Inset and background: The Kingsley Specialty Care nursing home in Kingsley, Iowa (Google Maps).
An Iowa nursing home has been penalized after state officials said a nurse failed to give a resident the care she needed, leading to the woman’s death.
Kingsley Specialty Care in Kingsley, Iowa, was fined $10,500 after the Iowa Department of Inspections, Appeals and Licensing concluded the facility did not provide CPR to a resident who was experiencing breathing distress. State records reviewed by Iowa Capital Dispatch said the woman, whose name and age were not disclosed, told staff on May 9 that she was having trouble breathing and wanted to be taken to a hospital.
Inspectors said the registered nurse later reported that she tried to put together an oxygen delivery device but “couldn’t find all the working parts.” As she went to the facility’s basement to locate the missing equipment, the resident’s condition worsened and she eventually became unresponsive.
Meanwhile, a nurse’s aide who stayed in the room attempted “several times” to call the nurse back, according to the records, but “didn’t respond.” The aide ultimately had to “yell for her” to return.
By the time the nurse came back, neither employee knew whether the resident had a do-not-resuscitate order. After checking at the nurse’s station, they confirmed that the woman was a “full-code” patient, meaning CPR should have been started while she remained unresponsive.
The two then went back to the room, where the aide began chest compressions and another aide called 911. The nurse checked for a pulse and stated that the resident “was gone.” According to the findings, the nurse did not perform any lifesaving measures.
When inspectors questioned the aide, she told them that she had expected the nurse to take charge. Instead, she said the nurse “kind of acted like she was in shock.” The nurse told inspectors that she was “flustered” and did not think to retrieve the crash cart to take immediate action.
Emergency medical technicians arrived 10 minutes after the 911 call. When they got to the patient’s room, they saw an employee they believed to be a nurse standing at the foot of the bed. They asked why no one was giving the patient CPR, and the employee said she was “giving her some air.”
The EMTs told inspectors that there was no equipment in the room that was normally used for respiratory support, such as an Ambu bag, bottled oxygen, or a crash cart.
According to the report, the patient was taken to a hospital, where she was pronounced dead.
The facility was cited for not providing basic CPR to a patient. The $10,500 state fine also covered a separate violation in connection with a nurse who reportedly took a patient’s medication.
Iowa Capital Dispatch reported that the Iowa Department of Inspections, Appeals and Licensing normally suspends state fines until a federal agency decides if it wants to impose a penalty of its own.
