The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NORTHEASTERN HEALTH SYSTEM 1400 EAST DOWNING STREET TAHLEQUAH, OK 74465 Oct. 16, 2013
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on policy and procedure review and staff interview, the hospital failed to ensure there was a comprehensive abuse policy that contained all the required components.

Findings:

This deficiency was cited on a Medicare Recertification Survey on October 26 and 27, 2011. The deficiency stated, "The policies did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker and did not contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect by these individuals."

On 10/15/13 a hospital policy titled, "Abuse Reporting", was provided to the surveyors by Staff A. The hospital's abuse policy was reviewed.

The current policy did not contain all the required components for abuse protection such as:
a. when and how often staff would be trained to identify and report abuse;
b. how the hospital would protect the victim(s) during an investigation;
c. measures the hospital would take to prevent abuse from occurring and;
d. how the hospital would screen potential employees.

The above findings were reviewed with Staff A on 04/15/13 and she stated she did not have any policy that contained all the elements required. The findings were also presented in the exit conference on the afternoon of 10/16/13 with administration. No further documentation was provided.