Officials in Wisconsin discovered a string of federal failures and abuses at a nursing home where a recalcitrant nurse cut off a man’s foot without his consent and wanted to put it in her family’s taxidermy shop and offer to warn children to “put your shoes on” in cold weather.
Nurse Mary Brown, 38, of Durand, has since been charged with two counts of felony 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 nurse aide who spoke to state investigators said the man “really refused after his foot was gone.” According to the Milwaukee Journal Sentinelwhich reviewed the state inspection report.
No doctor authorized or ordered amputation of the man’s foot. As a nurse, Brown did not have the authority or training to provide amputations in any event because such a procedure was simply outside the scope of practice for registered nurses. Furthermore, the man, aged 62, who did not have a cognitive disability and was responsible for making his own medical decisions, did not consent to the amputation.
The man was placed in a nursing home, Spring Valley Health and Rehabilitation Center, in March after he fell in his home with the heat off, resulting in frostbite that left his feet black and oozing.
State inspectors found that once he was admitted to the nursing home, the staff failed to notify the nursing home or any physician that the man’s condition was worsening. Although they should have done weekly assessments of his foot, the facility did not do any for months.
Two days before Brown cut off the man’s foot, the patient had fallen from his bed, injuring his foot, was delirious and “spoken with a word of authority,” according to the government inspection report.
According to a criminal complaint, the man’s foot was at that point hanging with tendons and leather approximately two inches long. However, a nurse changed his bandages He could still move his toes the day Brown cut his foot offaccording to the Milwaukee Journal Sentinel.
However, nursing home staff failed to notify the hospice or doctor of the man’s condition after the fall, even though the man was too delirious to take morphine pills, according to the examination report.
On May 27, Brown unilaterally decided to amputate his foot for his “convenience”, despite being advised not to by other nurses. When Brown entered the man’s room with two aides to change the bandages, she “severed the tendon of the victim who had amputated his entire right foot” using bandage scissors. A nursing assistant later testified to state officials that the man “felt everything and it hurt so bad.”
Brown reportedly put his foot in a biohazard bag and put it in a freezer. A nurse aide at the facility told investigators that Brown later pressured her to return the foot because Brown wanted to keep it in her family’s taxidermy shop and display it with a sign that read, “Put your shoes on, kids.”
Meanwhile, leadership at the nursing home failed to properly respond to the incident, according to the state report. According to federal regulations, the nursing home was required to report the incident to state authorities within 24 hours. But, it took a full week for the nursing home to report the incident. At that time, an anonymous complaint had already alerted the state, and the man died.
The nursing home’s investigation of the incident was also lacking, in particular the lack of interviews with any doctors, the nursing home, or one of the nursing assistants who attended the amputation.
The actions resulted in five citations against the nursing home for violating federal regulations, according to the Milwaukee Journal Sentinel:
- Not consulting a doctor when his condition worsened.
- Providing care outside of professional standards.
- Not coordinating effectively with the nursing home.
- Failure to immediately report the incident to the state.
- Failure to complete a full investigation.
The outlet noted that the nursing home has a history of problems, including a failure to report and investigate sexual assault and a failure to report and investigation into a head injury to a resident after he fell from his wheelchair.
The Milwaukee Journal Sentinel has reached out to the president of the nonprofit that runs that nursing home, Marsha Bronckhorst. She said the facility was cooperating with investigators, but declined to comment further.