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Based on interview and record review the Hospital failed to ensure that two out-patients (Patient #2 and Patient #6) from a sample nine out-patients had a progress note in their record by the physical therapist who assessed Patient #2 and Patient #6 after their fall.

A Fall Report, dated 10/4/18, indicated that Patient #2 fell at 10:40 A.M. while receiving out-patient therapy resulting in a goose egg to the back of his/her head. An ambulance was called and Patient #2 was transported to an acute care hospital.

The Out-Patient Therapy Note, dated 10/4/18 at 1:54 P.M., indicated Patient #2 received his/her therapy for balancing activities and gait training on uneven terrain; however, there was no note in Patient #2's medical record to indicate the fall, the sustained injury, nor the care provided to Patient #2.

A Fall Report, dated 12/4/18, indicated Patient #6 fell outside in a parking lot. Patient #6 was assisted and able to stand after his/her fall. Patient #6 agreed to come inside the building to be evaluated by a physical therapist. Patient #6 reported no injury and no bruising was observed. An assessment of Patient #6's blood pressure and oxygen saturation level and were performed.

Patient #6's Out-Patient Therapy Notes, dated 12/4/18 at 3:07 P.M., indicated Patient #6 received his/her physical therapy; however, there was no note documented regarding the assessment and care provided to Patient #6 after his/her fall in the parking lot.

The Surveyor interviewed the Vice President for Out-Patient Services at 9:00 A.M. on 2/6/19. The Vice President said he would expect to see a note in the medical record if care was provided to a patient after a fall.