Oskaloosa Care Center: CPR Withheld After Code Mix-Up - IA

He was a Full Code. Nobody knew.

When a nurse opened his electronic health record to find his wife's phone number after calling his time of death, she saw it plainly: Full Code. The paper chart said DNR. The sticker on his door, the quick visual check every nurse relies on in an emergency, was wrong. It had been placed on the wrong side of the door after a room change and never corrected.

By then, it was too late.

Federal inspectors who investigated the death at Oskaloosa Care Center assigned it the most serious classification available: Immediate Jeopardy to resident health or safety. The September 17, 2025 complaint inspection documented, in the nurses' own words, a cascade of failures that left a man's final moments unattended by any of the interventions he and his family had specifically chosen.

The charge nurse, identified in the inspection report as Staff C, described arriving in the resident's room to find him slumped in his recliner, nearly sliding out, unresponsive, soaked in sweat, and having had a bowel movement. She and another staff member got him to the floor. She told Staff B to call 911. Outside the room, she looked for the code status sticker on the door and it wasn't there, which she interpreted to mean he was a DNR.

Staff C told Staff B to double-check the code status in the paper chart. The director of nursing arrived and opened the resident's airway. They were ready to start compressions. But Staff B had not come back.

Staff C left the room to find out why.

At the nursing station, Staff B was fumbling. She could not locate the code status in the paper chart. Staff C directed her to the Advanced Directives section. Staff B found it and called back: DNR. Staff C returned to the room and called the time of death.

Then she opened the electronic health record.

"Staff C asked Staff B why the EHR stated Full Code when the paper chart said DNR," the inspection report states. Staff C told inspectors directly: "If she had known he was a Full Code, she would have started CPR."

There was a second failure running alongside the first. Staff C had told Staff B to call 911 at the start of the emergency. She assumed it had been done. After speaking with the resident's wife, she thought to cancel the ambulance and turned to Staff B.

"You called the ambulance, right?" she asked.

Staff B said she had forgotten. She had gone to look for the crash cart instead.

Staff B's own account to inspectors did not soften this. She said she and Staff C had both looked at the code status and both misread it. She said she did not know where the crash cart was at first. She said she was working on calling 911 when she went to retrieve the crash cart. "She stated she was flustered and should have called 911," the report documents. "She stated she probably would have initiated CPR if she had known he was a Full Code."

The director of nursing, who arrived to find the resident displaying agonal breathing, ashen and diaphoretic, gave inspectors her own accounting. She said she would have started CPR if she had known the correct code status, but said she trusted a fellow nurse's reading of the chart. After the time of death was called, she contacted the attending physician, identified as Staff F, told her the resident was a No Code, and received an order to release the body to the funeral home.

It was only after Staff C called the family and discovered the EHR listed Full Code that the director of nursing called Staff F back to correct the record. That call came at 7:57 a.m.

The director of nursing told inspectors she did not believe initiating CPR would have changed the outcome. But she did not stop there. "She stated they owed it to the family to do so."

A fourth staff member, identified as Staff G, was at the medication cart when the emergency began. She heard someone direct Staff B over the two-way radio to call 911 and said Staff B was close enough to the radio to hear the request clearly. Staff B then asked Staff G to locate the crash cart. After Staff G retrieved it, Staff B told her the resident was a DNR.

The administrator told inspectors the Full Code sticker had been on the chart but placed on the wrong side of the door after a room change. After the resident's death, staff checked every door sticker in the facility and added a second reference book at each nursing station listing all residents' code statuses.

The director of nursing acknowledged that Staff B had been trained on crash cart location during orientation.

What the inspection report captures, across four separate staff interviews, is not a single person's mistake. It is a system that failed at every redundancy point simultaneously. The door sticker was wrong. The paper chart was misread, by two nurses, under pressure, and neither caught the error. The 911 call was never made. The crash cart's location was unknown to the nurse assigned to retrieve it. And the electronic health record, which held the correct information, was not checked until after the time of death had been called and the family had been notified.

The resident's wife learned her husband had died before anyone at Oskaloosa Care Center knew they had let him die without the resuscitation he had asked for.

The director of nursing put it plainly: they owed it to the family. That debt was not paid.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Oskaloosa Care Center from 2025-09-17 including all violations, facility responses, and corrective action plans.

Additional Resources

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