If you were not allowed to leave the confused patient alone then perhaps it would have been more prudent to make him a 1:1, otherwise you cannot be in two places at once. Was there a bed alarm on him that no one responded to? And how do you keep intubated patients from grabbing the tubes if you're not allowed restraints? I'm confused. I have a new appreciation for my ICU. As for the fall post shift change, you should not be solely responsible for that one. Even with a chair alarm, the nurse was at the bedside. How would the scenario have changed with a chair alarm? Would it have enabled an invisible force field preventing the standing of a patient. No.