A nursing home worker accused of failing to evaluate a choking resident who subsequently died has been given a warning by state regulators.
The Iowa Board of Nursing recently charged licensed practical nurse Samantha Smith of Burlington with failing to assess or evaluate a patient and committing an act that might adversely affect a patient’s welfare.
According to the board, Smith was employed last year as a nurse at the Klein Center, which is a nursing home that’s part of Southeast Iowa Regional Medical Center in West Burlington.
The board alleges that on Dec. 5, 2025, Smith responded to an incident involving a female resident of the home who appeared to be choking. State inspection reports indicate another resident of the home had alerted the staff to the fact that the woman had been coughing and vomiting while trying to eat.
People are also reading…
The staff made note of the woman’s labored breathing and described her in their reports as choking, according to inspectors. The board alleges Smith failed to perform the necessary assessments of the woman’s vital signs and instead took her to her bedroom.
Smith then gathered the resident’s medications for the evening and allegedly placed the pills in the woman’s mouth and gave her water while the woman continued to cough and gag, eventually spitting out the pills, according to state inspectors.
The inspectors allege Smith then directed a certified nurse aide to put the woman to bed, after which Smith placed the woman’s CPAP mask in place, covering the woman’s mouth and nose, to help with the woman’s sleep apnea.
About 10:30 p.m., five hours after the choking episode in the dining room, the resident was checked by another nurse who discovered the woman was struggling to breathe and had vomited in her CPAP mask. According to state inspectors, the resident’s oxygen saturation levels were at 34% — with anything below 88% typically considered a medical emergency — and another nursing home worker reported overhearing the nurse exclaim, “Oh, my God.”
An ambulance was summoned, but the resident died before emergency services arrived at the nursing home, according to the board.
State inspectors later reported that when they asked the licensed practical nurse — identified in board records as Smith — whether she had performed “any assessments, like listening for lung sounds, vital signs or checking oxygen levels, (she) teared up and stated no.”
State inspectors proposed, but held in suspension, a $10,000 fine against the Klein Center. State fines are typically suspended in lieu of federal penalties imposed by the Center for Medicare and Medicaid Services.
The Iowa Board of Nursing recently settled its disciplinary case against Smith by issuing her a warning. As part of that settlement, Smith has agreed to complete 15 of educational training on patient assessments.
The Iowa Capital Dispatch was not able to reach Smith for comment.
