A US Alzheimer's care facility is facing a $14,446 (10,000 USD) fine after pronouncing a woman dead who was later found alive when a funeral director unzipped her body bag, according to documents from the Iowa Department of Inspections and Appeals.
The 66-year-old woman, who has not been identified, was admitted to the Glen Oaks Alzheimer's Special Care Center facility in Urbandale, Iowa, on December 20, due to "senile degeneration of the brain," according to the documents.
She was admitted to hospice on December 28.
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On January 3, according to the report, "At 6.00am Resident #1's mouth was open, her eyes were fixed, and there were no breath sounds. [The nurse] 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."
The family was contacted and a funeral home was called, according to records.
Both the nurse and the funeral director, who arrived from Ankeny Funeral Home and Crematory to pick up the woman, reported no signs of life at around 7.38am.
"At approximately 8.26am, funeral home staff unzipped the bag and observed Resident #1's chest moving and she gasped for air.
"The funeral home then called 911 and hospice," the state report said.
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After first being taken to a local emergency room for care, she was found to be breathing but unresponsive. She was later returned to the hospice on January 3, due to her advanced directives, according to the report.
The facility reported the incident to the Iowa Department of Inspections and Appeals (DIA) on January 4.
According to the documents, she died at Glen Oaks the next day, with family by her side.
The violation issued to the care facility by DIA states, "Based on interview and record review, the licensee failed to provide adequate direction to ensure appropriate [care] and services were provided."
In an email to CNN, facility executive director Lisa Eastman said Glen Oaks has been in "close communication with the family of the resident."
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"We just completed an investigation by the Department of Inspections and Appeals regarding the matter. 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."
In a statement to CNN, the funeral home said, "Out of respect for the privacy and confidentiality of the families we are honored to serve, we are not in a position to comment further on this matter."
The Ankeny Police Department told the Des Moines Register it is not pursuing criminal charges.
