F0880

D

Failure to Post Enhanced Barrier Precautions Signage for Resident on EBP

North Hollywood, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to Enhanced Barrier Precautions (EBP) for one resident. The resident was admitted with diagnoses including cerebral infarction, an unstageable pressure ulcer of the right upper back, and a gastrostomy tube, and had severely impaired cognitive skills for daily decision making. Physician orders directed that the resident be placed on EBP due to the presence of the gastrostomy tube, and the resident’s care plan, revised later, documented EBP related to both the gastrostomy tube and a stage 4 pressure ulcer. The facility’s EBP policy required staff to post an EBP sign on the resident’s room door to inform caregivers of the appropriate tasks requiring PPE use.

During observation, surveyors noted there was no EBP sign posted outside the resident’s room, despite the resident being on EBP. An LVN confirmed the resident was on EBP due to the gastrostomy tube and pressure ulcer and stated that EBP signage identifies required precautions and PPE to be used when providing care. The LVN indicated the IPN was responsible for ensuring EBP signage was posted and acknowledged that failure to post signage could result in staff not wearing appropriate PPE, increasing the risk for transmission of infection. The IPN confirmed the resident was on EBP and stated that if signage was not posted, staff might not implement appropriate PPE use, potentially contributing to the spread of infection. The DON also stated that an EBP sign should be posted outside the resident’s room to notify staff and visitors of required precautions and confirmed the facility failed to ensure the EBP signage was posted, in contradiction to the facility’s written EBP policy.