Employees at an Iowa medical care center mistakenly deemed a 66-year-old woman in hospice care dead and coordinated her transportation in a cloth bag to a funeral home, according to a report from the Iowa Department of Inspections and Appeals.
The report noted that when a staff member at the funeral home unzipped her bag, they witnessed her "chest moving and she gasped for air."
The Iowa Department of Inspections and Appeals fined the Glen Oaks Alzheimer's Special Care Center $10,000 for violating a resident's dignity and for failing to "assume the responsibility for the overall operation of the residential care facility."
The center's executive director, Lisa Eastman, said the center has been in communication with the family of the affected resident.
"We care deeply for our residents and remain fully committed to supporting their end-of-life care," Eastman said in a statement to ABC News. "All employees undergo regular training so they can best support end-of-life care and the death of our residents."
According to the report, the resident, suffering from dementia, anxiety and depression, began living in the facility in December 2021. She was transferred into hospice care on Dec. 28, 2022, because of "senile degeneration of the brain." There, staff began administering morphine and alprazolam, also known as Xanax.
The report noted that, based on nurse's notes, she "appeared calm and comfortable" on Dec. 29; however, she began not coming out of her room for meals and refused food on Dec. 30. Hospice staff eventually noted a decline in temperature and that "she did not open her eyes and did not speak or respond" on Jan. 1. On Jan. 2, she began to suffer multiple "minor" seizures.
On Jan. 3, after a 12-hour shift, a staff member reported that "she did not feel a pulse, and the resident was not breathing at that time." According to the report, a licensed practical nurse assessed the woman's condition for five minutes, then "felt [the resident] had passed away" at roughly 6:00 a.m. She then called her family and on-call hospice nurse, who called the funeral home.
The report later noted that the resident had a do not resuscitate order.
A funeral director arrived at the care center at 7:38 a.m., then "placed [the woman] body on the gurney inside a cloth bag and zipped it shut." According to the report, the funeral director also reported no signs of life.
At 8:26 a.m., the funeral home staff unzipped the bag, witnessed her chest moment and gasp for air, then called 911.
When emergency medical services arrived at the funeral home, the woman had "no eye movement, no verbal or vocal response, and no motor response. She was returned to the hospice the same day and "continued hospice care around the clock."
The woman "passed away at the facility with hospice and her family at her side" two days later, the report noted.