DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
441585 A. BUILDING __________
B. WING ______________ 		05/10/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CARIS HEALTHCARE 10651 COWARD MILL RD SUITE B, KNOXVILLE, TN, 37931
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0517      
40105 Based on agency policy review, medical record review, agency investigation review, and interview, the agency failed to prevent sexual abuse for 1 patient (Patient #1) of 4 patients reviewed for abuse. The findings include: Review of the agency policy titled, "Abuse, Neglect, Mistreatment, And Exploitation," reviewed 2/25/2020, showed "...[agency name] follows all Federal and State requirements regarding alleged violation involving mistreatment, neglect, or verbal, mental, sexual and physical abuse..." Medical record review showed Patient #1 was admitted to the agency on 11/4/2021 with diagnoses including Malignant Neoplasm of Sigmoid Colon, Vitamin D Deficiency, Melena, Traumatic Brain Injury, Renal Infarction, Post-Traumatic Stress Disorder, Panic Disorder, Depression, Low Back Pain, and Osteoarthritis. Review of Patient #1's Hospice Plan of Care dated 11/4/2021- 2/1/2021, showed the patient was alert and he was to have skilled nurse visits 1 time per week for 12 weeks. Review of Patient #1's visit note dated 11/4/2021, showed the Patient was alert and oriented to person, place, and time. Review of the visit schedule showed the patient was seen by Registered Nurse (RN) #1 on 11/4/2021, 11/10/2021, 11/15/2021, 11/22/2021, and on 11/30/2021. The patient was seen by Licensed Practical Nurse (LPN) #1 on 12/2/2021, 12/8/2021, and 12/10/2021 (phone call). Review of the agency investigation showed a Fact Finding Report dated 12/7/2021, "...[Patent #1] called the corporate office and was transferred to our office at approx. 9:44 AM 12/7/21. [Patient #1] stated to the Office manager...that he had been sexually assaulted by our nurse [RN #1]. He [Patient #1] told her [Office Manager] that he had video and photographic proof..." Review of the agency's Fact Finding Report dated 12/8/2021 showed "...I [The Administrator] received a call from...SW [Social Worker] at approx. 4:10 PM and said that there was an issue. She stated when she and the LPN [LPN #1] went to see patient [Patient #1] he asked them if they knew what was going on. They said they knew something was going on but had no idea what. He then proceeded to tell them that he had been a victim of sexual assault from our nurse [RN #1]. He then proceeded to show them several nude pictures of [RN #1] that he had on his phone...Employee suspended pending investigation..." Further review of the Administrators witness statement dated 12/8/2021, showed RN #1 reported to the Administrator that she had sent Patient #1 (2) nude photos of herself. Review of a Case Conference Summary dated 12/15/2021, showed "...Sw [Social Worker] completed initial visit with pt [patient] in his room on 12/8/2021...RN also present for visit. During SW's initial visit with pt on 12/8/2021, he reported that a prior nurse case manager [RN #1] had "sexually taken advantage " of him. The pt showed this SW pictures from his phone of the prior nurse case manager in compromising positions. SW reported this information to...Admin [Administrator]...Assessments have been completed for danger or harm to the patient and Investigations have been completed. The patient was offered the opportunity to move to another agency but was declined. SW will continue to monitor pt for distress..." Review of the agency's Request For Termination dated 12/10/2021, showed "...Involuntary Termination of [RN #1]...Chronology of Events Leading to Decision to Terminate: Accusation of sexual assault against patient and employee admitted to sending nude pictures to patient via phone..." During an interview on 5/9/2022 at 10:25 AM, the Administrator stated RN #1 had been Patient #1's nurse. The patient had only wanted nursing services at the time of his admission, he was seen weekly by the nurse, and had been on service for about 1 month when he reported the allegation of abuse. RN #1 had taken another position in the agency and was no longer going to be seeing patients. At that time, she was training another nurse to take her patients. The Administrator stated RN #1 had expressed to her that she was uncomfortable caring for Patient #1 and the Administrator had told RN #1 to tell Patient #1 that a new nurse would be seeing him because she had taken another role in the agency and would no longer be making patient visits. The Administrator stated on 12/7/2021, Patient #1 had called the agency's office and told the Office Manager he had been sexually assaulted by RN #1 and he had photo and video proof. The Administrator stated she then spoke to RN #1 about the patient's allegation and RN #1 had stated that she knew he was going to do that because she wasn't going to be his nurse any longer. The next day, on 12/8/2021, the Administrator had sent another nurse (LPN #1) and the SW to the patient's home. She stated she got a call from them saying he had shown them photos of RN #1 performing sexual acts with Patient #1 and it had been clear in the photos that the person was RN #1. The Administrator confirmed sexual relationships between employees and patients were not tolerated within the company and RN #1 was terminated on 12/10/2021. During a telephone interview on 5/9/2022 12:06 PM, SW #1, stated she went to see Patient #1 after he had made comments about a nurse "...doing something to him..." She stated she went to the patient's home with another nurse (LPN #1). SW #1 stated "...he flashed his cell phone in front of us and it was pictures of [RN #1] nude...one was of her clothed snuggling with him, her laying on his chest. He said that they had sexual intercourse, oral intercourse..." The SW confirmed the phots were of RN #1 and the patient had stated the photos were a mixture of ones he had taken of RN #1 and some she had sent to his phone. During a telephone interview on 5/9/2022 at 12:37 PM, LPN #1 stated she had went with SW #1 to Patient #1's home and he had shown her "...pictures of him having sex with [RN #1]..." and stated RN #1's face was visible in the photos. LPN #1 stated "...she was having sex with him [Patient #1]...oral sex with him... he also had video..." LPN #1 stated she did not watch the video and the patient had stated RN #1 had sent some of the pictures to his phone. LPN #1 confirmed the nurse in the photos was RN #1 "...it was [RN #1]...she took advantage of my patient..." During a telephone interview on 5/9/2022 at 3:24 PM, RN #1 stated she did have a relationship with Patient #1 "...We basically started dating and ended up having a relationship...initially it started by I called him using my cell phone and he started texting me constantly first about random things and then started talking more in depth...we started dating very briefly, then I told him if we were going to date that I couldn't be his nurse..." RN #1 confirmed she did have an intimate relationship with Patient #1 and they did have sexual intercourse. RN #1 stated "...honestly he initiated the intimate relationship, but It is my fault, I knew better..." RN #1 stated she tried to switch his care to a different nurse "...but he got mad about that and that's when the relationship ended, he told me that if you're not gonna be my nurse I don't need you...everybody knows there is an ethical boundary..." During a telephone interview 10:50 AM 5/10/2022, Patient #1 stated "...it's a plain up sure case of she drugged me up and raped me..." Patient #1 stated he did not have a consensual relationship with RN #1.