I work on a step down critical care adult unit. While generally the patient problems are multifactorial all are cardiac patients with continuous telemetry monitoring. A large number of patients are considered "heavy" and as such may have an active dx of AMS new onset or simply a dx with baseline cognitive impairment. Despite being overwhelmed with this category of patients the unit is not equipped with bed alarms on every bed, and fall prevention remains an ongoing issue.....not that a five patient assignment coupled with various high risk patients with active dx or sx such as ETOH withdrawal, ALZ, s/p CVA, delirium, sundowners, or AMS secondary to uro sepsis makes bed alarms the answer to patient safety. After only one year on this unit and countless high fall risk patients I have managed to prevent any falls from occurring with regard to my assigned patients/and other patients as well. Countless redundant fall related documentation is required albeit the time required for such charting remains a hindrance from actual time availed to the patient. Care companions or sitters are made available rarely as often the PCT's or Certified Techs are pulled from the unit shift resources to sit at the patient bedside, leaving the unit understaffed beyond a stretched patient to HCP ratio. 24 visitation has been a welcomed resource I have utilized in part to help keep the patient safe and improve upon the patients needs being met (sad but true) despite being located in one of the wealthiest counties in my State and Country. Not always are there family members available to remain bedside, either due to circumstance or simply refusal to do so, and not always does a patient have remaining living relatives at all. On occasion there are family members that have earned a general reputation by staff as being difficult. My approach is to make the family feel welcome and cared about as they are there under stressful circumstances to support and care for their loved one in their own capacity. I pursue the enhancement of communication, remain courteous and avoid robotic auto pilot nursing which banishes small talk and laughter. Always inquire what my patient's "number one" may be on that given day or hour, never excluding a family member concern or number one problem, in turn making their concern(s) a high priority for me as well regarding their overall care. The family can offer insight and valuable pieces of information which may enhance a plan of care, and overall outcomes. For instance a patient may have c/o valid sx sharing them only to their family, slight nuances of change like decreased conversation over several hours may be picked up by such family prior to any HCP. So for these reasons and many more I always appreciate total patient care with inclusion of their valued family unit.