A hospice care facility has been fined $10,000 after healthcare workers mistakenly declared a woman in their care dead.

The woman, according to a report from the Iowa Department of Inspections and Appeals, was discovered alive more than two hours later inside a body bag at a funeral home.

The 66-year-old woman was admitted to the hospice care unit of Glen Oaks Alzheimer’s Special Care Center in Urbandale on Dec. 28 “due to senile degeneration of the brain,” the report filed on Wednesday, Feb. 1, states.

As the patient’s condition worsened, a staff member noted signs she died in the early morning hours of Jan. 3.

“(The worker) reported the resident’s eyes were open,” the report states. “She felt her neck at the carotid artery and listened to her chest. She did not feel a pulse and the resident was not breathing at that time. She felt the resident had passed away and notified the nurse.”

At 6 a.m., a nurse assessed the woman’s condition for five minutes and also believed she had died. The facility then called the woman’s family member and funeral home, according to the inspectors’ report.

The director of a funeral home arrived at 7:38 a.m. and put the woman “inside a cloth bag and zipped it shut,” according to the report.

But when funeral home workers unzipped the body bag at 8:26 a.m., they found the woman’s chest moving and her gasping for air, the inspector said.

Paramedics registered a pulse on the woman, but said “there was no eye movement, no verbal or vocal response and no motor response.”

She was readmitted to the hospice facility and died two days later with her family at her side, according to the report.

The state’s inspector said the hospice facility did not treat the resident with dignity and did not provide her appropriate care. A month-long investigation led to the state imposing a $10,000 fine.

“We care deeply about our residents and we remain fully committed to supporting their end-of-life care,” Lisa Eastman, the executive director of the facility, said in a statement to the Des Moines Register. “All of our employees are given regular training in how best to support end-of-life care and the death transition for our residents.”

The Urbandale facility is about 8 miles from Des Moines.

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