An Alzheimer’s care center in Iowa was fined $10,000 after mistakenly declaring a patient dead, according to a report from the state’s Health Department.
The patient, a 66-year-old woman who was not named in the report, was declared dead by staff members of the Glen Oaks Alzheimer’s Special Care Center in Urbandale, Iowa, on Jan. 3, and transported to a funeral home, according to the report.
But when staff members at the funeral home unzipped the body bag, she was alive and gasping for air, according to a citation from the Iowa Department of Inspections and Appeals.
The woman was admitted to the special care center in December 2021 with early onset dementia, anxiety and depression. She entered hospice care in late December 2022 with senile degeneration of the brain and was treated with the anxiety drug lorazepam and morphine, a painkiller, according to the report.
Starting around last month, her vital signs and responsiveness worsened. She refused meals and had seizures. A doctor ordered an increase in morphine and lorazepam “due to active decline,” the report said.
Early on Jan. 3, a care center employee at the end of a 12-hour shift found the woman unresponsive and conferred with a nurse, who declared the woman dead. The nurse informed the woman’s daughter and secured orders from a doctor to release her to a funeral home.
Funeral home workers unzipped the body bag and noticed that the woman’s chest was moving and watched as “she gasped for air,” the report said. They called 911 and the hospice.
An ambulance transported the woman to an emergency room with a low temperature and shallow breathing. The woman had a do-not-resuscitate directive, so she was brought back to the hospice at the Alzheimer’s care center, where she died two days later.
Iowa’s Health Department fined the center $10,000 for two violations, which included a rule that says care homes must preserve the dignity of residents. The report did not address what, if any, actions were taken regarding the nurse.
On Sunday, an employee at Glen Oaks Alzheimer’s Special Care Center said she was not able to comment. The center’s executive director, Lisa Eastman, did not immediately respond to an email seeking comment.
Ms. Eastman sent a statement to the local television station KCCI, which reported on the case.
“We care deeply for our residents and remain fully committed to supporting their end-of-life care,” Ms. Eastman said in the statement. “All employees undergo regular training so they can best support end-of-life care and the death of our residents.”
The center did not dispute the Health Department’s findings, according to the report. It has 30 days from Feb. 1, the date of the citation, to request a formal hearing or pay the penalty.
The center is a 66-bed residential facility run by Dallas-based Frontier Management, one of the largest senior housing managers in the United States.
The center or its administrator has been fined more than a dozen times since opening in 2001, according to Iowa Health Department records, for violations that include a lack of specialized staff training in memory care and a lack of infection control during the pandemic, when patients who tested positive for Covid-19 were roomed with other residents.
It is not unheard-of for people to be declared dead only to be found alive hours later.
In 2020, a woman in Michigan with cerebral palsy was declared dead by paramedics but was discovered to be breathing hours later by a funeral home worker who was preparing to embalm her body.
In 2018, a South African woman was pronounced dead at the scene of a car wreck but hours later was found alive in a mortuary.