A 66-year-old woman was declared dead only to awaken hours later gasping for air at an Iowa funeral home.
According to a citation from the Health Facilities Division of the Iowa Department of Inspections and Appeals, which oversees health facility safety, the woman spent at least nearly 40 minutes in a body bag traveling from the Glen Oaks Alzheimer’s Special Care Center to the funeral home.
The incident occurred on January 3rd.
“At approximately 8:26 a.m. funeral home staff unzipped the bag and observed Resident #1’s chest was moving and she was gasping for air,” the report states.
The funeral home dialed 911 and contacted hospice. According to the report, when EMS arrived, they were able to record a pulse and a shallow breath.
According to the report, EMS transported the woman, who had early onset dementia, to the hospital, and she was later transferred back to the care facility, where she died surrounded by family on Jan. 5.
A staff member who checked on the patient couldn’t find a pulse and noticed the woman didn’t appear to be breathing, according to the report.
The nurse told the agency that she had checked on the woman “every hour on the hour throughout the night” to give her lorazepam and morphine as prescribed for comfort.
According to the report, the nurse stated that there were no breath sounds and that she checked the woman’s abdomen and found no movement as well as being unable to find a pulse using her stethoscope.
The facility “failed to ensure residents received dignified treatment and care at the end of life,” according to the agency’s citation.
The facility received a $10,000 fine.
In a statement to PEOPLE, the facility’s executive director, Lisa Eastman, said they have been in close communication with the resident’s family.
“We just completed an investigation by the Department of Inspections and Appeals regarding the matter,” Eastman said. “We care deeply for our residents and remain fully committed to supporting their end-of-life care. All employees undergo regular training so they can best support end-of-life care and the death of our residents.”