Aviata at Saint Lucie: Dialysis Neglect Death - FL
Resident #1 arrived at Aviata at Saint Lucie on July 23 with end-stage renal disease, chronic kidney disease, congestive heart failure, and diabetes. His physician ordered hemodialysis at the facility's onsite clinic every Monday, Wednesday, and Friday, along with vital signs before and after each treatment and daily assessment of his chest catheter for bleeding or infection.
The resident never received a single dialysis treatment during his six-day stay.
Staff prepared him for dialysis on July 24. Certified nursing assistant Staff B cleaned the resident and placed a pad under him so "he would be ready to go to dialysis when the dialysis nurse came to pick the resident up." She notified the nurse around 12:30 PM that the resident was ready because "no one had shown up yet." When Staff B returned from lunch at 2:30 PM, she found the resident still in bed exactly as she had left him.
"Staff B reminded the nurse that she had him ready for dialysis and stated the nurse was aware the resident was a dialysis patient," the inspection report states.
No dialysis occurred on July 26. Licensed practical nurse Staff D was assigned as the resident's day shift nurse but left no nursing progress note documenting any assessment that day. Staff E, a nursing assistant working that Friday, said she "was not informed Resident #1 needed to go to dialysis on 07/26/24."
By July 29, the resident had missed three scheduled dialysis sessions. Staff B again prepared him for treatment, but "the resident was not feeling well that day." When dialysis staff finally arrived to assess him, they determined he was too unstable for the procedure and contacted his physician for orders to transfer him to the emergency department.
At 4:45 PM on July 29, Staff D documented that Resident #1 was "sent out to the ED to get dialyzed per physician order, due to the resident not receiving dialysis for 7 days."
The resident arrived at the hospital via ambulance at 5:16 PM with severe hyperkalemia and uremia. His potassium level measured 7.6, critically high on a scale where normal ranges from 3.5 to 5.2. His blood urea nitrogen level was 155, more than seven times the upper limit of normal. Both conditions result directly from kidney failure when dialysis treatments are missed.
Hospital records show the resident also had sepsis from a large stage 3 pressure ulcer and chronic bone infection in his sacral region. He was started on IV antibiotics but had "a poor prognosis per the hospitalist notes." The resident died in the hospital on July 31, two days after his emergency transfer.
The breakdown occurred in the communication between the nursing home's admissions staff and the dialysis provider. Admissions personnel Staff A said she sent the resident's information to the dialysis provider on June 25, before his initial admission in July. When the resident was readmitted on July 23, Staff A said the information was sent again.
But the dialysis provider's director of nursing, Dialysis Staff H, told investigators she "had not received any communication from the nursing home regarding dialysis for Resident #1 until it was requested on 07/29/24." The communication only came after a dialysis nurse informed her supervisor that there was a resident at the facility who needed dialysis.
Staff A claimed her coworker Staff I had faxed the information on July 23 due to internet issues preventing email. However, Staff A admitted she "is not able to provide documentation of the fax being sent and confirmation of receipt to the Dialysis DON."
The nursing home's director of nursing told inspectors on August 7 that she was aware the resident had not received dialysis since his July 23 admission and was waiting for more information from Staff A, who was not in the facility that day.
During the entrance conference, inspectors requested the facility's policy for dialysis services. The director of nursing stated "they did not have a policy for dialysis services and did not have a policy for the process of new admissions requiring dialysis services."
Licensed practical nurse Staff C, who was the resident's nurse on July 24, told investigators she "did not remember what happened on 07/24/24 with this resident regarding dialysis." She explained that she would only know if a resident needed dialysis "if told in report from the previous shift or the dialysis nurse would come to pick them up."
Staff C added she "does not remember the day and that she was doing good to remember yesterday."
The facility's medical director explained the consequences of missing dialysis treatments during an October interview: "The implications for a resident who does not have needed dialysis treatment can lead to fluid overload causing dyspnea and cardiac issues such as heart failure. It can also cause increased potassium levels leading to cardiac concerns."
Dialysis Staff G, a certified clinical hemodialysis technician employed by the dialysis provider, confirmed that he and his colleague were at the facility during the resident's stay but "were not informed of the need for dialysis until Monday, 07/29/24." On that day, the resident "was very unstable, so the decision was made to send the resident to the ED for dialysis."
The resident's care plan, dated July 25, specifically listed interventions including encouraging the resident to attend scheduled dialysis appointments and monitoring for signs of bleeding, infection, bacteremia, and septic shock. None of these interventions prevented the communication breakdown that left him without treatment.
Staff B, who cared for the resident on both July 24 and July 29, described his deteriorating condition on the final day: "Staff B further stated the resident was not feeling well that day and the resident ended up being transferred to the hospital."
The inspection found the facility in immediate jeopardy for neglect. Federal inspectors determined that the failure to provide necessary dialysis services caused physical harm to the resident, contributing to the severe complications that led to his hospitalization and death.
Following the inspection, the facility changed dialysis providers, implemented electronic confirmation systems for admissions, installed a communication box outside the dialysis room, and required nursing assistants to transport residents to and from dialysis treatments. Staff received mandatory education on abuse and neglect policies.
The resident's death certificate would likely list multiple causes, but the hospital records document the direct medical consequences of missing seven days of dialysis: critically high potassium levels that threaten heart function and toxic waste buildup that occurs when kidneys fail and artificial filtration is not provided.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At Saint Lucie from 2024-08-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AVIATA AT SAINT LUCIE in FORT PIERCE, FL was cited for immediate jeopardy violations during a health inspection on August 7, 2024.
Resident #1 arrived at Aviata at Saint Lucie on July 23 with end-stage renal disease, chronic kidney disease, congestive heart failure, and diabetes.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.