State issues a warning to caregiver after nursing home resident dies

State licensing officials have issued a warning to an Iowa nurse for her role in the death of a nursing home resident.

The board alleges that Elaine Allison, aka Elaine McCoy, of Beacon was working as a licensed practical nurse at the Oskaloosa Care Center on Sept. 6, 2025, when there was a serious medical emergency and a resident of the home became unresponsive.

The board alleges a registered nurse asked Allison to call an ambulance and to verify the resident’s “code status” to determine whether lifesaving measures should be taken. Allison forgot to call the ambulance, according to the board, and also incorrectly identified the resident as “no code,” meaning no cardiopulmonary resuscitation or other lifesaving measures should be taken.

As a result, the board alleges, no CPR was performed and the man was subsequently pronounced dead.  A later review of the resident’s file indicated the man was a “full code” patient who had asked for lifesaving measures to be taken.

After charging Allison with committing an act that might adversely affect a patient’s welfare, the board recently agreed to settle the matter by issuing Allison a warning and directing her to complete 30 hours of educational training. The Iowa Capital Dispatch was not able to reach Allison for comment.

Typically, a nursing home resident’s code status is marked on a sticker applied to the door of each resident’s room to prevent confusion and save time in the event of an emergency. According to a state inspectors’ report, the Oskaloosa Care Center’s director of nursing indicated the deceased resident’s door did not have the correct sticker due to recent changes in room assignments.

Inspectors reported that on the morning of the incident, employees entered the man’s room and saw him slumped over in his recliner and in distress – gasping, sweating profusely and stating he needed to sit. According to the inspectors’ reports, one of the workers 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 in the room and instructed a licensed practical nurse – Allison, according to board records — to call an ambulance and verify the resident’s code status. After it was reported that the resident had a do-not-resuscitate order in place, the staff concluded the resident was dead and began to clean and clothe the body for the family’s viewing, according to inspectors.

The inspectors’ report of the incident indicates Allison told investigators she had been “flustered” during the incident had been “working on” calling 911 while also trying to locate the home’s crash cart, which had a defibrillator on board for restoring a patient’s heartbeat in cases of cardiac arrest.

According to inspectors, Allison said she “probably” would have initiated CPR had she known the resident was a full-code patient.

The Iowa Department of Inspections, Appeals and Licensing 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. According to the state agency, those failures placed residents of the home in immediate jeopardy.

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.