A 66-year-old Iowa woman lived a nightmare scenario and woke up inside a body bag “gasping for air” after her nursing home assumed she was dead and shipped her to a funeral home.
The Glen Oaks Alzheimer’s Special Care Center near Des Moines is facing a $10,000 fine after three staffers were unable to tell that the unidentified woman was still alive according to a report released by the Iowa Department of Inspections and Appeals.
The report tells the grisly tale: “On 1/05/22 at 2:10 p.m. interview with LPN F revealed she had been with Resident #1 every hour on the hour throughout the night of 1/2/23 to 1/3/23 administering her lorazapam and morphine as ordered for comfort.
“At 6:00 a.m. Resident #1’s mouth was open, her eyes were fixed, and there were no breath sounds. 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.
“LPN F believed she stayed and continued to assess Resident #1’s condition for five minutes. She felt Resident #1 had passed away.
“She notified Resident #1’s family member and the on call hospice nurse. Hospice agreed to call the funeral home and did so.
“The Funeral Director arrived at the facility to pick up Resident #1 at approximately 7:38 a.m. A second LPN (LPN D) and the Funeral Director placed Resident #1’s body on the gurney inside a cloth bag and zipped it shut.
“When interviewed both LPN D (1/11/23 at 9:25 a.m.) and the Funeral Director (1/9/23 at 8:52 a.m.) reported there were no signs of life at that time.
“The Funeral Director left with Resident #1 at approximately 7:48 a.m.At approximately 8:26 a.m. 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.
“Record review revealed EMS (Emergency Medical Services) arrived at the funeral home at 8:30 a.m. on 1/03/23. EMS recorded Resident #1’s vitals as BP (blood pressure) 65/40, pulse at 108, oxygen saturation level at 74, and respirations at 17.
“There was no eye movement, no verbal or vocal response and no motor response. On 1/03/23 at 10:03 a.m. EMS transported Resident #1 to MercyOne’s Emergency Department (ED) for further evaluation.
“ED records revealed her BP at 69/54 temperature at 96.9 Respiration shallow at six per minute, SPO2 73%.
“The resident had advanced directives on file and paperwork showing she was on hospice. The director of the hospice agency and the family confirmed she was DNR (do not resuscitate).
“Resident #1 returned to the facility on 1/03/22 with continued hospice care around the clock. On 1/05/23 at 01:40 a.m.
“Resident #1 passed away at the facility with hospice and her family at her side. Review of facility policy in place at the time, Death of a Resident, revealed upon a resident’s death all appropriate parties would be notified.
“If the death was unexpected the Medical Examiner was to be notified. If the death was expected post mortem procedures would be completed by staff.
“The policy did not include any other steps for staff to follow if it was believed a resident had died.
“On 1/12/23 at 1:21 p.m. the Administrator confirmed these findings. 481-57.25(135C) Dignity preserved.
“The resident shall be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and in care for personal needs.
“Based on interview and record review the facility failed to ensure residents received dignified treatment and care at end of life,” the report said.
A 66-year-old Iowa woman woke up inside a body bag “gasping for air” after her nursing home assumed she died and shipped her to a funeral home. https://t.co/mkpyWYvXDu
— Trooper Bob (@TrooperBob_SC) February 3, 2023
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