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A hospice facility in Iowa has been fined $10,000 after mistakenly presuming a woman dead hours before she was discovered gasping for air inside a body bag at a funeral home, officials said.
A nurse at Glen Oaks Alzheimer’s Special Care Center in Urbandale determined that the 66-year-old woman had died on Jan. 3 and the resident was transferred to a funeral home, the Iowa Department of Inspections and Appeals said in a report issued Wednesday.
The woman, who has not been publicly identified, was admitted to hospice care Dec. 28 because of “senile degeneration of the brain,” the report states.
At 6 a.m. Jan. 3, a nurse checked on the patient but did not find any signs of life, according to the report.
Her “mouth was open, her eyes were fixed, and there were no breath sounds,” the report said, adding that a nurse was unable to locate the woman’s pulse using her stethoscope.
The nurse put her hand on the woman’s abdomen and “noted no movement,” the report said. The nurse presumed the resident had died and notified her family member and the on-call hospice nurse, according to the report.
“Hospice agreed to call the funeral home and did so,” it stated.
Nearly an hour and forty minutes later, a funeral director placed the woman’s body on a gurney “inside a cloth bag and zipped it shut,” the report said. The director left with the woman about 10 minutes later, the report said. Shortly before 8:30 a.m., staff at the funeral home discovered the woman was still alive, the report said.
“Funeral home staff unzipped the bag and observed Resident #1’s chest was moving and she was gasping for air. The funeral home then called 911 and hospice,” the report said.
When EMS arrived, they recorded the woman’s pulse, and noted she had no eye movement or verbal, vocal or motor response, according to the report.
The woman was taken to the emergency room. She was returned to the hospice facility and died with her family at her side two days later, according to the state report.
The state fined the facility $10,000, the maximum amount allowed under Iowa law, according to a spokesperson for the Iowa Department of Inspections and Appeals.
A state citation dated Wednesday said the facility “failed to provide adequate direction to ensure appropriate cares and services were provided” and it failed to ensure she received “dignified treatment and care at end of life.”
The executive director for the hospice facility said that representatives have been in touch with the resident’s family.
“We care deeply for our residents and remain fully committed to supporting their end-of-life care,” Executive Director Lisa Eastman said in a statement. “All employees undergo regular training so they can best support end-of-life care and the death of our residents.”
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