IN THE COURT OF CRIMINAL APPEALS OF TENNESSEE

AT NASHVILLE

Assigned on Briefs April 9, 2024

STATE OF TENNESSEE v. GARDTRELLA MARIE DAY-KNOWLES

Appeal from the Criminal Court for Davidson County

No. 2020-A-689 Jennifer Smith, Judge

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No. M2023-00644-CCA-R3-CD

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The Appellant, Gardtrella Marie Day-Knowles, was convicted by a Davidson County jury 

of neglect of an impaired adult, for which she received a sentence of seven years’ 

supervised probation. See Tenn. Code Ann. § 71-6-117 (2017) (amended 2019, repealed 

2020). On appeal, the Appellant argues that the trial court erred by: (1) allowing witnesses 

to describe conditions of animal neglect in her home; (2) refusing to redact an unfairly 

prejudicial comment from the victim’s medical records; and (3) allowing a witness to 

testify about her memory of the contents of a report under the public records hearsay 

exception. After review, we conclude there was no reversible error and affirm the judgment 

of the trial court.

Tenn. R. App. P. 3 Appeal as of Right; Judgment of the Criminal Court Affirmed

CAMILLE R. MCMULLEN, P.J., delivered the opinion of the court, in which JILL BARTEE 

AYERS, and MATTHEW J. WILSON, JJ., joined.

Martesha Johnson Moore, District Public Defender, and Emma Rae Tennent (on appeal) 

and Casey Elliot and Crandall Story (at trial), Assistant District Public Defenders, for the

appellant, Gardtrella Marie Day-Knowles.

Jonathan Skrmetti, Attorney General and Reporter; Katherine Orr, Assistant Attorney 

General; Glenn Funk, District Attorney General; and Brittani Flatt and Mindy Vincore, 

Assistant District Attorneys General, for the appellee, State of Tennessee.

OPINION

The victim, Cheoril Howard, suffered an anoxic brain injury in 2006 that resulted 

in an inability to walk, speak, swallow, or control her bladder and bowel. Her daughter, 

05/24/2024
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the Appellant, became her caretaker. For eleven years, TennCare provided the victim with 

home health services. In 2018, however, the victim lost her insurance coverage and the 

home health services ceased.

On October 25, 2018, the Appellant called 911 because the victim was seizing. 

When emergency personnel arrived, they discovered the victim in horrific conditions. The 

home smelled of feces, urine, and “death.” The floor was covered in feces and trash. The 

victim’s PEG, or feeding tube, was non-functioning, meaning that she had not been 

receiving adequate nutrition or medication. She was severely underweight, covered in bugs 

and feces, and lying in rotten feeding solution. The bed sores on her body and the large 

indentation in her mattress indicated that she had been lying in the same position for a long 

period of time. The victim was transported to the hospital, and the Appellant was later 

charged with gross neglect of an impaired adult. See Tenn. Code Ann. § 71-6-119 (2007) 

(amended 2019, repealed 2020).

Pretrial Motions in Limine. Defense counsel filed several pretrial motions in 

limine to exclude evidence. As relevant to this appeal, she filed a Rule 404 motion to 

exclude evidence of prior bad acts relating to the Appellant’s animals and a Rule 401/403 

motion to redact statements contained in the victim’s medical records. See Tenn. R. Evid. 

401, 403, 404.

The Rule 404 motion specifically sought to prohibit references to animal control, 

testimony about animals or their conditions, and photographs of animals or their living 

conditions. Defense counsel argued that such evidence was inadmissible because its only 

purpose was to show that the Appellant neglected her animals and therefore must have also 

neglected her mother. During a hearing on the motion, she argued that the animal control

officer should be prohibited from testifying entirely because her testimony would be both 

cumulative and prejudicial. The State said it did not intend to introduce photographs of the 

animals or ask any witnesses about the neglect of the animals. The State argued, however, 

that the condition of the home including the animal feces, “overflowing” litter box, and 

ammonia smell was relevant evidence. The trial court denied the motion in part, stating:

The animal control officer has direct knowledge about the condition of the 

residence, about the odor, about the things that she saw involving the feces 

and the litter box and the stability of the flooring and other things that are 

absolutely relevant to a charge of neglect, which is a continuing offense. And

I’m not going to limit the State’s case, certainly not on cumulative grounds, 

because of the burden that they bear.
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I will prohibit the [] animal control officer from testifying or offering any 

testimony about potential neglect of animals or the condition of the animals 

themselves.

The court also directed the State not to introduce photographs of the dog. 

The Rule 401/403 motion sought to redact several statements from the victim’s 

medical records that contained “inflammatory, prejudicial, and irrelevant language.” As 

relevant to this appeal, defense counsel sought to redact the following statement:

APS [“Adult Protective Services”] contacted. It will be a travesty if APS 

does not seek removal from her current living situation. The patient had a 

clogged PEG tube and was not receiving nutrition nor medication. She was 

covered in excrement (per EMS) and her daughter will not participate in her 

discussions regarding her care (per Palliative Care). Long term placement 

will be needed.

At a hearing on the motion, defense counsel argued that it would “not [be] proper for the 

jury to review [Dr. Carrico’s] opinion on that. It is inflammatory language and it is greatly 

prejudicial and not probative in this case at all.” The State argued that the language was 

not inflammatory and was simply “verification of what he observe[d] about [the victim’s] 

condition and what he wants to see happen with [her] treatment plan[.]” The trial court 

ruled that the statement was admissible because “it has to do with . . . the discharge planning 

and [] the doctor’s opinion about where she should be living during that [] post[-]discharge 

period is relevant[.]” 

Trial. At trial, Karin Jenkins, a former captain and Emergency Medical Technician 

(“EMT”) for the Nashville Fire Department, testified that on October 25, 2018, she and 

another EMT were dispatched to a home for reported seizures. When they arrived, the 

Appellant opened the door. The home was “in total disarray.” There was an “unbelievable 

stench of feces and urine,” and piles of feces on the couch and floor. In the kitchen, there 

was a dog. The floor was torn and “looked like [the dog] had been trying to eat [it].” There 

was a sink full of dirty dishes, “rotten [and] molding.” A photograph of the kitchen was 

admitted into evidence. 

When Ms. Jenkins reached the victim’s room, she smelled “the stench of decay.” 

The victim was curled in a ball on a hospital bed, seizing. Bugs were crawling on her and 

the bed. There was a feeding bag hanging from an IV pole, but the tube that attached to 

the victim had fallen on the floor. The floor was “covered in filth” and “unrecognizable as 

carpet.” A photograph of the feeding tube on the floor was admitted into evidence. The 

Appellant told Ms. Jenkins she fed the victim approximately thirty minutes before and the 
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feeding tube must have disconnected during the seizure. Ms. Jenkins did not believe the 

Appellant because both the inside of the feeding bag and the victim’s feeding port in her 

abdomen were “dry and crusty.” Photographs of the feeding bag were admitted into 

evidence.

Ms. Jenkins described the victim as “filthy.” The victim’s hair was matted and she 

was wearing a full diaper that had been there “for way, way, way too long.” She was 

“unbelievably underweight” and dehydrated. When Ms. Jenkins and the other EMT lifted 

the victim, a bed sheet stuck to her body. They transported the victim with the sheet 

because they feared they could not safely separate it from her skin. Underneath the victim 

was a “curdled, rotten substance” that Ms. Jenkins believed was rotten feeding solution. 

Because of a large indentation in the mattress, the victim had been lying on the hard surface 

underneath the mattress. A photograph of the indentation and the bugs on the mattress, 

along with videos of the bugs crawling on the mattress and around the feeding tube, was 

admitted into evidence. 

Ms. Jenkins loaded the victim into the ambulance and called the police department

and animal control. When she reentered the home to retrieve her medical bag, the 

Appellant was removing items from the victim’s room. Despite the fire department’s 

prohibition on taking photographs, Ms. Jenkins began taking photographs of the scene to 

document the “horrific” conditions.

Andrey Volfson, a former patrol officer for the Metropolitan Nashville Police 

Department (“MNPD”), testified that the fire department requested his assistance at the 

home. The home had a putrid smell that he compared to the smell of a corpse. He noticed 

large clumps of animal hair throughout the house and on the walls. The victim was still in 

her room and appeared “indented into the mattress.” She looked thin, extremely sick, and 

significantly older than her actual age of fifty-five. Mr. Volfson tried to communicate with 

her, but she was unresponsive. He spoke with the Appellant, the victim’s caretaker, who 

said there was mold in the home. He contacted APS.

Ashley Harrington, an animal control officer, testified that the home was in “kind 

of [a] deplorable condition[].” In the kitchen, a dog was tied to the kitchen table with a 

retractable leash. There were piles of feces and a comforter that had been “torn up” and 

“strewn about the kitchen.” The flooring was also torn and “very uneasy to walk on.” Ms. 

Harrington was told there were two cats in the bedrooms. There was a “very full” litterbox 

in the bathroom and a strong ammonia smell.

Jeremy Ivey, a paramedic for the Nashville Fire Department, testified that there was 

a strong smell of urine and feces in the home. He observed feces on the floor, and trash 

covering the floor and the furniture. His boots stuck to the carpet because it was “so filthy.” 
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There was a dog in the home. When he entered the victim’s room, there was a “smell of 

death.” The victim was lying in a hospital bed and seizing. There was a feeding bag 

containing a dried substance attached to an IV pole. The portion of the feeding tube that 

attached to the victim’s body was lying on the floor “in filth.” He observed cockroaches 

and other bugs on the victim’s body. There was an “imprint” in the mattress because the 

victim had not been moved. The skin on the victim’s back was broken from lying in the 

same position for a long period of time. The Appellant said she was changing the victim’s 

diaper and was about to start her feeding tube when the victim began seizing.

Defense counsel filed a written motion for a mistrial. She said that, despite the trial 

court’s ruling that all mentions of the dog should be excluded from testimony, four 

witnesses mentioned a dog chained to a table in the kitchen. She argued that this evidence 

violated Rule 404 and denied her the right to a fair trial. The court denied the motion, 

reasoning that the testimony did not go beyond the bounds of its pretrial ruling and if it did, 

defense counsel failed to contemporaneously object. 

Maria Pardue, a paramedic for the Nashville Fire Department, testified that she 

arrived at the home after the victim had been transported to the hospital. There was a large 

stack of boxes and minimal furniture. As she walked, her feet stuck to the floor. There 

was a strong smell of feces and urine. She observed a large hole in the kitchen floor. In 

the victim’s room, there was “obvious insect activity, both dead and alive.” There was a 

large indent in the bed, which develops if a bedbound patient is not rotated regularly. The 

portion of the feeding tube that attached to the victim’s stomach was on the floor. The 

feeding bag contained “dried crackly parts” which indicated that the bag had not been used 

to administer food recently. The room did not contain certain medical supplies necessary

to care for a bedbound patient, including skin wipes and diapers. In the bathroom directly 

across from the victim’s room, there was mold in the bathtub and a black substance in the 

toilet. Ms. Pardue “went against the rules” of the department and took photographs of the 

home because she “felt like what [they] saw and what [they] experienced needed to be 

documented beyond [their] words.”

Nurse Blaire Knighton testified that she was working in the emergency room when 

the victim arrived after having a seizure. The victim had a preexisting anoxic brain injury 

that impeded her ability to swallow. The victim received food and medication from a PEG

tube, which was “crusty.” After ensuring the victim was stable, Nurse Knighton cleaned 

the victim. There was feces “caked” onto the victim’s body and a dead bee in her diaper. 

Nurse Knighton removed dead roaches and bugs that had been imprinted into the victim’s 

legs “because she had been [lying] on them for so long.” The victim was extremely thin

and her toenails were overgrown. The victim’s hair on the right side had been “rubbed off” 

and the tissue had been damaged from lying on the same side for too long. An APS report 
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was filed within an hour of the victim’s arrival because Nurse Knighton “knew that this 

woman [could not] go back to the place that she [came] from.” 

The State questioned Nurse Knighton about the care of uninsured patients. Nurse 

Knighton said the hospital treats uninsured patients and employees are not allowed to ask 

about a patient’s insurance until after the patient has been evaluated by a doctor. If a patient 

is uninsured, the hospital has employees who can help them get insurance. Nurse Knighton 

indicated that a patient like the victim should have been able to receive home health 

services through an insurance program.

On cross-examination, Nurse Knighton acknowledged that tissue damage or “bed 

sores” can develop even when a patient is receiving proper medical care. People who are 

immobile and incontinent, like the victim, are at a higher risk of developing bed sores. Bed 

sores are classified in four stages, with stage four being the most severe. The victim’s bed 

sores were stage one. Nurse Knighton also acknowledged that she could not tell how long 

it had been since the victim had received her seizure medication. 

Nurse Sarah Perry testified that she treated the victim at the hospital. The victim’s 

medical records were admitted into evidence over the objection of defense counsel. The 

victim was 64 inches tall and weighed only 63.3 pounds, which indicated she was not 

getting the nutrition she needed. Her skin was damaged from lying on one side 

continuously. To prevent such damage, a patient must be turned every two hours and their 

skin must be continually cleaned. The victim received nutrition and seizure medication 

through a gastric tube. The victim’s skin around the tube was “broken down” which 

indicated the tube was leaking. A leak may occur when a patient’s weight drastically 

changes because the surgically implanted tube is no longer the correct size. The victim’s 

tube was replaced while she was in the hospital. The victim did not have any seizures in 

the hospital because she was receiving her seizure medication. 

One week after the victim’s arrival at the hospital, the Appellant came to see her. 

The Appellant asked Nurse Perry when the victim would be coming home, and Nurse Perry 

said she was not sure if the victim would be coming home. The Appellant became agitated 

and told her that she took good care of the victim. The Appellant blamed the victim’s 

malnourishment and bed sores on “[t]he health services.” The Appellant returned one week 

later and again said she wanted the victim to go home with her. She said “the checks” she 

needed to cover the victim’s expenses had stopped coming. She had been caring for the 

victim for twelve years, but home health stopped coming in January that year. She said 

she would prefer for the victim to go to a long-term facility if no one was going to help her 

at home. The victim was discharged to a skilled nursing facility.
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On cross-examination, Nurse Perry acknowledged that the victim’s PEG tube 

clogged during her hospital stay, despite being checked multiple times a day. On redirect 

examination, she emphasized that clogs happen frequently and are easily fixed, whereas 

surgical replacement of a PEG tube is rare.

Tessa Aquino, a former APS investigative specialist, testified that she was assigned 

to assist the victim. Four days after the victim’s arrival at the hospital, Ms. Aquino met 

with her. The victim was unable to communicate verbally and was “very skinny and 

contracted.” A photograph of the victim was admitted into evidence. While Ms. Aquino 

was at the hospital, the Appellant and her children came to see the victim. The Appellant

said she was unemployed and survived on the $800 per month in social security income 

that she received for the victim’s care. The Appellant said the victim was supposed to go 

to Neighborhood Wound Care weekly, but records showed she had only gone three times 

in the past seven months. The Appellant wanted the victim to return to her home, but the 

hospital employees wanted her to be discharged to a nursing facility. Ms. Aquino sought 

emergency temporary custody of the victim. The court order granting temporary custody 

was admitted into evidence. Ms. Aquino also notified the Social Security Administration 

that the victim’s funds were not being used for her care. 

Ms. Aquino referred the victim to Choices, a TennCare program that provides either 

in-home care or funding for nursing home care. This program would have funded more 

care than what the victim’s insurance provided. However, the victim’s insurance would 

have provided for home health services had the Appellant called the insurance company. 

The Appellant had been offered additional services through Choices in the past, but 

declined the services. She did not want her mother to go to a nursing home because “it 

might affect the life insurance policy.” At the mention of a life insurance policy, defense 

counsel requested a bench conference. Defense counsel argued that the Appellant’s 

statement was from a previous report. The State argued that the report was not hearsay as 

a public record or report under Rule 803(8), nor was the statement hearsay as a statement 

of a party opponent under Rule 803(1.2). The trial court overruled the defense’s objection.

Ms. Aquino testified that a court granted APS permanent custody of the victim. The 

victim was discharged to a nursing facility, where she regained a limited ability to swallow. 

After one year, her weight had almost doubled. 

Doctor Brian Carrico testified that he treated the victim at the hospital. When the 

victim was admitted to the hospital, her PEG tube was non-functioning because it was

clogged. The victim, therefore, had not been receiving her seizure medication or nutrition. 

She was severely underweight and had significant muscle wasting caused by malnutrition. 

Doctors replaced her PEG tube using interventional radiology. The victim was discharged 

to a skilled nursing facility. Approximately two years later, she died from COVID-19.
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The Appellant testified that she became the victim’s caretaker in 2006. At that time, 

the Appellant was twenty-seven-years-old and had three children ages twelve, nine, and 

five. The hospital set up twenty-four-hour nursing care, covered by TennCare. TennCare 

also provided the majority of the necessary medical supplies and transportation to medical 

appointments. The nurse fed the victim a meal in the mornings, and tube fed the victim at 

night. When the victim’s “trache” was removed, TennCare reduced the nursing care to 

twenty-seven hours per week, and provided a care assistant ten hours per week. The 

Appellant was responsible for the victim’s care at night. Prior to the victim’s hospital 

admission, the Appellant had been trying to get her a new hospital bed. TennCare said the 

victim would not be eligible for a new bed until the following year, so the Appellant had 

been placing extra blankets on top of the mattress.

The Appellant was notified in 2017 that the victim was going to lose her insurance 

coverage. She wrote a letter to TennCare to try to get the insurance back; the letter was 

admitted into evidence. Her appeal was denied. The Appellant began having to pay for 

the victim’s supplies such as Ensure and diapers. The victim’s social security income was 

usually not enough to cover their bills and expenses, and her sister and aunt “pitched in [] 

routinely.” She could not work because she had to care for the victim. She did not take 

the victim to doctor’s appointments because she did not have reliable transportation. She 

did take the victim to the hospital sometime in 2018 when she could not afford Ensure. 

Then, Medicaid began paying for feeding solution and bags. The Appellant changed the 

victim’s clothes and bedding every other day. In the mornings, the Appellant would put 

the victim in her wheelchair until midday. The Appellant lived in Section 8 housing, and 

the home was “falling apart.” She was in the process of moving.

The Appellant described the day paramedics took the victim to the hospital. The 

Appellant was gone for an hour and a half that morning. When she returned, the victim 

was having a seizure. She pulled the covers back, and the victim’s feeding tube fell on the 

floor. She did not tell Ms. Jenkins that she had just fed the victim. She only tube fed the 

victim at night. She emphasized that she tried to do what she could and did not realize the 

victim was in danger in her care. 

On cross-examination, the Appellant said she gave the victim Ensure because she 

could not afford the feeding solution. The Appellant acknowledged that there was an APS 

referral in 2017, while the victim still had some home health services. She said James 

Calway at APS told her that he could help her get additional care through TennCare and 

Choices. She denied, however, that she expressed concern about losing life insurance 

proceeds if she enrolled the victim in Choices. She said the victim never had life insurance. 

On redirect examination, she said the reason she did not want to enroll the victim in the 

Choices program is because if TennCare decided not to cover the services, she would be 
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financially responsible for them. The photographs of the Appellant’s home taken during 

the 2017 APS investigation were admitted into evidence. The photographs, which the 

Appellant said were an accurate representation of what the home usually looked like, 

showed a clean kitchen and living room. 

On rebuttal, James Calway, an APS investigative specialist, testified that he 

investigated a report about the poor condition of the Appellant’s home in 2017. The home 

was infested with cockroaches. Mr. Calway referred the victim to Choices, which would 

provide five additional hours of care and free pest control. The Appellant said she 

anticipated getting a life insurance policy and was concerned how the Choices program 

would affect her ability to do so. He never told her that she might have to pay for the home 

health or pest control services. A Choices representative attempted to contact the Appellant 

but the Appellant did not return any of her phone calls. 

The jury convicted the Appellant of the lesser included offense of neglect of an 

impaired adult.1 After a hearing, the trial court sentenced the Appellant to seven years’ 

supervised probation. The Appellant filed an unsuccessful motion for new trial.

ANALYSIS

On appeal, the Appellant challenges several of the trial court’s rulings on the 

admissibility of evidence. The admissibility of evidence rests within the sound discretion 

of the trial court, whose ruling we will not disturb absent an abuse of discretion. State v.

Clayton, 535 S.W.3d 829, 859 (Tenn. 2017). A trial court abuses its discretion when it 

“applies an incorrect legal standard or reaches a conclusion that is ‘illogical or 

unreasonable and causes an injustice to the party complaining.’” State v. Lewis, 235 

S.W.3d 136, 141 (Tenn. 2007) (quoting State v. Ruiz, 204 S.W.3d 772, 778 (Tenn. 2006)).

To be admitted, evidence must be relevant. Tenn. R. Evid. 402. Relevant evidence 

is “evidence having any tendency to make the existence of any fact that is of consequence 

to the determination of the action more probable or less probable than it would be without 

the evidence.” Tenn. R. Evid. 401. Even relevant evidence, however, “may be excluded 

if its probative value is substantially outweighed by the danger of unfair prejudice, 

confusion of the issues, or misleading the jury, or by considerations of undue delay, waste 

of time, or needless presentation of cumulative evidence.” Tenn. R. Evid. 403. Unfair 

prejudice is “an undue tendency to suggest decision on an improper basis, commonly, 

 

1 Though it does not impact this appeal, the definition of neglect of an impaired adult provided in the jury 

instruction contains an error. The trial court instructed the jury that it must find that the defendant grossly

neglected an impaired adult. The statute contains no such requirement. See Tenn. Code Ann. § 71-6-117 

(2017) (amended 2019, repealed 2020) (“It is an offense for any person to knowingly, other than by 

accidental means, abuse or neglect any adult within the meaning of this part.”).
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though not necessarily, an emotional one.” State v. Banks, 564 S.W.2d 947, 951 (Tenn. 

1978) (quoting Fed. R. Evid. 403 advisory committee note). 

I. 404(b) Evidence of Animal Neglect. The Appellant argues that the trial court 

erred by allowing witnesses to describe conditions of animal neglect in her home. She 

specifically points to Ms. Harrington’s testimony, wherein she said she was summoned to 

the home as an animal control officer and described piles of feces, a “very full” litterbox, 

an overwhelming ammonia smell, and a dog tied to the kitchen table with a retractable 

leash. She also points to Ms. Jenkins’ testimony that it looked like the dog had been trying 

to eat the kitchen floor. She contends that this testimony of a prior bad act violated 

Tennessee Rule of Evidence 404(b) because it was only relevant to prove her character. 

Alternatively, she argues that even if the testimony was admissible for another purpose, it 

should have been excluded because its probative value was outweighed by the danger of 

unfair prejudice. See Tenn. R. Evid. 404(b)(4). The danger of unfair prejudice lies in the

“opportunity for the jury to infer that, because [the Appellant] did not properly care for her 

pets, she must also have committed the crime of neglect charged in this case.” The State 

responds that evidence of the conditions the victim was subjected to in the Appellant’s 

home was relevant to prove the charged offense of gross neglect of an impaired adult. We 

conclude that the testimony related to the conditions of the home was properly admitted, 

but the testimony about the dog being tied to the kitchen table with a retractable leash and 

trying to eat the floor should have been excluded.

“Evidence of other crimes, wrongs, or acts is not admissible to prove the character 

of a person in order to show action in conformity with the character trait.” Tenn. R. Evid. 

404(b). This rule recognizes that such evidence “carries with it the inherent risk of the jury 

convicting the defendant of a crime based upon his bad character or propensity to commit 

a crime,” rather than convicting him based on the strength of the evidence. State v. 

Thacker, 164 S.W.3d 208, 239 (Tenn. 2005) (citing State v. Rickman, 876 S.W.2d 824, 

828 (Tenn. 1994)). This risk is “particularly strong when ‘the conduct or acts are similar 

to the crimes on trial.’” State v. Clark, 452 S.W.3d 268, 289 (Tenn. 2014) (quoting 

Rickman, 876 S.W.2d at 828). Such evidence, however, may be admissible for “other 

purposes” such as establishing motive, intent, guilty knowledge, identity of the defendant, 

absence of mistake or accident, a common scheme or plan, contextual background, 

opportunity, or preparation. Tenn. R. Evid. 404(b); State v. Berry, 141 S.W.3d 549, 582 

(Tenn. 2004).

Before admitting evidence of other crimes, wrongs, or acts, the following 

requirements must be met:

(1) The court upon request must hold a hearing outside the jury's presence;
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(2) The court must determine that a material issue exists other than conduct 

conforming with a character trait and must upon request state on the record 

the material issue, the ruling, and the reasons for admitting the evidence;

(3) The court must find proof of the other crime, wrong, or act to be clear and 

convincing; and

(4) The court must exclude the evidence if its probative value is outweighed 

by the danger of unfair prejudice.

Tenn. R. Evid. 404(b). If the trial court substantially complies with these requirements, we 

will review its ruling for an abuse of discretion. Clark, 452 S.W.3d at 287 (citing State v. 

DuBose, 953 S.W.2d 649, 652 (Tenn. 1997)). Without substantial compliance, however, 

the trial court will be afforded no deference. DuBose, 953 S.W.2d at 652.

Because the trial court failed to evaluate whether the danger of unfair prejudice 

outweighed the evidence’s probative value, we will review its ruling de novo. See id.; 

State v. Sexton, 368 S.W.3d 371, 404 (Tenn. 2012) (holding that the trial court’s ruling 

was not entitled to deference when it failed to find that the prior act was proven by clear 

and convincing evidence). Prior to trial, the trial court prohibited the State from presenting 

direct testimony about the neglect of animals. The court declined, however, to limit 

testimony about the conditions of the home, including those that suggested an animal in 

the home was being neglected. After a de novo review, we conclude that though the

majority of the testimony was admissible to establish gross neglect of the victim, the

testimony about the dog being tied to the kitchen table with a retractable leash and trying 

to eat the floor should have been excluded.

Testimony about the conditions of the home, including the feces, full litter box, and 

ammonia smell was properly admitted. This evidence was relevant to establish that the 

Appellant grossly neglected the victim, which was an element of the charged offense. 

Tenn. Code Ann. § 71-6-119(a) (2007) (amended 2019, repealed 2020) (“It is an offense 

to knowingly, other than by accidental means, physically abuse or grossly neglect an 

impaired adult if the abuse or neglect results in serious mental or physical harm.”). The 

proof of the conditions of the home is clear and convincing based on the photographs of 

the home and the testimony of multiple witnesses who observed the conditions. Though 

this evidence could lead to an inference that the Appellant neglected her animals, the 

danger that the jury convicted on this improper basis does not outweigh its probative value. 

The probative value is substantial because the testimony shows that the Appellant failed to 

maintain a sanitary environment necessary for the victim’s care.
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Testimony about the dog being tied to the kitchen table with a retractable leash and 

trying to eat the kitchen floor, however, should have been excluded. These specific facts 

are not relevant to establish an essential element of the charged offense or for any other 

permissible purpose. The testimony was therefore inadmissible under Rule 404(b). The 

erroneous admission of the testimony, however, does not entitle the Appellant to relief 

because she cannot show that it more probably than not affected the verdict. See Clark, 

452 S.W.3d at 287 (when a trial court erroneously admits evidence, the defendant bears 

the burden of showing that the evidence more probably than not affected the verdict); Tenn. 

R. App. P. 36(b). There was overwhelming evidence that the Appellant neglected the 

victim. The victim’s PEG tube was non-functioning, meaning that she had not been 

receiving adequate nutrition or medication. She was severely underweight, covered in bugs

and feces, and lying in rotten feeding solution. She had not been rotated as required for 

bedbound patients, causing bed sores and a large indention in her mattress. Accordingly, 

the error was harmless. 

II. Dr. Carrico’s “Travesty” Statement. The Appellant next argues that the trial 

court abused its discretion by refusing to redact the following statement from the victim’s 

medical records:

APS contacted. It will be a travesty if APS does not seek removal from her 

current living situation. The patient had a clogged PEG tube and was not 

receiving nutrition nor medication. She was covered in excrement (per EMS) 

and her daughter will not participate in her discussions regarding her care 

(per Palliative Care). Long term placement will be needed.

She contends that the statement was not relevant because it makes no material issue more 

or less probable. See Tenn. R. Evid. 401. Alternatively, she argues that even if the 

statement was relevant, its probative value is substantially outweighed by its cumulative 

nature and the danger of unfair prejudice. See Tenn. R. Evid. 403. The State responds that 

the statement was relevant “as Dr. Carrico’s expert opinion about the necessary medical 

treatment for [the victim]” because the State had to prove the victim was an impaired adult. 

The State also contends that the statement’s probative value was not substantially 

outweighed by the danger of unfair prejudice because the statement was not highlighted to 

the jury and appeared on two pages of an eight hundred and forty-five page exhibit.

The admission of Dr. Carrico’s statement describing the severity of the victim’s 

condition and the need to remove her from the Appellant’s home was not an abuse of 

discretion. First, the statement was relevant because it made it more probable that the 

Appellant grossly neglected the victim and that the neglect resulted in serious physical 

harm, both of which were elements of the charged offense. See Tenn. Code Ann. § 71-6-

119(a) (2007) (amended 2019, repealed 2020) (“It is an offense to knowingly, other than 
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by accidental means, physically abuse or grossly neglect an impaired adult if the abuse or 

neglect results in serious mental or physical harm.”). Second, the statement’s probative 

value was not substantially outweighed by the danger of unfair prejudice. See Tenn. R. 

Evid. 403. Though the Appellant expresses concern about the use of the word “travesty,” 

we agree with the State that the danger of unfair prejudice was minimal. The statement

appeared on two pages of the eight hundred and forty-five pages of medical records 

admitted into evidence and was not highlighted to the jury. Accordingly, the danger of 

unfair prejudice did not substantially outweigh the statement’s probative value in 

establishing the elements of the charged offense.

III. Hearsay Within Hearsay. The Appellant argues that the trial court erred by 

allowing Ms. Aquino to testify that the Appellant previously said applying for a long-term 

care program could affect her ability to collect the victim’s life insurance. This statement 

was contained in a prior APS report, which was not prepared by Ms. Aquino and was not 

admitted into evidence. The Appellant contends that though the Appellant’s statement was 

admissible as an admission of a party-opponent, Ms. Aquino’s testimony about what she 

read in the report did not fit within the business records exception.

2

 Though the State does 

not explicitly concede error, it argues only that the testimony did not prejudice the 

Appellant because the statement was also properly admitted through Mr. Calway. We 

agree with the Appellant.

Hearsay is generally not admissible. Tenn. R. Evid. 802. Hearsay is defined as “a 

statement, other than one made by the declarant while testifying at the trial or hearing, 

offered in evidence to prove the truth of the matter asserted.” Tenn. R. Evid. 801(c). 

However, there are several exceptions to the general prohibition on hearsay. See Tenn. R. 

Evid. 803. If an out-of-court statement contains multiple levels of hearsay, referred to as 

“hearsay within hearsay,” the statement is not admissible unless each level fits within a 

hearsay exception. Tenn. R. Evid. 805. Two exceptions are relevant in this appeal—an 

admission by a party-opponent and public records and reports. First, a statement offered 

against a party that is “the party’s own statement in either an individual or a representative 

capacity” is not excluded by Rule 802. Tenn. R. Evid. 803(1.2). Second, a record “of 

public offices or agencies setting forth the activities of the office or agency or matters 

observed pursuant to a duty imposed by law as to which matters there was a duty to report”

is not excluded by Rule 802 “[u]nless the source of information or the method or 

circumstances of preparation indicate lack of trustworthiness.” Tenn. R. Evid. 803(8). 

Whether a statement qualifies as hearsay and whether it fits within one of the 

exceptions to the hearsay rule are questions of law subject to de novo review. Kendrick v. 

 

2 Though the Appellant claims that the trial court admitted the testimony as a business record, the trial 

transcript reflects that the court instead admitted it as a public record.
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State, 454 S.W.3d 450, 479 (Tenn. 2015) (citing State v. Schiefelbein, 230 S.W.3d 88, 128 

(Tenn. Crim. App. 2007)). The trial court’s factual findings and credibility determinations, 

however, are binding unless the evidence in the record preponderates against them. Id.

(citing State v. Gilley, 297 S.W.3d 739, 759-61 (Tenn. Crim. App. 2008)).

Ms. Aquino testified about a statement made by the Appellant and documented in 

an APS report. She did not have firsthand knowledge of this statement and was testifying 

about her memory of the contents of the APS report. The trial court overruled the 

Appellant’s objection after the State argued that the testimony was admissible because it 

was an admission by a party opponent contained in a public record.

The trial court erred by allowing this testimony because, though the Appellant’s 

statement was admissible as a statement by a party-opponent, Ms. Aquino’s testimony 

about what she read in the report was not admissible under the public records exception. 

See Tenn. R. Evid. 803(1.2), (8). In State v. B.F., the Tennessee Court of Appeals held

that the business records exception provides for the admission of records, not the admission 

of witness testimony about her memory of the contents of the record. State v. B.F., No. 

E2004-00338-COA-R3-PT, 2004 WL 2752808, *2-3 (Tenn. App. Dec. 2, 2004), no perm. 

app. filed. This holding was based on the exception’s text and underlying principle. Id. 

The text clearly indicated that the rule applied only to tangible documentation—“[a]

memorandum, report, record, or data compilation, in any form.” Id. at *3 (quoting Tenn. 

R. Evid. 803(6)). Additionally, business records are exempt from the general prohibition 

against hearsay because “regularly kept records typically have a high degree of accuracy.” 

Id. (quoting 2 McCormick on Evidence § 286 (John W. Strong, 5th ed. 1999)). A witness’s 

testimony about the record’s contents, however, does not exhibit the same high degree of 

accuracy. Id. This logic applies equally to the public records exception. See Tenn. R. 

Evid. 803(8) (public records include “records, reports statements, or data compilations in 

any form”). Accordingly, Ms. Aquino’s testimony about a statement she read in a previous 

APS report of which she had no firsthand knowledge was inadmissible. See also Lumpkin 

v. State, 524 S.W.2d 302, 305 (Tex. Crim. App. 1975) (holding that witness testimony 

based on knowledge gained by studying records is inadmissible hearsay, regardless of 

whether the underlying record falls within a hearsay exception).

This error, however, does not entitle the Appellant to relief because she cannot show 

that it more probably than not affected the verdict. See Clark, 452 S.W.3d at 287 (when a 

trial court erroneously admits evidence, the defendant bears the burden of showing that the 

evidence more probably than not affected the verdict); Tenn. R. App. P. 36(b). The 

Appellant’s statement contained in the report was properly admitted through Mr. Calway, 

who had firsthand knowledge of the statement. On rebuttal, Mr. Calway testified that the 

Appellant failed to apply to Choices in 2017 after expressing concern about a life insurance 
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policy. Therefore, even if the trial court had properly excluded Ms. Aquino’s testimony 

about the statement, the statement would have been admitted into evidence.

IV. Cumulative Error. While not directly raised in the issues presented, the

Appellant weaves into her argument that if the alleged evidentiary errors do not alone 

warrant relief, their cumulative effect deprived her of a fair trial. We disagree.

The cumulative error doctrine recognizes that “there may be multiple errors 

committed in trial proceedings, each of which in isolation constitutes mere harmless error, 

but which when aggregated, have a cumulative effect on the proceedings so great as to 

require reversal in order to preserve a defendant’s right to a fair trial.” State v. Hester, 324 

S.W.3d 1, 76 (Tenn. 2010). The doctrine applies when there has been more than one error 

committed in trial proceedings, but circumstances warranting a reversal are rare. Id. at 76-

77; see also State v. Gilliland, 22 S.W.3d 266, 273 (Tenn. 2000) (“Although the 

Constitution of our state and of the United States guarantees criminal defendants the right 

to a fair trial, neither guarantees criminal defendants the right to a perfect trial.”). The 

Tennessee Supreme Court has provided the following guidance for assessing whether the 

aggregated errors deprived the defendant of a fair trial:

A reviewing tribunal must consider each such claim against the background 

of the case as a whole, paying particular weight to factors such as the nature 

and number of the errors committed; their interrelationship, if any, and 

combined effect; how the [trial] court dealt with the errors as they arose 

(including the efficacy—or lack of efficacy—of any remedial efforts); and 

the strength of the [State’s] case. The run of the trial may also be important; 

a handful of miscues, in combination, may often pack a greater punch in a 

short trial than in a much longer trial.

Hester, 324 S.W.3d at 77 (quoting United States v. Sepulveda, 15 F.3d 1161, 1196 (1st Cir. 

1993)).

The cumulative effect of the two errors identified was not so great as to require 

reversal. The erroneous admission of Ms. Aquino’s testimony about the Appellant’s 

statement had little, if any, effect on the trial because the statement was properly admitted 

through Mr. Calway. In other words, the jury would have heard the statement about the 

Appellant’s purported financial motive for the offense regardless of the trial court’s ruling 

on the Appellant’s hearsay objection. Therefore, even when combined with the erroneous 

admission of testimony related to animal neglect, the effect was harmless.
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CONCLUSION

We conclude that there was no reversible error and affirm the judgment of the trial 

court.

___________________________________________

CAMILLE R. MCMULLEN, PRESIDING JUDGE