The nurse hears the patient calling for help and enters the room to find the patient on the floor. One of the side rails is down on the bed. Which documentation is most appropriate?

The side rail of the bed was down, and the patient was found on the floor. Proper reporting of incidents is to document what was observed factually and accurately. As the nurse did not witness the fall or the preceding events, the nurse can only speak to what was observed: the side rail was down and the patient was on the floor. It is not accurate to say the client fell out of bed or the client lowered the side rail themselves because the nurse did not witness these events. It is also not appropriate to suggest the side rail was not secured by hospital staff as this is not known fact.

The nurse hears the patient calling for help and enters the room ...

Category: Safety and Infection Control
Difficulty: 5

Topics: Communication & Documentation Assessment Health Care Ethics, Law, and Policy Health Care Quality Mobility

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