After renegade nurse chops off man’s foot, state finds heap of system failures

The Wisconsin nursing home where a nurse cut off a man's foot without his consent and wanted to have it put on display to warn children to wear their boots in cold weather had a lot of failures.

Mary Brown, a nurse from Durand, has been charged with two felony counts of elder abuse for her role in the illegal amputation. She is due to appear in court.

Six days after he lost his foot, the man died. A nursing aide who spoke with state investigators said the man declined after he lost his foot.

The man's foot was not cut off by a doctor. Brown didn't have the authority or training to perform an amputation as a nurse because it's outside of the scope of practice for nurses. The man who was in charge of making his own medical decisions was not willing to have his leg severed.

Gruesome details

The man's feet were blackened and necrotic after he fell in his home and the heat was turned off.

The staff at the nursing home failed to inform Hospice or any physician that the man's condition was getting worse. The facility didn't conduct any assessments over the course of months.

According to the state's inspection report, the patient fell from his bed two days before Brown cut off his foot.

The man's foot was hanging on two inches of skin and a tendon. The nurse who changed his bandages said he could wiggle his toes if Brown cut off his foot.

According to the inspection report, the nursing home staff failed to inform the doctor or Hospice of the man's condition after he fell.

Brown decided to amputate the foot for his "comfort" even though other nurses advised her against it. She cut the victim's foot with bandage scissors when she entered his room to change his bandages. One of the nursing aides testified that the man felt everything and it hurt very badly.

Failures

The foot was put in a freezer by Brown. The nursing assistant said that Brown wanted to display the foot in her family's shop and that she was pressured to retrieve it.

According to the state report, leadership at the nursing home failed to respond appropriately. The nursing home should have reported the incident to the state. It took the nursing home a week to report it. The man had died as a result of an anonymous complaint.

The nursing home didn't interview any of the doctors or nursing aides who were present for the amputation.

Five citations were given to the nursing home for violating federal regulations.

• 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 nursing home failed to report a sexual assault and a resident's head injury after he fell from his wheelchair, according to the outlet.

Marsha Brunkhorst is the president of the nonprofit that runs that nursing home. She wouldn't say if the facility was cooperating with investigators.