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Based on observation and interview, the facility failed to ensure a safe setting for 11 of 102 patients (Patient #s A, B, C, D, E, F, G, J, K, L, & M) as shown by the presence of potentially hazardous objects and furnishings which included:

1. Loose, easily removable sharp Formica veneer on a patient's bathroom sink;
2. Golf-type pencils in patient bedrooms, and;
3. Sharp rusty bolt securing toilet to floor in patient's bathroom.


Findings included:


Review of facility document titled "Environment of Care" showed there was a checklist used by clinical staff for both day & night shifts to assess the environment of the patient areas. The checklist showed there was an entry to assess "found contraband" and "damage to property" in patient rooms.

Observation on 9/1/23 at 10:30 am-12:00 pm of three facility units, accompanied by RN Supervisor- Staff #3 showed the following:

Rooms 507, 601, 703, and 705 contained small golf-type pencils. All four of these rooms were occupied by two patients for each room.

In an interview at the times of these findings, Staff# 3 stated these hazards should not be present inside the rooms and removed them.

Room 602's bathroom sink top had an approximately 3" x 4" inch piece of Formica-type veneer missing, exposing sharp, jagged edges. The thin, flat veneer was easily able to be pried-off the sink top and could have create sharp hazardous pieces used for self-harm.

In an interview at the time of this finding, Staff #3 who was present, acknowledged this was a dangerous safety hazard and promptly notified administrative staff.

Record review of facility patient census showed that both patients occupying Room 602 (Patients #L & M) with the loose veneer were currently on suicide precautions.

Room #504 had an exposed sharp, rusty bolt from the toilet connection to the floor present in the patient bathroom. Staff #3 who was present at the time, acknowledged this was a safety hazard.

Based on record review and interview, the facility failed to ensure that 1 of 5 patient needs were appropriately met (Patient #H), as shown by;

1. Registered nurses not notifying the physician when the patient had a change in condition, and;

2. Not conducting a pain evaluation assessment.


Findings included:


Review of facility policy titled "Cypress Creek Hospital Administrative Policy on Documentation, last reviewed 09/2022 showed that all disciplines shall document observations, assessments, and interventions. Also, a registered nurse shall write a note for [patients with] medical instability and their treatment.

Record review showed that on 7/12/23, Patient #H was admitted to the facility under the care of Doctor-Staff #5 and was discharged on 7/17/23. The patient's clinical records did not show any exam findings or complaints of back or hip pain for the initial medical history & physical assessment.

Record review of Patient #H's Medication Administration Record showed pain medication was administered seven times for lower back & left hip pain, starting three days after admission:

7/15/23 at 10:54 am - Acetaminophen 500 mg for lower back pain;
7/16/23 at 4:10 am - Acetaminophen 500 mg for lower back pain;
7/16/23 at 9:53 am - Ibuprofen 800 mg for left hip pain;
7/16/23 at 3:51 pm - 500 mg Acetaminophen for left hip pain;
7/16/23 at 8:08 pm - 800 mg Ibuprofen for lower back pain;
7/17/23 at 5:42 am - 800 mg Ibuprofen for lower back pain, and;
7/17/23 at 9:56 am - 500 mg Acetaminophen for left hip pain.

Record review of daily nursing assessment and nursing progress notes for Patient #H on 7/15/23 did not show anything entries addressing back pain.

Record review of Patient #H's daily nursing assessment for 7/16/23 showed the patient had complained of lower back pain; There was a pain assessment and progress notes done showing the patient had complained. However, there was no indication that the patient's physician was notified. Review of all other nursing progress notes on the other dates the patient was in the facility failed to show that any physician was ever notified about the patient's back & hip pain.

Record review of Patient #H's daily nursing assessment for 7/17/23 showed that the Pain Assessment portion was left blank.

In an interview on 9/1/23 at 3:30 pm, Staff #2 was shown the 7/17/23 daily nursing assessment for Patient #H and acknowledged that there was no pain assessment documented.

Record review of Patient #H's Discharge Summary from her physician Staff #5 failed to show and address anything regarding back/hip pain. No aftercare or instructions for medical follow-up was ordered or recommended for the patient's pain.

Record review of the patient's treatment plan failed to show it addressed back/hip pain.

Review of medical records from Patient #H after discharge from facility on 7/17/23 showed the following; the patient had gone to an emergency room where x-rays were taken on 7/19/23 for the diagnosis of left side sciatica, then an MRI was done on 7/21/23. The MRI showed two lower back disc herniations causing impingement on nerves (L3/L4 -in between the third and fourth lower back vertebral bones- revealed a 3.4 mm disc herniation putting pressure on the left L3 nerve root and at L5/S1, a 5.5 mm disc herniation was present, putting pressure on the left L5 nerve root).