Wisconsin officials uncovered a series of failures and federal violations at a nursing home where a renegade nurse cut off a man’s foot without his consent. in cold weather.
The nurse, Mary Brown, 38, from Durand, has since been charged with two counts of elder abuse in connection with the illegal amputation, which took place on May 27. She is due to appear in court on December 6.
The man died on June 2, six days after losing his foot. A nurse who spoke to state investigators said the man “really refused 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 by no means had the authority or training to perform an amputation because such a procedure is simply outside the practice of 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.
Gruesome details
The man had been placed in the nursing home, Spring Valley Health and Rehabilitation Center, in March after falling in his home with the heating turned off, leading to frostbite that left his feet black and necrotic.
State inspectors found that once he was placed in the care of the nursing home, staff failed to notify the hospice or a physician that the man’s condition was deteriorating. While they should have conducted weekly assessments of his feet, the facility has not conducted assessments for months.
Two days before Brown cut off the man’s foot, the patient fell out of bed, further injuring his foot, and was delirious and “talking in word salad,” according to the state inspection report.
According to an indictment, the man’s foot was hanging by a tendon and about two inches of skin at the time. 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 did not notify hospice or a doctor of the man’s condition after the fall, even though the man was so delirious that he was unable to take his morphine pills, the inspection report said.
On May 27, Brown decided to unilaterally amputate the foot for his “comfort,” despite other nurses advising her against it. When Brown entered the man’s room with two nurses to change his bandages, she “severed the victim’s tendon, completely amputating his right foot,” using bandage scissors. One of the nurses would later testify to government officials that the man “felt everything and it hurt a lot.”
Failures
Brown reportedly placed 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 keep it in her family’s taxidermy shop and show it with a sign that read, “Wear your boots.” , children.”
The management of the nursing home, meanwhile, did not respond well to the incident, according to the state report. Under 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, the state had already filed an anonymous complaint and the man had died.
The nursing home’s investigation into the incident was also lacking, specifically missing interviews with any physicians, hospices, or any 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 see a doctor when his condition worsened.
- Providing care beyond 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 a failure to report and investigate a sexual assault and a failure to report and investigate a resident’s head injury after he fell out of his wheelchair.
The Milwaukee Journal Sentinel reached out to the president of the nonprofit that runs that nursing home, Marsha Brunkhorst. She said the facility was cooperating with investigators but declined to comment further.
