An Iowa nursing home has been cited by state officials after a resident died when staff failed to initiate cardiopulmonary resuscitation (CPR), could not locate emergency equipment, and neglected to call for an ambulance.
The Iowa Department of Inspections, Appeals, and Licensing (DIAL) determined that the Mahaska County facility did not follow the resident’s advance directives, which indicated that life-saving measures were to be performed. The agency said the facility’s failures placed residents in immediate jeopardy.
According to inspectors, staff found the resident in distress one morning in September 2025, gasping for air and sweating heavily. A nurse left the room to retrieve medical equipment, and the resident soon became unresponsive. The director of nursing arrived and ordered another employee to check the resident’s code status and call an ambulance.
A staff member mistakenly reported over a radio that the resident had a do-not-resuscitate (DNR) order, leading workers to stop emergency efforts and begin postmortem care. The resident’s correct record later showed he was a “full code,” meaning CPR should have been administered.
Inspectors found that staff had also struggled to locate the facility’s crash cart, which contained a defibrillator and other emergency supplies. One employee later admitted she forgot to call 911 while searching for the equipment.
Officials said the confusion stemmed partly from an incorrect door label that indicated a DNR order. The director of nursing told inspectors she would have initiated CPR if she had known the resident’s correct status but had trusted the information provided by another nurse.
As a result of the incident, DIAL proposed a $10,000 state fine, which was placed on hold pending possible federal penalties from the Centers for Medicare & Medicaid Services (CMS).
Compliance Perspective
Issue
Facility staff must ensure residents receive timely and effective emergency care in accordance with professional standards, the comprehensive person-centered care plan, and the resident’s preferences. Staff must verify and honor residents’ advance directives, including DNR orders, upon admission and throughout their stay, documenting verbal or written instructions and promptly obtaining physician orders when needed. Emergency response procedures should be well-defined, and staff must be competent and CPR-certified to provide life-saving care consistent with resident directives and professional standards.
Discussion Points
- Review policies and procedures on advance directives, DNR orders, CPR, and emergency care to ensure staff understand how to verify resident wishes, document verbal or written instructions, obtain physician orders, and provide life-saving care in accordance with professional standards. Facilities may find it helpful to consult with an experienced consultant to ensure policies reflect current regulations and best practices.
- Train all licensed staff on CPR, DNR orders, advance directives, and emergency response procedures, emphasizing accurate documentation, honoring resident preferences, and maintaining current CPR certification. Med-Net Academy offers the course CMS Requirements for Basic Life Support, which reviews CMS expectations for basic life support, including when to initiate CPR, required staff certification, honoring resident preferences, physician orders related to CPR and other end-of-life choices, documentation of verbal wishes, verifying advance directives, and questions state surveyors may ask along with requested policies.
- Periodically audit resident records and emergency preparedness to ensure DNR orders and advance directives are accurately documented, physician orders are obtained and signed, staff competencies are current, and emergency procedures are followed. Working with a consultant can help identify potential gaps and guide corrective actions proactively.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*