GRAND JUNCTION, CO - Federal inspectors found Eagle Ridge Post Acute failed to notify family members after a resident's fall and denied recommended rehabilitation services to a woman seeking to maintain her independence.
Family Left Uninformed After Resident Fall
A 68-year-old resident experienced an unwitnessed fall on February 10, 2024, while transferring from her bed to her mobility scooter. Staff found her sitting on the floor between the bed and scooter with no apparent injuries or head trauma.
However, facility documentation revealed a critical communication breakdown. While policy required notification of the resident's power of attorney and emergency contact, records show only the resident herself was informed of the incident at 6:47 a.m. The resident's representative, who served as both power of attorney and emergency contact, was never contacted about the fall.
"The resident representative said she was the resident's power of attorney and emergency contact and should have been made aware of and notified when the resident fell," according to the inspection report.
The facility's own Director of Nursing acknowledged the error during the federal inspection. "The DON said the notification of the fall should not have been the resident but the resident's family. She said the resident's emergency contact should have been notified after the fall."
Recommended Therapy Services Denied
In a separate violation, inspectors found a 65-year-old resident with chronic obstructive pulmonary disease, diabetes, and generalized muscle weakness was denied restorative therapy services despite professional recommendations.
The woman, who required substantial assistance with transfers, showers, toileting and personal hygiene, told inspectors she felt increasingly weak since her readmission and wanted to work toward greater independence.
"Resident #54 said she felt both worried and sad that she was becoming more dependent on staff for assistance when she would rather work with the therapy department to keep as much of her independence as possible," the report stated.
Physical therapy services ended in January 2024 due to lack of payment coverage, but therapists specifically recommended a restorative therapy program to maintain function. The discharge summary documented that both the resident and facility staff received education on positioning, pressure relief techniques, safe transfers, and compensatory strategies.
Despite these clear recommendations, no physician's order for restorative nursing services was ever written, and the resident received no maintenance therapy.
Staff Knowledge Gaps Identified
The inspection revealed concerning gaps in staff understanding of restorative care protocols. A certified nurse aide told inspectors she "did not know what restorative therapy services were," while a licensed practical nurse was "not aware of any restorative therapy services being provided in the building."
The facility's Director of Rehabilitation acknowledged the importance of restorative services, stating they "would have helped prevent physical decline" for the affected resident. However, communication breakdowns prevented implementation of recommended care.
Medical Significance of Violations
Falls in nursing homes represent serious safety concerns, particularly for residents using mobility devices. Proper family notification ensures continuity of care and allows loved ones to monitor for delayed complications that may not be immediately apparent.
Restorative therapy serves as a critical bridge between active rehabilitation and custodial care. These programs focus on maintaining existing function and preventing decline in residents who no longer qualify for traditional therapy services. Without such intervention, residents often experience progressive weakness, increased fall risk, and loss of independence.
The combination of muscle weakness, diabetes, and COPD places residents at heightened risk for functional decline. Restorative programs typically include range of motion exercises, strength maintenance activities, and mobility training designed to preserve independence and quality of life.
Administrative Response
Facility leadership acknowledged systemic issues during the inspection. The nursing home administrator identified restorative therapy as an area requiring improvement within their quality assurance program, while the Director of Nursing reported efforts to educate staff on proper protocols.
Management cited significant turnover in the physical therapy department as contributing to communication failures, though inspection records showed clear written recommendations had been provided to nursing staff months earlier.
The facility planned to hire a dedicated restorative therapy aide beginning in July 2024 to address service gaps and ensure proper implementation of maintenance programs for residents requiring ongoing support.
These violations highlight the importance of comprehensive communication protocols and staff education in maintaining safety and quality of care for vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Eagle Ridge Post Acute from 2024-06-12 including all violations, facility responses, and corrective action plans.
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