When the nurse finds a patient on the floor, the patient says, "I fell out of bed." After assessing the patient, the nurse helps the patient back in bed. What should the nurse do next?
Explanation & Rationale
A. While continuous monitoring is part of post-fall protocol, the nurse has already performed an initial assessment before moving the patient. The next priority step in the legal and clinical sequence of events is to alert the medical team of the incident. Assessment is a prerequisite, but it does not fulfill the duty of reporting. B. Doing nothing is a violation of professional standards and clinical safety protocols, even if no visible injury is present. Some injuries, such as internal hemorrhaging or hairline fractures, may not be immediately apparent upon initial inspection. All falls must be treated as significant events to ensure patient safety and to analyze systemic failures. C. Completing an incident report is a necessary administrative task that documents the event for quality improvement purposes. However, the patient's immediate clinical safety requires communication with the healthcare provider first. The incident report is an internal document and is not a substitute for the clinical communication required to update the medical plan. D. Notifying the health care provider is the immediate priority after ensuring the patient is safe and back in bed. The provider must be informed to evaluate the need for diagnostic imaging, such as X-rays or CT scans, and to update orders. This step ensures that any latent injuries are diagnosed and that the fall is officially documented.