Failure to Post Enhanced Barrier Precaution Signage for Resident With Tracheostomy
Penalty
Summary
Facility staff failed to implement the ordered enhanced barrier precautions (EHB) for a resident with a tracheostomy. The resident, admitted with diagnoses including tracheostomy status and a feeding tube, had a physician’s order for "Enhanced Precaution r/t Trach every shift" active since 11/04/25. The discharge MDS documented short-term memory loss and moderately impaired cognitive abilities for daily decision-making. During surveyor rounds from 1/12/26 through 1/14/26, no EHB signage was observed on the door or wall of the resident’s room, despite the active order and the presence of a tracheostomy and enteral feeding at the bedside. Staff interviews confirmed that EHB precautions were required for residents with tracheostomies, feeding tubes, PICC lines, or dialysis, and that staff had been in-serviced on following posted EHB signs for high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, device care, and wound care. A CNA described the need to follow EHB signage for such residents, and an RN acknowledged that the resident with a tracheostomy should have been on EHB precautions and that signage should have been posted, explaining that the resident had been moved to another room the previous day and no new signage was put up. Throughout the survey, EHB signs were observed on all floors for other residents, but not for this resident, and facility leadership did not provide additional information to refute the absence of signage.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.