Survey Report for 441587

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	441587	A. BUILDING __________ B. WING ______________	10/30/2019
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
CARIS HEALTHCARE	208 SUNSET DRIVE, SUITE 370, JOHNSON CITY, TN, 37604
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
L0517	38389 Based on agency policy review, medical record review, agency documentation review, and interview the agency failed to ensure the right to be free from abuse for 1 patient (#1) of 14 patients reviewed for abuse. The findings include: Review of the agency policy, ABUSE, NEGLECT, MISTREATMENT, AND EXPLOITATION, reviewed 6/8/18, revealed "...POLICY STATEMENT: Caris Healthcare follows all Federal and State requirements regarding alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse...by anyone providing services on behalf of the hospice..." Medical record review revealed Patient #1 was admitted to the agency on 11/29/17 with diagnoses of Alzheimer's Disease, Dementia, and Age Related Osteoporosis. Continued medical record review revealed Patient #1 resided in an Assisted Living Facility (ALF). Medical record review of Patient #1's hospice plan of care revealed, "...Certification period From: 3/24/19 To: 5/22/19... Aide [Home Health Aide] 2 Week 8 [twice weekly for 8 weeks]; 1 Week 1 [once a week for one week]...Home Health Aide to assist with personal care..." Medical record review of Patient #1's visit calendar revealed Hospice Aide (HA) visits conducted by HA #1 on 4/15/19 and 4/18/19. Record review of the agency's "Gift log" (Grievance log) revealed 4/18/19, "...ALF staff reported allegations of [agency HA] being rough and rude with patient..." Record review of the agency's "Fact Finding Report" (agency investigation) revealed, "...Date Occurence Reported: 4/19/19...Person Reporting Event: [ALF Licensed Practical Nurse(LPN)]...Event being reported: Health Aide being rough and rude to patient...What happened?...On 4/18/19 [agency] HA forcefully...Put her fist on patient's head and shoved it under the hot water...Facility nurse stated patient normally doesn't speak but water was hot enough for patient to scream saying the water was hot...This was so forceful and rough that a facility staff member intervened at that point...Facility nurse and CNA [Certified Nurse Aide] both stated that [agency] HA was rude, loud, and very rough with patient...Facility nurse said...I don't think it's safe for her to see other patients...Potential Impact to patients/caregivers/family: Due to acts of this [agency] HA, unfortunately, the patient was mistreated and not treated with respect...The patient had to endure rough care and this is not appropriate for anyone to go through..." Telephone interview with ALF LPN #1 on 10/30/19 at 8:22 AM, revealed Patient #1 was very tiny, sweet, will not fight back, and she may say please or stop. "...I remember the staff reported the aide was being hateful, nasty, with her [Patient #1]...I wouldn't want her taking care of my loved one... the incident [on 4/18/19] my aide walked in on the [HA] giving her a shower... the staff said she was in the patients bathroom giving the patient a shower, being hateful with her... [Patient #1] does not say a lot, but she told her the shower was too hot... she [HA] had grabbed [Patient #1's] forehead, and pushed it into the shower with the shower too hot..." ALF Aide #1 stopped it and took over the care of the patient. ALF Aide #1 informed her of the incident after it happened when the Hospice Aide had left the facility. Telephone interview with ALF Aide #1 on 10/30/19 at 8:38 AM revealed, she was outside Patient #1's door, speaking with another patient when she heard Patient #1 yell the water was too hot. "...[Patient #1] says a phrase over and over "oh please"...the [HA] had [Patient #1] in the shower and I heard [Patient #1] say, "that's too hot" which was out of the ordinary...When I went in there, I put my hand under the shower, and it was too hot. I turned the water off and told the [HA] if [Patient #1] said it was too hot it was too hot..." Further interview revealed, "...When I opened the door to the bathroom, she [HA] had her knuckles made into a fist onto [Patient #1's] forehead to hold her forward into the water that was too hot [fist left hand, sprayer for shower right hand]..." Continued interview revealed, the agency had contacted her about the incident, and the shower was the first encounter she had with the HA. Continued interview revealed, "...[HA] said "well, it feels fine to me" despite the patient telling her it was too hot...Yes, I think it was abuse...You have to have a heart when taking care of older people, you can't just throw them around...I understand people have bad days, but you can't treat people that way...I would not feel comfortable with her caring for other patients...I can only imagine what else she would do, and that's what bothers me the most..." ALF Aide #1 became tearful when asked if she felt abuse had occurred to Patient #1 on 4/18/19. Interview with the agency Patient Care Manager (PCM) on 10/30/19 at 10:41 AM, in the Administrator's office, revealed ALF LPN #1 called on 4/19/19 and told her there was a HA they had concern about. "...The incident was when she had the water on hot and she basically forced her head under the water, and that's when [Patient #1] screamed out that the water was hot... [ALF Aide #1] told [ALF LPN #1] and then they called me and made me aware...I called the [agency Administrator] and told her what had happened and called the agency Regional Vice President (RVP) to let her know..." Continued interview revealed the RVP told her to fill out the fact finding form and to suspend the HA immediately until the investigation was completed. The RVP called the agency Vice President of Human Resources to make him aware of the suspension. Further interview revealed the PCM called the agency HA and told her she needed to come into the office. She called the patient's daughter on 4/19/19 and made her aware. "...She was nice and honestly I don't think that I would have been..." Continued interview revealed the HA came in the office on 4/19/19 and she was informed of the suspension, notified of the investigation, and questioned about the incident "...she did not admit or deny...she said the patient was trying to get up so she had to hold her down...she did not have a rebut to the hot water..." Further interview revealed she offered for the HA to make a written statement and she said she would have to think about it. The PCM offered to let her write a statement over the weekend and email it, with no response. On Monday 4/22/19, the Administrator spoke with the agency VP of Human Resources and informed him of the concerns. "...She wasn't a right fit and after the incident that happened on 4/18/19 we asked if it was enough for termination given she was in her 30 days from hire..." Continued interview revealed the HA was terminated on 4/23/19 "...to be honest it being abuse never crossed my mind...looking back now, Yes, I do feel like she was abused that day...if she was nonverbal and it made her say something, that's pretty bad..." Further interview confirmed Patient #1 had been abused by the agency HA.