Inspectors find string of failures at western Wisconsin nursing home where nurse severed patient's foot
The nursing home in western Wisconsin where a nurse is facing felony elder abuse charges for amputating a man's foot didn't immediately report the incident to state regulators and failed to complete an investigation, according to a state inspection report.
Spring Valley Health and Rehabilitation Center was cited for five violations, including three that fall into the most serious category, where a patient was in "immediate jeopardy."
The 40-bed nursing home has been cited for similar problems in previous inspections − though none with such extreme consequences.
The June 21 report followed a visit by state inspectors to the nursing home on June 8 and 9, which was prompted by an anonymous complaint about the actions of registered nurse, Mary K. Brown, of Durand.
Brown severed a 62-year-old patient's necrotic foot on May 27. Under federal rules, the incident should have been reported within 24 hours to the state.
Yet it was an anonymous complaint on May 29 that alerted the state, according to the inspection report and a spokeswoman with the state Department of Health Services. The patient, who has not been identified, had been receiving hospice care at the nursing home. He died on June 2, six days after losing his foot.
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The nursing home reported the incident on June 3, a full week after it occurred, the inspection report said. The next day, Pierce County Medical Examiner John Worsing notified local law enforcement that he received the "man's body with the foot laying next to it," according to the criminal complaint.
Kevin Larson, the nursing home's administrator, did not reply to an email or voicemail with questions about the inspection report and its findings. In a document filed with the state, nursing home officials said they did not agree with the findings and were not admitting noncompliance.
The nursing home is owned by the village of Spring Valley but operated by a nonprofit called Spring Valley Health Care Services. The nonprofit's board president is also Village President Marsha Brunkhorst, according to the most recent nonprofit tax form available from 2020.
When reached for comment last week by the Milwaukee Journal Sentinel, Brunkhorst said the village is cooperating with investigators and that Brown is no longer employed by the facility. She declined to comment on what the village board was doing in response to the incident.
The village is looking to find a nursing home management firm "as soon as possible," according to minutes from an August village board meeting. Village Trustee Brad Jorgenson said the village began exploring the possibility of a management firm even before the May incident, as a way to make the nursing home more profitable.
The removal of the 62-year-old patient's foot resulted in five citations against 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.
Brown, the 38-year-old nurse, used a pair of bandage scissors to sever the remaining tissue connecting the man’s foot to his ankle, according to the inspection report and the criminal complaint against her.
The man's foot had been hanging on by a tendon or two, and perhaps by a bit of skin, according to the records.
Brown faces felony abuse charges; she is scheduled to appear in court Dec. 6.
"In this case, there is enough blame to go around," said Sam Brooks, an attorney and public policy director with The National Consumer Voice for Quality Long-Term Care. "I am not excusing the behavior of the nurse but pointing out how the system failed this gentleman.”
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More details, more failures
The June inspection report includes more details about the chain of events leading up to the removal of the man’s foot, and his death six days later, as well as a string of failures by the facility’s leadership and its staff.
The resident had been at the nursing home since March, when he was admitted as a hospice patient with a severe case of frostbite that left his feet blackened. He was not cognitively impaired and, although he was in hospice care, was in charge of his own medical decisions.
The inspection found that staff at the facility repeatedly failed at key junctures to notify a doctor or hospice of the worsening condition of the man’s feet, including after a fall that caused further injury.
Staff at the nursing home went months without completing what should have been weekly assessments of his feet, inspectors found.
On May 25, two days before the amputation, the man fell out of bed and was found on the floor, according to the inspection report. The man was delirious and "talking in word salad."
His foot had become mostly detached from his ankle because of the fall, according to the report.
The staff members who found him repositioned his foot and bandaged it to keep it in place. But they did not tell a physician about the fall or the deterioration of his foot, the inspection report says.
Later that night, the man was still delirious, to the point he could not swallow his morphine pills, according to the report. Still, staff did not tell a physician or ask for advice on how to treat him. Nor did they tell one of the hospice nurses who came over from St. Croix County to provide care for the man.
Two days later, Brown — who was a staff nurse, not a hospice nurse — did not consult a physician or hospice before cutting the man's foot off, in the presence of two nursing aides. She did not document it in his chart or tell a physician what she did, inspectors found.
The nursing home's investigation of the incident, which was sent to the state on June 3, was missing interviews with hospice, the physician and the resident, inspectors found. It only included statements from Brown, Director of Nursing Tracy Reitz, and only one of the two nursing aides in the room when Brown cut off the foot.
An aide who did not witness the incident but was interviewed by state inspectors said that following the amputation, the resident's condition seemed to visibly worsen, according to the inspection report.
"She indicated the resident really declined after his foot was gone," the report said. "She said his color was worse and his condition overall was worse."
In a document submitted by the facility in response to the inspection, officials said they tried to interview the resident while he was still alive but that he was “verbally unresponsive.” They said hospice workers and the man's physician were not interviewed because no one from hospice was present during the incident and “there was no physician contacted before or after” the incident.
Nursing home had earlier problems
The 40-bed nursing home has been cited for similar problems in previous inspections − though none with such extreme consequences.
Since 2021, the facility has been cited on two other occasions for problems reporting or investigating instances of alleged abuse or possible crimes, including last year when a resident touched another resident in a sexually inappropriate way.
In that case, the facility did not report it to police or to regulators and did not investigate it at all, according to the inspection report. Regulators instead found out about the incident from a complaint. When they arrived to investigate, they found the then-director of nursing had told aides to omit information or lie about the incident. That director of nursing no longer works at the facility.
The nursing home was fined $10,000 in connection to that incident.
In the other case, which occurred in March, facility officials did not investigate after a resident who was being taken by van to an appointment slipped out of his wheelchair onto the foot rests and hit his head on a chair in front of him, according to the inspection report. He suffered a cut and bruising to his forehead, but a physician wasn't immediately told of the incident, the report says. Larson, the administrator, told inspectors the incident was never reported to him.
Larson did not respond to questions about the history of similar violations.
What a nurse can and can't do
The hierarchy of medical care is guided by a "scope of practice" for any licensed medical professional in the state, including doctors, nurse practitioners and registered nurses. The scope of practice outlines what medical professionals can and cannot do, according to state and federal law.
It is not within a registered nurse’s scope of practice to amputate a limb.
A physician interviewed by inspectors said that what Brown did was "not within the nurse's scope of practice."
Larson, the Spring Valley nursing home administrator, told the police investigator that the best practice would have been to ask a doctor for an order to amputate the man's foot, and that a doctor would have provided it, according to the criminal complaint.
However, doctors are never supposed to write orders or delegate tasks that are not within another health care worker’s scope of practice.
Brooks, the advocate for quality long-term care, echoed this, saying a doctor would never give such an order.
“Medicine is not about hypothesizing what a doctor would say. Nurses are not doctors and neither are administrators,” Brooks said. “I am astonished that an administrator would openly defend this nurse by claiming a doctor would have allowed it. I worry for every resident in this facility.”
The nursing home submitted what is called a "plan of correction" to the state in response to the violations, as is required to continue receiving federal funding. In the plan, nursing home officials said they provided continuing education and training to the nursing staff on issues identified in the inspection, including wound care, consulting with a physician about changes to a patient's condition, and identifying and reporting instances of alleged abuse. They also said they would monitor some of the issues by conducting regular audits.
It is unclear whether the facility will be, or has been, fined in relation to the May incident.
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