BELLEVILLE, IL - Federal inspectors found serious deficiencies in pressure ulcer prevention at Belleville Healthcare Center during a March 2025 inspection, citing the facility for allowing a vulnerable resident to develop two new Stage 2 pressure injuries due to inadequate repositioning care.
Extended Immobility Leads to New Pressure Injuries
The inspection documented that a resident with paranoid schizophrenia and existing Stage 3 pressure ulcer remained in the same position for hours without proper repositioning. Surveyors observed the resident lying on his left side continuously from 8:25 AM through 11:33 AM on March 25, 2025 - a period exceeding three hours without position changes.
The facility's wound nurse discovered two new pressure injuries during routine care. One injury occurred on the resident's left ischial area, measuring approximately 2 centimeters in diameter with surrounding erythema extending 5-6 centimeters. The second injury developed on the left hip, measuring 0.5 centimeters with erythema covering 4 centimeters by 1.5 centimeters.
Catheter Tubing Creates Additional Risk Factor
The wound nurse determined that one pressure injury resulted directly from the resident lying on top of his catheter tubing while positioned on his left side. The injury showed "the exact indentation" of the tubing, according to the inspection report.
"It could have been caused by excessive time being on top of the tubing without being repositioned," the wound nurse stated during the inspection.
This finding highlights a critical aspect of pressure injury prevention - ensuring residents are not positioned on medical devices or foreign objects that can create pressure points.
Medical Significance of Pressure Injury Prevention
Pressure injuries develop when sustained pressure reduces blood flow to tissue areas, typically over bony prominences. For immobile residents, regular repositioning every 1-2 hours is essential to prevent tissue breakdown. The areas most vulnerable include the tailbone (coccyx), hip bones, and shoulder blades.
Stage 2 pressure injuries involve partial-thickness skin loss extending into the dermis, appearing as shallow open ulcers or intact blisters. Without proper intervention, these injuries can progress to deeper stages involving fat, muscle, and bone, potentially leading to serious complications including infection and sepsis.
Facility Policies Existed But Implementation Failed
Belleville Healthcare Center maintained written policies requiring proper repositioning for at-risk residents. The facility's turning and repositioning policy, dated August 2024, specified that residents at risk of pressure injuries must be turned and repositioned unless medically contraindicated.
The policy explicitly prohibited positioning residents on medical devices or foreign objects and required avoiding placement on existing pressure injury sites. For chair-bound residents unable to make position changes independently, repositioning was required every hour.
Staff Training and Expectations Clear
Multiple staff members interviewed during the inspection demonstrated understanding of proper repositioning protocols. A licensed practical nurse explained that turning schedules prevent skin breakdown, typically occurring every 1-2 hours. A certified nursing assistant noted that failure to turn residents would likely cause skin breakdown.
The Assistant Director of Nursing confirmed expectations that nursing staff turn residents requiring repositioning at least every two hours, stating that failure to meet this timeframe puts residents at risk for skin breakdown.
Resident Communication Reveals Care Gaps
The affected resident provided insight into his experience during the inspection. He reported that staff sometimes repositioned him roughly, causing pain, but indicated willingness to be turned when staff were gentle.
"No one asked or offered to turn me yesterday," the resident stated regarding March 25, 2025. "I was on my left side for most of the day."
His roommate corroborated the account, stating he didn't observe staff coming in to turn the resident frequently.
Existing Pressure Injury Complicated Care
The resident's care was complicated by an existing Stage 3 pressure injury to his coccyx, which had been present for approximately six months. The wound nurse explained that this injury initially developed from moisture exposure, as the resident "likes to pour liquids on himself leaving him wet."
The existing wound required specialized care including wound vacuum therapy, adding complexity to positioning decisions. However, the development of additional pressure injuries indicated insufficient attention to pressure redistribution across all vulnerable areas.
Regulatory Response and Oversight
The inspection was conducted as part of a complaint investigation, indicating external concerns about care quality had reached regulatory authorities. The facility received citations under federal regulations governing pressure ulcer prevention and treatment.
Federal nursing home regulations require facilities to provide care and services to maintain each resident's highest practicable physical and mental well-being. This includes implementing comprehensive care plans to prevent complications like pressure injuries in vulnerable residents.
Industry Standards for Prevention
Best practices for pressure injury prevention include comprehensive skin assessments, individualized turning schedules, appropriate support surfaces, and staff education. Risk factors such as immobility, cognitive impairment, and existing wounds require enhanced monitoring and intervention.
The resident's care plan documented his need for assistance with positioning and transfers, indicating staff awareness of his vulnerability. However, the development of new injuries suggests gaps between written protocols and actual implementation.
Broader Implications for Resident Safety
Pressure injury prevention represents a fundamental aspect of nursing home care quality. The development of facility-acquired pressure injuries often indicates broader systemic issues with staffing, training, or care coordination.
The inspection findings raise questions about supervision and accountability systems designed to ensure consistent implementation of care plans. The extended observation period during which the resident remained in one position suggests potential staffing adequacy concerns or insufficient monitoring protocols.
Resident Rights and Quality Assurance
Federal regulations establish residents' rights to receive professional standards of care that promote maintenance or enhancement of their quality of life. The development of preventable pressure injuries represents a failure to meet these standards and protect vulnerable residents from harm.
Quality assurance programs in nursing homes should include regular monitoring of pressure injury rates, analysis of contributing factors, and implementation of corrective actions to prevent future occurrences.
The Belleville Healthcare Center inspection demonstrates the ongoing challenges nursing homes face in consistently implementing evidence-based care practices for their most vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Integrity Hc of Belleville from 2025-03-28 including all violations, facility responses, and corrective action plans.
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