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.

Based on review of hospital documents and interviews with staff, the hospital failed to ensure that all grievances/complaints not resolved at the time of the complaint by staff present are included in the hospital's grievance process. Three of four complaints/grievances on the grievance log reviewed during the investigation were not included in the hospital's grievance process.


1. One grievance which was entered into the system was not included in the grievance process because it was not considered a grievance. The grievance log described the grievance as a "billing issue", but the patient's issues also concerned patient care issues. No investigation was conducted and no letter was sent to the complainant.

2. The second grievance concerned a complaint of pain and care issues. These issues required an investigation, but staff stated that they did not consider this a grievance and did not treat it as such.

3. The third grievance was listed as one complaint, but was really two different incidences on two separate days. The first incident did not have an investigation and the second incident did not have an investigation that interviewed all parties involved.

5. The hospital's definition in their grievance policy of a complaint does not agree with CMS's definition. Any complaint/grievance that cannot be resolved at the time by staff present is considered a grievance and should be treated as such. The hospital says if it can be resolved within 24 hours and involves staff present while the patient is actively receiving care then it considered a complaint and is not considered a grievance and is not treated as such.
Based on the review of abuse and neglect policies and procedures, a written letter from a hospital staff member, patient complaints/grievances and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describes the procedures to follow when a patient alleges abuse by a hospital employee.


1. The hospital's policy, Reporting of Abuse, Neglect and Exploitation with an effective date of 05/1/2001, stipulates all employees of Oklahoma Surgical Hospital, particularly those responsible for patient care, are required to report instances of abuse, neglect or exploitation. The policy defines abuse/neglect as any intentional harmful or offensive conduct. This includes: assault battery; sexual assault; unreasonable physical constraint; prolonged deprivation of food and water; the use of prolonged or unnecessary physical or chemical restraints; any acts or procedures used as means of punishment; and verbal abuse. In the section "accountability: 3. If an employee is suspected of abusing or harassing a patient, the immediate supervisor of the employee should be notified. The supervisor should then contact Human Resources for further direction. Surveyors also reviewed the policy "Employee conduct /Disciplinary Process". None of the policies clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

2. On the afternoon of 3/31/11, Staff C told surveyors Patient #1 called the hospital the day after an outpatient procedure and alleged sexual misconduct by a hospital staff member (Staff E). Staff C told surveyors the hospital staff member (Staff E) was not on duty the day the allegation was made. Staff C stated staff E had been removed from patient care duties during the investigation. Staff C also told surveyors Human Resources had not been contacted for further direction. In an interview later in the afternoon Human Resources confirmed they had not been involved in the investigation.

3. On the morning of 3/31/11, surveyors reviewed the Patient #1's grievance, the hospital's investigation, and a written statement by Staff E. The written statement alleged that Staff E had been grabbed in the groin by the complainant and sexual comments were made by the complainant at that time. On 3/31/11, Staff C told surveyors she was not aware this occurred until Staff E provided a written statement four days after the complaint. Staff C told surveyors Staff E told a supervisor but did not complete a incident report or report the alleged misconduct to anyone else. Staff C told surveyors the supervisor did not complete an incident report or notify Risk Manager about the occurrence.

4. On the morning of 3/31/11, surveyors reviewed the abuse and neglect training for hospital employees. There was no documentation that hospital staff were trained regarding abuse of patient's by hospital employees.