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Part One - TERCAP Summary and Recommendations
The completed TERCAP report highlights a critical incident involving a 54-year-old patient who fell post-operatively, leading to severe harm requiring prolonged hospitalization and additional therapy. The contributing factors include a nurse on her third consecutive 12-hour night shift, a high patient-to-staff ratio, and a failure to adhere to patient assessment protocols and hourly rounding. To minimize legal risks, the following recommendations are proposed:
1. Staffing Assessment and Adequacy:
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