The Iowa Department of Inspections, Appeals and Licensing has issued a warning to Elaine Allison, a licensed practical nurse, after a resident of the Oskaloosa Care Center died following a medical emergency. According to the state board, Allison was working at the facility on September 6, 2025, when a resident became unresponsive. The board alleges that a registered nurse asked Allison to call an ambulance and verify the resident’s “code status” to determine whether lifesaving measures should be taken. Allison forgot to call the ambulance and incorrectly identified the resident as “no code,” meaning no cardiopulmonary resuscitation or other lifesaving measures should be taken. As a result, no CPR was performed, and the man was later pronounced dead.
A later review of the resident’s file indicated the man was a “full code” patient who had requested lifesaving measures. The board charged Allison with committing an act that might adversely affect a patient’s welfare and agreed to settle the matter by issuing her a warning and directing her to complete 30 hours of educational training. The Iowa Capital Dispatch was not able to reach Allison for comment.
State inspectors reported that the deceased resident’s door did not have the correct sticker indicating his code status due to recent changes in room assignments. On the morning of the incident, employees entered the man’s room and saw him slumped over in his recliner, gasping and sweating profusely. One worker left the room to obtain equipment to check the man’s vital signs, at which point the man’s eyes rolled back in his head as if he was having a seizure. The director of nursing arrived and instructed Allison to call an ambulance and verify the resident’s code status.
According to inspectors, Allison told investigators she had been “flustered” during the incident and had been “working on” calling 911 while also trying to locate the home’s crash cart, which had a defibrillator. Allison said she “probably” would have initiated CPR had she known the resident was a full-code patient. The state agency charged the facility with failing to carry out CPR in accordance with a resident’s wishes and for workers’ inability to locate the facility’s crash cart in an emergency. The state proposed, but held in suspension, a $10,000 fine against the care facility. The federal Center for Medicare and Medicaid Services later fined the home $45,354.
