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SV nurse cut off patient’s foot without permission

Woman facing felony charges for amputation

A Durand woman who used to work at Spring Valley Health Care & Rehabilitation Center allegedly cut off a 62-year-old patient’s foot without permission and made jokes about putting it in a taxidermy display.

Felony physical abuse of elder person – intentionally cause great bodily harm and felony mayhem, both with the increased penalty for elder person victim, charges were filed Nov. 3 in Pierce County Circuit Court against Mary K. Brown, 38. She has not yet appeared in court. If convicted, she faces up to $100,000 in fines and/or 40 years in prison.

According to the complaint: Pierce County Medical Examiner John Worsing contacted a Pierce County Sheriff’s Office investigator June 4 regarding the death of a 62-year-old man at Spring Valley Health & Rehabilitation Center (S830 Westland Drive). The man’s body had been sent to Ramsey County, Minn. for an autopsy due to the unusual circumstances of his death. When Worsing viewed the body at the funeral home, his foot was not attached to his body; it was lying beside him.

The man had been at the nursing home because he had fallen in his home and the heat went out, resulting in severe frostbite in both feet, which became necrotic. He entered SVHCRC in March 2022. When Worsing reviewed the man’s medical chart, it indicated that Brown had amputated his right foot on May 27.

According to the chart’s notes from a St. Croix Hospice nurse dated June 1, a SVHCRC nurse (Nurse 1) told her that at shift change May 27, Brown had told her she was going to cut off the man’s foot for comfort. Nurse 1 and another nurse told her not to and to leave the foot attached. Nurse 1 said when she went into the man’s room at 8 a.m. May 27, two or more inches of flesh and a tendon kept the foot attached to the man’s body. Later that night at 4 or 5 p.m., Brown and two Certified Nursing Assistants (Nurses 3 and 4) went into the man’s room to do a bandage change, at which time Brown decided to cut the tendon and flesh and amputated the foot with a gauze scissors. The foot had been broken prior to the incident.

She allegedly told the CNAs she couldn’t figure out why no one had amputated it yet and started cutting it with the scissors. It took about one minute to cut through the flesh and tendons. Brown didn’t know what she should do with the foot, so Nurse 3 asked Nursing Home Administrator Kevin Larson, who wanted to throw it away. It was eventually decided to put the foot in a Ziplock bag, then in a biohazard bag, and Larson put it in a basement freezer. Nurse 3 said she wanted to call Director of Nursing Tracy Reitz, but Larson did not call her.

Nurse 1 stated that no physician had ordered the amputation. The foot, which was black, was placed in a freezer in the basement to be sent with the man’s body to the funeral home when he died. Nurse 1 reported the incident to the state. She also told the hospice nurse that the man told her during the amputation, he felt everything and “it hurt very bad.” Nurse 4 said he had gripped her hand tightly during the amputation and moaned a little.

The hospice nurse reported the incident to Reitz, and Reitz told her that Brown and one of the CNA’s said the man appeared to have no pain during the procedure. Nurse 4 said the victim moaned when the tendon was cut and his foot amputated and that Brown had been pushing her to retrieve it so she could preserve it for a taxidermy display at her family’s business, which she thought was weird. She said Brown had been talking about cutting off the foot and they had all told her not to.

Another nurse told the investigator that on Thursday, May 26, the man was still able to wiggle his toes and that two tendons and 5 centimeters of skin were holding the foot to the body. She said Brown apologized for cutting off the foot and said it was her intent to help the man pass away with some dignity. Brown also told the nurse that her family owns a taxidermy shop and that she wanted to preserve the foot and put it on display with a sign that said, “Wear your boots kids.”

Nurses said the man’s family did not know about the amputation.

Larson told investigators that he completed a self-report for the state and that he had a five-day window to do so, per state policy. He said the incident was reported late because the state portal was down. Brown never wrote a report on the incident and nothing was written in the man’s chart on May 27 except for a medication note from St. Croix Hospice. In fact, the man’s chart had many missing entries. Larson also said Brown hadn’t asked for permission to cut off the man’s foot and that no doctor had ordered it.

Larson told investigators he believes a doctor would have ordered the amputation and that Brown did it for the man’s dignity and comfort. He said he had told Brown to just stabilize the foot because the man was close to dying, possibly within hours. The man hung on longer than people expected and Brown thought cutting off the foot was the right thing to do. When Brown asked him what to do with the foot, he thought it had just fallen off. He admitted that it was wrong that she removed it without a doctor’s orders.

Reitz told investigators that the foot was dead, foul smelling and hanging on by a tendon. She also said the man was “slightly coherent” and apologetic about the foot’s smell, which she likened to a mummy. She said that in the past, other patients’ toes have fallen off and staff has kept them in the freezer. She was notified of the incident on May 29 by Nurse 3, who was distraught by the incident. She too said the foot should have been removed by a doctor and that she spoke with Brown about the “scope of her practice” and what she should have done. Reitz felt Brown did it for compassion without malice, but had not documented the incident.

Brown told police she cut off the foot so she could get Vaseline gauze right on the stump to provide comfort. She said the man never showed signs of feeling the amputation and that she thought he would like it better if the foot were gone. When asked about her scope of practice, Brown admitted she should have gotten a doctor’s order and called a doctor first. Because of the state of his feet, she thought that the doctor would just tell her to leave it alone. She admitted that the man never asked her to remove his foot.

Administrators of the nursing home agreed that it was outside of the scope of Brown’s practice to conduct such a procedure and a doctor’s order was necessary prior to any amputation. Brown no longer works at the facility, according to a nursing home employee, but had put in her two weeks’ notice before the incident and was allowed to finish out her time.

Brown is slated to appear in Pierce County Circuit Court at 9:45 a.m. Dec. 6.

November 8, 2022