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Based on review of facility documentation, policies, and an interview with the Chief Nursing Officer at the time of the incident, on the afternoon of 07/17/12 at the facility; it was determined that the patient was assisted out of the restraint bed, into a wheelchair by the patient technician without orders from the charge nurse and the patient fell.

Findings were:
Review of nurses progress note 01/09/12 stated, "0600 up with assist of pt care tech, pt was reported to get out of wheelchair and fall. Laceration to the fore head and pt hands observed.

Review of policy SO4-N STAFFING, NURSING, revised date 08/12/03. " The knowledge and skill level of the staff, knowledge and skill level necessary to effectively employ the present technology, the degree of supervision required by each nursing staff member and relevant infection control and safety issues are also considered. "

In an in-person interview with the Case Manager, and the Chief Nursing Officer at the time of the incident on the afternoon of 07/17/12 at the facility, it was confirmed that patient # 1 fell while trying to get out of the wheelchair and sustained a laceration to the forehead.