On January 3rd, a staffer at the Glen Oaks Alzheimer’s Special Care Center realized one of the patients, a 66-year-old woman, wasn’t breathing. The staffer notified a nurse, who had been checking in on the patient every hour on the hour, ensuring the woman received lorazepam and morphine – as requested.
The nurse proceeded to check for a pulse but couldn’t find one – even with the stethoscope. Further complicating the matter, the patient – who had early onset dementia – wasn’t making any breathing sounds with her mouth/nose, and there was no movement in her abdomen to suggest she was breathing.
All signs pointed to the patient being dead – which is how the Care Center treated the situation. She was eventually placed in a body bag and sent from the Glen Oaks center to a nearby funeral home, where the process would continue. That’s when the unthinkable happened – the type of thing you see in the movies.
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“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 Health Facilities Division of the Iowa Department of Inspections and Appeals wrote in a citation following the incident. The woman spent 40 minutes in the body bag.
The staff called 911 and hospice the moment they realized the woman was alive. Emergency Medical Services (EMS) arrived shortly after and were able to find a pulse and breath – though they were both very faint. She was taken to the hospital before being sent back to the Glen Oaks Special Care Center.
On January 5th, just two days after the horrific incident, the woman passed away at the care center – she was surrounded by family. The Department of Inspections and Appeals found that ‘the facility failed to ensure residents received dignified treatment and care at end of life’ and fined the facility $10,000.
“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,” said Lisa Eastman, the executive director at the Glen Oaks Alzheimer’s Special Care Center.
What Violations Were Made By the Glen Oaks Care Center?
The report by the Department of Inspections and Appeals was nine pages long and describes the incident in full detail. In the report, which follows a month-long investigation, the Department lays out two violations that were made by the Glen Oaks Special Care Center – which is where the $10,000 fine came from.
The first violation was for code 57.7(5)a – “Assume the responsibility for the overall operation of the residential care facility.”
The second violation was for code 57.25 [481-57.25(135C)] – “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.”
“If, within thirty (30) days of the receipt of the citation, you (1) do not request a formal hearing or; (2) withdraw your request for a formal hearing, and (3) pay the penalty; the assessed penalty will be reduced by thirty–five percent (35%) pursuant to Iowa Code section 135C.43A (2013),” the report also stated.
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The 66-year-old woman was admitted to the care center in December 2021 and was transferred to hospice care on December 28, 2022 – just six days before she was mistakenly pronounced dead. Our thoughts are with the family and everyone else involved.
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