An Iowa nursing home is in hot water after state officials said a patient died when staff failed to provide basic emergency care as she struggled to breathe.
Kingsley Specialty Care in Kingsley, Iowa, was hit with a $10,500 fine after the Iowa Department of Inspections, Appeals and Licensing found the facility failed to provide CPR to a patient who was having serious breathing problems.
According to state records obtained by the Iowa Capital Dispatch, the unnamed female patient told staff on May 9 that she was having trouble breathing and wanted to be taken to a hospital.
A registered nurse who responded later told inspectors that she tried to assemble an oxygen delivery device but “couldn’t find all the working parts.” The nurse then went to the facility’s basement to find the missing parts.
While she was gone, the patient’s condition quickly worsened.
A nurse’s aide who stayed in the room tried “several times” to call the nurse back, but the nurse allegedly did not respond. The aide eventually had to yell for her.
By the time the nurse returned, the patient had become unresponsive.
The nurse and aide reportedly did not know whether the patient had a do-not-resuscitate order. After checking at the nurse’s station, they confirmed the woman was a “full-code” patient, meaning CPR should have been performed.
The aide then began chest compressions, while another aide called 911.
The nurse checked the patient’s pulse and allegedly said the woman “was gone.” According to inspectors, the nurse never performed any lifesaving measures.
When inspectors questioned the aide, she said she expected the nurse to take control of the emergency. Instead, the aide said the nurse “kind of acted like she was in shock.”
The nurse later told inspectors she was “flustered” and did not think to retrieve the crash cart or take immediate action.
Emergency medical technicians arrived about 10 minutes after the 911 call. When they entered the patient’s room, they saw an employee they believed to be a nurse standing at the foot of the bed.
The EMTs said they asked why no one was giving the patient CPR. The employee allegedly responded that she was “giving her some air.”
The EMTs also told inspectors they did not see normal respiratory support equipment in the room, such as an Ambu bag, bottled oxygen, or a crash cart.
The patient was taken to a hospital, where she was pronounced dead.
State officials cited the facility for failing to provide basic CPR to the patient. The $10,500 fine also included a separate violation involving a nurse who reportedly took a patient’s medication.
According to the Iowa Capital Dispatch, the Iowa Department of Inspections, Appeals and Licensing typically suspends state fines until a federal agency decides whether it will impose its own penalty.
