It’s a deep rooted fear in all of us – being buried alive, but when a nurse at Glen Oaks Alzheimer’s Special Care Center in Urbandale, Iowa checked on one of their patients, they were sure the 66-year-old woman was dead. They couldn’t find a pulse and saw no signs of life in the woman, who had been admitted to the facility in December for dementia.
The body was then bagged and sent to a local nursing home. That’s when the woman suddenly woke up struggling 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 remains anonymous. “The funeral home then called 911 and hospice.”
Emergency medical personnel arrived on the scene and soon found a pulse but no other movement or motor response. She was then transferred to a hospital before ultimately returning to the hospice facility in Urbandale. She then passed away with her family on Jan. 5, just two days after being mistakenly pronounced dead.
The Iowa Department of Inspections and Appeals is now fining the facility $10,000, the maximum amount allowed under state law, for the ordeal. In its official report, the agency said the facility “failed to provide adequate direction to ensure appropriate care and services were provided.” The agency added that Glen Oaks failed to ensure the patient received “dignified treatment and care at end of life.”
The facility has yet to respond to the investigation, but Lisa Eastman, executive director of the hospice center, said Glen Oaks has been cooperating with the Iowa Department of Inspections and Appeals. She also noted that the facility has 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 added. “All employees undergo regular training so they can best support end-of-life care and the death of our residents.”
But the facility has a mixed history of compliance. It was fined $500 last year for failing to complete a background check on a new employee. Glen Oaks is not a skilled nursing facility, which means it isn’t subject to the same oversight regulations imposed on nursing homes.
The report summarizes the nurse’s original assessment of the woman, who is referred to as “Resident #1.”
“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.”
Several minutes later, 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.
The state agency said the amount of the fine will be reduced by 35% if the facility agrees to pay the fee within 30 days.