After renegade nurse chops off man’s foot, state finds heap of system failures
Officials in Wisconsin found a series of failures and federal violations at a nursing home where a renegade nurse cut off a man's foot without his consent and wanted to have it stuffed in her family's taxidermy shop and put on display to warn children to "wear your boots" in cold weather. The nurse, Mary Brown, 38, of Durand, has since been charged with two felony counts of elder abuse in connection with the illegal amputation, which occurred on May 27. She is scheduled to appear in court on December 6.
The man died on June 2, six days after losing his foot. A nursing aide who spoke with state investigators said the man "really declined after his foot was gone," according to the Milwaukee Journal Sentinel, which reviewed a state inspection report. No doctor authorized or ordered an amputation of the man's foot.
And as a nurse, Brown did not have the authority or training to provide an amputation in any case because such a procedure is simply outside of the scope of practice for registered nurses. Further, the man, a 62-year-old patient who was not cognitively impaired and was in charge of making his own medical decisions, had not consented to the amputation.
The man had been placed in the nursing home, Spring Valley Health and Rehabilitation Center, in March after he fell in his home with the heat turned off, leading to frostbite that left his feet blackened and necrotic. State inspectors found that once he was placed in the care of the nursing home, staff failed to notify hospice or any physician that the man's condition was worsening.
Though they should have been conducting weekly assessments of his feet, the facility did not perform any assessments over months. Two days before Brown cut off the man's foot, the patient fell from his bed, injuring his foot further, and was delirious and "talking in word salad," according to the state's inspection report. According to a criminal complaint, the man's foot at that point was hanging on by a tendon and roughly two inches of skin.
However, a nurse who changed his bandages said he could still wiggle his toes the day Brown cut off his foot, according to the Milwaukee Journal Sentinel. Still, nursing home staff failed to notify hospice or a doctor of the man's condition after the fall, even though the man was so delirious he could not take his morphine pills, according to the inspection report. On May 27, Brown unilaterally decided to amputate the foot for his "comfort," despite other nurses advising her against it.
When Brown entered the man's room with two nursing aides to change his bandages, she "cut the victim's tendon, which amputated his right foot completely," using bandage scissors. One of the nursing aides would later testify to state officials that the man "felt everything and it hurt very bad."
Brown reportedly put the foot in a biohazard bag and placed it in a freezer. A nursing assistant at the facility told investigators that Brown later pressured her to retrieve the foot because Brown wanted to preserve it in her family's taxidermy shop and display it with a sign saying, "Wear your boots, kids."
Leadership at the nursing home, meanwhile, failed to respond to the incident properly, according to the state report. According to federal regulations, the nursing home should have reported the incident to state authorities within 24 hours. But, it took the nursing home a full week to report the incident.
At that point, an anonymous complaint had already alerted the state, and the man had died. The nursing home's investigation of the incident was also lacking, notably missing interviews with any doctors, hospice, or one of the nursing aides present for the amputation. The actions resulted in five citations against the nursing home for violating federal regulations, according to the Milwaukee Journal Sentinel:
- Failure to consult a physician when his condition worsened.
- Providing care outside professional standards.
- Failure to coordinate effectively with hospice.
- Failure to immediately report the incident to the state.
- Failure to complete a full investigation.
The outlet noted that the nursing home had a record of problems, including failing to report and investigate a sexual assault and failing to report and investigate a resident's head injury after falling from his wheelchair.
The Milwaukee Journal Sentinel reached the president of the nonprofit that runs that nursing home, Marsha Brunkhorst.
She said that the facility was cooperating with investigators, but declined to comment further.