A 66-year-old woman was pronounced dead only to wake up hours later gasping for air at a funeral home in Iowa.
The woman spent at least nearly 40 minutes in a body bag traveling from the Glen Oaks Alzheimer's Special Care Center to the funeral home, according to a citation from the Health Facilities Division of the Iowa Department of Inspections and Appeals, which oversees health facility safety.
The incident happened on Jan. 3.
"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 report states.
The funeral home called 911 and hospice. When EMS responded, they were able to record a pulse and a shallow breath, according to the report.
EMS transported the woman, who had early onset dementia, to the hospital and she was later transferred back to the care facility where she died surrounded by family on Jan. 5, according to the report.
According to the report, a staffer who checked on the patient could not find a pulse and noticed the woman did not appear to be breathing.
"She felt the resident had passed away and notified the nurse," according to the report.
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The nurse told the agency she had been checking on the woman "every hour on the hour throughout the night" to administer lorazepam and morphine as ordered for comfort.
The nurse said there were no breath sounds and she also checked the woman's abdomen and found no movement and was also unable to find a pulse using her stethoscope, the report states.
According to the agency's citation, "the facility failed to ensure residents received dignified treatment and care at end of life."
The facility was fined $10,000.
In a statement to PEOPLE, the facility's executive director, Lisa Eastman, said they have been in close communication with the resident's family.
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"We just completed an investigation by the Department of Inspections and Appeals regarding the matter," Eastman said. "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."