After the patient arrived on an acute care floor from the emergency department a registered nurse with sixteen years direct patient care experience spent forty-five to sixty minutes with him at his bedside conducting his admission nursing assessment.  The nurse obtained information with which to score the patient on the Morse Fall Scale.  According to the Court, that is the standard of care for fall-risk assessment in a hospital setting.  The Court pointed out it requires an element of nursing judgment to interpret a patient’s responses and assign scoring in each category of risk.  The nurse deemed the patient a high fall risk and worked with the patient accordingly. She instructed the patient to use the call button and wait for help to get out of bed, to sit up in bed and wait a minute before standing, not to lean on his bedside table for support, to report any liquid spills on the floor right away and never to bend over to pick up anything from the floor.

    Fall risk precautions were also implemented for the patient’s environment.  The nurse saw to it that the call button and the patient’s personal items were within the patient’s easy reach, put the bed in the lowest position and locked the wheels, turned on a night light in the room and checked that the floor was free of clutter.  The nurse also started hourly safety rounds by a nurse or nursing assistant, to be recorded on the white board in the patient’s room.

    As to the patient’s mental capacity, the nurse made sure he was oriented to name, time and place.  The nurse determined that the patient was not confused and that he understood his limitations.  The nurse was satisfied the patient understood the necessity and would call for assistance rather than try to get out of bed on his own. The patient was not confused and was fully oriented and understood the need to call for help.  The nurse raised the bed rails but decided it was not necessary to activate the bed alarm.

    The nurses who cared for the patient continued to find him alert and oriented but nevertheless they repeatedly reminded him not to get out of bed unassisted. Two days into his hospital stay his nurse found him standing up in his room.  She reminded him he was not supposed to get up on his own and the nurse assisted him back to bed.  The nurse decided not to activate the bed alarm.  One episode of forgetfulness did not negate hers and the other nurses’ assessments of the patient as capable of understanding his limitations and their instructions, she believed.