Hi I am a new RN grad and have worked for 3 months in a LTAC/Rehab hospital. Yesterday I recieved report from day nurse on a new pt that had soft wrist restraints and mittens on because they were pulling out the NG tube and Foley, well the MD signed an order to d/c the NG tube and foley, which I did. The day nurse also told me that pt was able to take off the restraints and they were a "houdini" to really watch them. When I did pt. rounding pt was asleep with restraints on. The day time RN said the pt. had been compliant with all requests and suggested we take the restraints off because the tubing had been d/c. The pt. had a brain injury was confused but cooperative, I educated pt. that I would take the restraints off if he would use the call light, and not get out bed w/out help. Pt was compliant the entire shift (8hour), did not get out of bed (all 4 side rails were up still), took meds no problem, used call light 3x. 10 minutes into PM shift change, we were 6 ft from pts room (door open) we observed pt at doorway and then pt fell and hit head causing laceration above eye, treated with pressure dressing, MD notified along with family and Central Nursing supervisor. MD ordered an enclosed bed for pt. Here is my problem, pt. had orders for restraints, day time nurse did not document that pt was able to take off restraints, if fact they did not document anything in nursing notes other than checking boxes. I documented end of shift what happened, and that day time nurse advised pt able to take off restraints. I removed restraints based on 2 pieces of info, 1st. pt compliant entire shift, and based on verbal report (although RN did not document anything) that pt. can remove restraints. I am angry at myself because I did not see the restraint order (we don't have electronic charting) until end of shift when Charge RN showed me in pt's chart. I filled out a inicident report just like I saw it, I even talked with my Tech who checked on pt 15 mins prior to incident and pt was still in bed and compliant with directions. I feel horrible, angry, and feel incompetent, I don't know if I made a bad decision with leaving the restraints off. If they were left on and pt was able to get out of bed with all straps around him, I felt that injury could be worse. I personally did not see pt take off own restraints. Do I self report to Board of Nursing, is this negligence? Thanks for your help.