— Then she woke up in a body bag gasping for air.
As the nurse at the hospice care facility in Iowa checked on the 66-year-old woman, it was clear to the caregiver the patient was dead.
The nurse found no pulse, movement or signs of life in the woman, who had been admitted to Glen Oaks Alzheimer’s Special Care Center in Urbandale, Iowa, for early onset dementia in late December, and “felt the resident had passed away,” according to a report from the Iowa Department of Inspections and Appeals this week.
But after the patient was placed in a body bag and transferred to a funeral home, there was one problem: The woman woke up. And she was desperately trying to breathe. “Funeral home staff unzipped the bag and observed Resident #1’s chest was moving and she was gasping for air,” the report said of the woman, who was not identified by the agency. “The funeral home then called 911 and hospice.”
After EMS personnel recorded her pulse but no other movement or motor response, the patient was transferred to a hospital. Two days after returning to the hospice facility that had mistakenly presumed she was dead, the woman died with her family by her side on Jan. 5, according to the state report published Wednesday.
Now, the hospice facility has been fined $10,000, the maximum allowed under state law, for mistakenly pronouncing the woman dead. The state cited in its report the facility “failed to provide adequate direction to ensure appropriate cares and services were provided.” The agency added the hospice facility failed to ensure the patient received “dignified treatment and care at end of life.”
Lisa Eastman, executive director of Glen Oaks Alzheimer’s Special Care Center, did not immediately respond to a request for comment Friday. Eastman said in a statement to the local CBS station in Des Moines the hospice facility cooperated and completed the investigation from the Iowa Department of Inspections and Appeals. She noted the facility has also been in “close communication with the family of the resident.”
“We care deeply for our residents and remain fully committed to supporting their end-of-life care,” Eastman said. “All employees undergo regular training so they can best support end-of-life care and the death of our residents.”
While it is rare for people to be incorrectly declared dead, it has happened before. In 2018, a Spanish prisoner was certified dead by three doctors before waking up in a mortuary. Later that year, a car crash victim in South Africa was covered in a silver sheet and taken to a morgue when a forensic officer noticed the person was still breathing. In 2020, a Michigan woman was about to be embalmed after she was pronounced dead from a heart attack until employees at a funeral home saw her breathing.
Glen Oaks, a state-licensed residential care facility, is not a skilled nursing facility, meaning it is not subject to the same oversight and federal regulations as nursing homes, according to the Iowa Capital Dispatch. The facility was fined $500 last year for failing to perform required background checks on employees after five workers did not have the mandated training.
The outlet reported that while the Iowa Department of Inspections and Appeals believes people living in a state residential care facility are unable to properly care for themselves, those residents “do not require the services of a registered or licensed practical nurse except for emergencies.”
If Glen Oaks does not contest the citation and pays the $10,000 fine within 30 days, then it will be reduced by 35 percent, according to the state administrative code. The patient was admitted to the facility on Dec. 20, 2021, after she was diagnosed with early onset dementia, anxiety and depression, according to the state report. She was admitted to hospice care about a year later, on Dec. 28, 2022, because of “senile degeneration of the brain,” the report said.
It was 6 a.m. on Jan. 3 when a nurse found no signs of life while checking on the patient, who is referred to by the state agency as “Resident #1,” the report said. “Resident #1’s mouth was open, her eyes were fixed and there were no breath sounds,” the report said. “She was unable to locate Resident #1’s apical pulse using her stethoscope. She placed her hand on Resident #1’s abdomen and noted no movement.”
After a few minutes, the nurse “felt the resident had passed away” and presumed the patient was dead, according to the report. The nurse then notified a family member and the on-call hospice nurse. “Hospice agreed to call the funeral home and did so,” the report said.
At 7:38 a.m., a funeral director arrived to retrieve the patient’s body and place it “on the gurney inside a cloth bag and zipped it shut,” according to the state report. Almost an hour later, staff members at the funeral home realized the woman was still very much alive when they saw her chest moving.
She was transported to an emergency room where officials noted that her breathing was shallow, according to the report. The woman was released that same day and returned to the hospice facility “with continued hospice care around the clock,” the agency said in the report. Two days later, she died surrounded by loved ones. This time, it was real.
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