with or without a full assessment and a specific care plan in her chart the court believed any competent nurse would know she was at risk to fall and would have observed certain fundamental precautions in caring for her.
apparently the patient rang her call bell and got no response, which led to her getting up on her own.
only the upper but not the lower bed rails were up, four bed rails being considered too restrictive by the nursing stuff caring for her.
the court seemed to suggest she would have been a candidate for soft restraints.