mumbled speech had persisted for over a week, along with a diffuse pinpoint rash covering all extremities.
Nobody documented any of it.
Inspectors found no nursing assessments or progress notes addressing the resident's changed speech patterns, full-body swelling, or visible rash. The facility's Director of Nursing confirmed staff do not necessarily document daily assessments on long-term care residents and confirmed vital signs were not recorded in the resident's record.
Myxedema coma occurs when waste products and fluids accumulate in body tissues due to severely low thyroid function. The condition causes extreme hypothermia and depressed mental status. Unlike typical fluid retention, the swelling cannot be resolved with diuretics and requires treating the underlying thyroid dysfunction.
The resident had physician orders for vital signs every shift, day and evening. While medication administration records showed staff signed off on completing vital signs, no actual measurements were documented after March 4. The only vital signs recorded were taken during the emergency transport to the hospital.
A separate diabetic resident faced dangerous blood sugar swings while staff repeatedly missed required physician notifications and blood glucose monitoring. Resident 36's blood sugar dropped to 53 mg/dl on July 6 and 50 mg/dl on July 17, both well below the 60 threshold requiring immediate physician contact.
Staff documented holding diabetes medication due to the dangerously low reading on July 17 but never recorded notifying the physician as ordered. The resident's physician had specifically ordered staff to "call MD for blood sugar under 60."
The diabetic resident's blood glucose monitoring showed erratic patterns with multiple missed testing times. Required 6:30 AM blood sugar checks were skipped on July 17, 19, 21, and 24. Without recorded glucose levels, staff could not administer sliding-scale insulin as prescribed.
The resident's readings swung wildly during the week before inspection. On July 19, blood sugar measured 257 at 4:30 PM after no morning reading was taken. The next day showed a morning reading of 216 followed by 269 at 11:30 AM.
When confronted about the missing documentation during the July 25 inspection, the facility's primary care physician approached inspectors to claim staff had actually notified him about low blood sugar episodes. The physician stated he was removing the notification order "because the resident's blood sugar has been stable."
The inspection also revealed respiratory care violations affecting two residents. Staff failed to assess breathing status before and after administering nebulizer treatments, despite facility policy requiring respiratory evaluations including breath sounds, cough effort, heart rate, and respiratory rate.
Resident 14, diagnosed with chronic obstructive pulmonary disease and other respiratory conditions, received twice-daily albuterol nebulizer treatments throughout July. No pre-treatment or post-treatment respiratory assessments were documented.
Resident 303 received nebulizer treatments on four occasions in March for wheezing. Staff administered the respiratory medications without documenting any evaluation of the resident's breathing status before or after treatment.
The facility's own nebulizer policy, updated in July 2023, explicitly requires evaluating respiratory status before administering medications and reviewing "pertinent lab results, as indicated." The policy also mandates post-treatment evaluation of breath sounds, cough effort, and respiratory rate.
All violations were classified as causing minimal harm or potential for actual harm affecting few residents. The inspection was conducted in response to complaints about the facility's care practices.
Palm Garden of Port Saint Lucie houses residents with complex medical conditions requiring careful monitoring and prompt responses to changing symptoms. The missed assessments and documentation failures represent breakdowns in basic nursing care protocols designed to prevent medical emergencies.
The resident who developed myxedema coma spent over a week displaying obvious symptoms while staff signed off on assessments they never completed. By the time emergency responders arrived, the person required immediate hospitalization in critical condition.
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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